摘要
目的对神经重症气管切开患者的拔管指征进行Meta分析,以确定这些患者拔管成功的有效指征参数。方法对中国知网、万方数据、维普数据库、科学网(Web of Science)、美国国立医学图书馆PubMed数据库、Cochrane图书馆数据库进行文献检索;检索时限均从建库至2019年4月。检索文献为有关神经重症气管切开患者拔管过程中拔管指征参数的病例对照研究、队列研究、随机对照试验(RCT)或调查。由2位研究者独立识别并筛选文献、提取数据,使用纽卡斯尔-渥太华量表(NOS)评估纳入文献质量,采用RevMan 5.3软件进行Meta分析。通过评估统计模型(固定效应模型或随机效应模型)、研究文献质量(低质量或高质量)是否会影响结果,进行敏感性分析以评估结果的稳定性;通过漏斗图定性评价纳入文献的发表偏倚。结果共纳入11项研究,涉及1357例患者。报告的神经重症气管切开患者拔管成功率为46.7%~97.5%;9项研究中拔管成功的定义是无再插管,另外2项未说明;所有研究NOS评分为6~8分,均为高质量研究。Meta分析显示,神经重症气管切开患者的意识水平〔格拉斯哥昏迷评分(GCS)≥8分比<8分:优势比(OR)=3.34,95%可信区间(95%CI)为2.22~5.03,P<0.001〕、气管分泌物量(少比多:OR=13.07,95%CI为5.64~30.32,P<0.001)、咳嗽反射(有比无:OR=14.33,95%CI为6.36~32.28,P<0.001)和吞咽功能(良比差:校正OR=18.56,95%CI为8.16~42.21,P<0.001)与拔管结果的相关性有统计学意义;而肺部感染(无比有:校正OR=1.94,95%CI为0.87~4.35,P=0.11)、血氧饱和度(≥0.95比<0.95:OR=2.34,95%CI为1.11~4.91,P=0.12)、堵管耐受性(良比差:OR=2.12,95%CI为0.67~6.71,P=0.20)及拔管方式(渐进比直接:OR=0.99,95%CI为0.95~1.04,P=0.93)与拔管结果的相关性无统计学意义。敏感性分析显示结果稳定。漏斗图显示,纳入研究对称分布于漏斗两侧,提示存在发表偏倚的可能性较小。结论神经重症气管切开患者有效的拔管指征是意识水平(GCS评分≥8分),气管分泌物量少,有咳嗽反射,吞咽功能良好。
Objective To analyze the extubation indications of tracheotomy patients with severe neuropathy by Meta-analysis in order to determine the effective indication parameters for successful extubation.Methods The literatures in databases including China National Knowledge Infrastructure(CNKI),Wanfang,VIP,Web of Science,PubMed and Cochrane Library were retrieved from their establishment to April 2019.The literatures were case-control studies,cohort studies,randomized controlled trials(RCTs)or surveys related to indication parameters for successful extubation in patients with severe neuropathy.Two researchers identified and extracted literatures and data independently.The quality of literatures was assessed by the Newcastle-Ottawa scale(NOS).Meta-analysis was performed by RevMan 5.3 software.The stability of the results were evaluated by assessing the statistical models(the fixed effects model or the random effects model)and literatures quality(inferior or superior),and by sensitivity analysis.The publication bias of literatures was assessed by funnel plot.Results Eleven studies involving 1357 participants were enrolled,and the rate of successful extubation was 46.7%-97.5%.Nine studies defined successful extubation as no need of re-intubation,and other two did not explain.All studies were high quality research,with NOS score of 6-8.Meta-analysis showed that the correlation between the level of consciousness[Glasgow coma score(GCS)≥8 vs.<8:odds ratio(OR)=3.34,95%confidence interval(95%CI)was 2.22-5.03,P<0.001],the amount of tracheal secretions(less vs.more:OR=13.07,95%CI was 5.64-30.32,P<0.001),cough reflex(with vs.without:OR=14.33,95%CI was 6.36-32.28,P<0.001),swallowing function(good vs.bad:adjusted OR=18.56,95%CI was 8.16-42.21,P<0.001)and successful extubation was statistically significant,and the correlation between the pulmonary infection(with vs.without:adjusted OR=1.94,95%CI was 0.87-4.35,P=0.11),oxygen saturation(≥0.95 vs.<0.95:OR=2.34,95%CI was 1.11-4.91,P=0.12),tolerance of tube plugging(good vs.bad:OR=2.12,95%CI was 0.67-6.71,P=0.20),method of tube drawing(gradually vs.abruptly:OR=0.99,95%CI was 0.95-1.04,P=0.93)and successful extubation was not statistically significant.Sensitivity analysis showed that the results were stable.Funnel plot showed that the studies distributed in both sides of the funnel symmetrically,indicating the publication bias of literatures was small.Conclusion The effective indication of extubation is consciousness level(GCS score≥8),less secretion,cough reflex and good swallowing function.
作者
丁玉菊
徐绍侠
张伟
张波
Ding Yuju;Xu Shaoxia;Zhang Wei;Zhang Bo(Anhui University of Chinese Medicine,Hefei 230038,Anhui,China;Department of Encephalopathy,the First Affiliated Hospital of Anhui University of Chinese Medicine,Hefei 230038,Anhui,China)
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2019年第11期1378-1383,共6页
Chinese Critical Care Medicine
基金
国家中医药管理局重点专科建设项目(12J1X1L102K105)。
关键词
气管切开术
拔管
神经重症患者
Tracheostomy
Extubation
Severe neuropathy patient
