作者：付延鑫1，2，董延春2，戴昂1，张红霞3，宁康2

单位：

1.261053 山东省潍坊市，潍坊医学院　2.250014 山东省济南市，山东第一医科大学第一附属医院（山东省千佛山医院）呼吸病学 山东省呼 吸疾病研究所　3.250014 山东省济南市，山东第一医科大学第一附属医院（山东省千佛山医院）护理学 山东省呼吸疾病研究所

Units：

1.Weifang Medical University, Weifang 261053, China 2.Department of Respiratory, the First Affiliated Hospital of Shandong First Medical University＆Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Jinan 250014, China 3.Department of Nursing, the First Affiliated Hospital of Shandong First Medical University＆Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Jinan 250014, China

关键词：

　慢性阻塞性肺疾病；呼吸衰竭；序贯机械通气；切换时机；网状Meta分析

Keywords：

Chronic obstructive lung disease; Respiratory insufficiency; Sequential mechanical ventilation; Switching time; Network meta-analysis

CLC：

R 563.9 R 563.8

DOI：

10.12114/j.issn.1008-5971.2022.00.021

Funds：

摘要：

背景　序贯机械通气是治疗慢性阻塞性肺疾病（COPD）合并呼吸衰竭的强有力手段，其治疗关键是 选择恰当的切换时机，但目前切换时机的界定标准尚未统一。目的　采用网状Meta分析方法比较不同切换时机的序贯 机械通气治疗COPD合并呼吸衰竭患者的临床效果，旨在为序贯机械通气切换时机的选择提供参考。方法　计算机检 索PubMed、Web of Science、Embase、Cochrane Library、中国生物医学文献数据库、中国知网、维普网、万方数据知 识服务平台，检索时间为2011年1月至2021年8月，检索序贯机械通气与有创机械通气（IMV）、不同切换时机的序贯 机械通气治疗COPD合并呼吸衰竭的随机对照试验（RCT），结局指标为呼吸机相关性肺炎（VAP）发生率、IMV时 间、机械通气时间、住院时间。采用Stata 15.1进行网状Meta分析，并根据累积概率排序图曲线下面积（SUCRA）大小 进行干预措施优劣排序。绘制倒漏斗图以评价文献的发表偏倚。结果　本网状Meta分析共纳入25篇RCT，包括2 063例 患者，涉及肺部感染控制窗（PICW）、自主呼吸试验（SBT）-2 h、格拉斯哥昏迷量表（GCS）-15分3种切换时机。 网状Meta分析结果显示，行以PICW、SBT-2 h、GCS-15分为切换时机的序贯机械通气治疗COPD合并呼吸衰竭患者的 VAP发生率低于行IMV治疗的COPD合并呼吸衰竭患者，IMV时间和住院时间短于行IMV治疗的COPD合并呼吸衰竭患者 （P＜0.05）。行以PICW、GCS-15分为切换时机的序贯机械通气治疗的COPD合并呼吸衰竭患者机械通气时间短于行 IMV治疗的COPD合并呼吸衰竭患者，行以GCS-15分为切换时机的序贯机械通气治疗的COPD合并呼吸衰竭患者机械通 气时间短于行以PICW、SBT-2 h为切换时机的序贯机械通气治疗的COPD合并呼吸衰竭患者（P＜0.05）。上述指标根 据SUCRA优劣排序均依次为以GCS-15分为切换时机的序贯机械通气、以PICW为切换时机的序贯机械通气、以SBT-2 h 为切换时机的序贯机械通气、IMV。倒漏斗图分析结果显示，报道VAP发生率、IMV时间、机械通气时间、住院时间 的文献存在发表偏倚的可能性较大。结论　与IMV相比，以PICW、SBT-2 h或GCS-15分为切换时机的序贯机械通气能 有效降低COPD合并呼吸衰竭患者VAP发生率，缩短其IMV时间及住院时间，以PICW、GCS-15分为切换时机的序贯机 械通气能有效缩短COPD合并呼吸衰竭患者机械通气时间，其中GCS-15分可能是序贯机械通气的最佳切换时机。

Abstract：

Background Sequential mechanical ventilation is the effective treatment on chronic obstructive pulmonary disease (COPD) patients with respiratory failure, and the key to its treatment is to select the appropriate switching time. However, the criteria for switching time of sequential mechanical ventilation have not been unified. Objective To compare the treatment effect of sequential mechanical ventilation with different switching time in the treatment of COPD patients with respiratory failure, and to provide reference for the selection of switching time of sequential mechanical ventilation. Methods PubMed, Web of Science, Embase, Cochrane Library, China Biomedical Literature Database, CNKI, VIP and Wanfang Data were searched by computer from January 2011 to August 2021, and the randomized controlled trial (RCT) of the sequential mechanical ventilation and invasive mechanical ventilation (IMV) and sequential mechanical ventilation at different switching time in the treatment of COPD patients with respiratory failure was searched. The outcome indicator included the incidence of ventilator-associated pneumonia (VAP) , duration of IMV, duration of ventilation, hospitalization time. Stata 15.1 was used for network meta-analysis, and the advantages and disadvantages of intervention measures were ranked according to the surface under the cumulative ranking curve (SUCRA) . An inverted funnel was drawn to evaluate the publication bias of the literature. Results A total of 25 RCTs were included in this network meta-analysis, including 2 063 patients, involving three switching times of pulmonary infection control window (PICW) , spontaneous breathing test (SBT)-2 h and Glasgow Coma Scale (GCS)- 15 points. The results of network meta-analysis showed that, the incidence of VAP in COPD patients with respiratory failure treated with sequential mechanical ventilation with PICW, SBT-2 h and GCS-15 points as switching time was lower than that in COPD patients with respiratory failure treated with IMV, duration of IMV and hospitalization time were shorter than those in COPD patients with respiratory failure treated with IMV (P < 0.05) . The duration of ventilation in COPD patients with respiratory failure treated with sequential mechanical ventilation with PICW and GCS-15 points as switching time was shorter than that in COPD patients with respiratory failure treated with IMV, and the duration of ventilation in COPD patients with respiratory failure treated with sequential mechanical ventilation with GCS-15 points as switching time was shorter than that in COPD patients with respiratory failure treated with sequential mechanical ventilation with PICW and SBT-2 h as switching time (P < 0.05) . According to the SUCRA, the order of the above indexes was sequential mechanical ventilation with GCS-15 points as switching time, sequential mechanical ventilation with PICW as switching time, sequential mechanical ventilation with SBT-2 h as switching time, and IMV. The results of inverted funnel analysis showed that there was a greater possibility of publication bias in the literature reporting the incidence of VAP, duration of IMV, duration of ventilation, hospitalization time. Conclusion Compared with IMV, sequential mechanical ventilation with PICW, SBT-2 h and GCS-15 points as switching time can effectively reduce the incidence of VAP in COPD patients with respiratory failure, shorten the duration of IMV and hospitalization time. Sequential mechanical ventilation with PICW and GCS-15 points as switching time can effectively shorten the duration of ventilation in COPD patients with respiratory failure, and GCS-15 points may be the best switching time to sequential mechanical ventilation.

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