Nghiên cứu trực tiếp so sánh các kỹ thuật thử thở tự phát thay thế: một bài tổng quan và phân tích tổng hợp

Critical Care - Tập 21 - Trang 1-11 - 2017
Karen E. A. Burns1,2,3, Ibrahim Soliman1,2, Neill K. J. Adhikari2,4, Amer Zwein1,2, Jessica T. Y. Wong5, Carolina Gomez-Builes1,2, Jose Augusto Pellegrini6,7, Lu Chen1,2, Nuttapol Rittayamai1,2, Michael Sklar1,2, Laurent J. Brochard1,2, Jan O. Friedrich1,2
1St Michael’s Hospital and the Keenan Research Centre/Li Ka Shing Knowledge Institute, Toronto, Canada
2Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
3Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
4Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
5Department of Public Health, University of Toronto, Toronto, Canada
6Division of Critical Care of Moinhos de Vento Hospital, Porto Alegre, Brazil
7Division of Critical Care of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

Tóm tắt

Ảnh hưởng của các kỹ thuật thử thở tự phát (SBT) thay thế đến thành công trong rút nội khí quản và các kết quả lâm sàng quan trọng khác vẫn chưa rõ ràng. Chúng tôi đã tìm kiếm MEDLINE, EMBASE, CENTRAL, CINAHL, Evidence-Based Medicine Reviews, Ovid Health Star, biên bản của năm hội nghị (1990–2016), và danh sách tham khảo cho các thử nghiệm ngẫu nhiên so sánh các kỹ thuật SBT ở người lớn hoặc trẻ em đã được nội khí quản. Các kết quả chính là thành công ban đầu của SBT, thành công trong rút nội khí quản, hoặc tái nội khí quản. Hai người đánh giá đã độc lập rà soát các trích dẫn, đánh giá chất lượng thử nghiệm, và trích dữ liệu. Chúng tôi đã xác định được 31 thử nghiệm (n = 3541 bệnh nhân). Bằng chứng chất lượng trung bình cho thấy rằng bệnh nhân thực hiện hỗ trợ áp suất (PS) so với SBT T-piece (chín thử nghiệm, n = 1901) có khả năng thành công SBT ban đầu tương tự (tỷ lệ rủi ro (RR) 1.00, khoảng tin cậy (CI) 95% 0.89–1.11; I2 = 77%) nhưng có khả năng cuối cùng rút nội khí quản thành công cao hơn (RR 1.06, CI 95% 1.02–1.10; 11 thử nghiệm, n = 1904; I2 = 0%). Việc loại bỏ một thử nghiệm với kết quả không nhất quán cho SBT và kết quả rút nội khí quản cho thấy rằng PS (so với T-piece) SBT cũng làm tăng thành công ban đầu của SBT (RR 1.06, CI 95% 1.01–1.12; I2 = 0%). Dữ liệu hạn chế cho thấy rằng bù trừ ống tự động cộng với áp lực đường thở dương liên tục (CPAP) so với CPAP đơn lẻ hoặc PS tăng cường SBT nhưng không tăng cường thành công trong rút nội khí quản. Bệnh nhân thực hiện PS (so với T-piece) SBT có vẻ có 6% (CI 95% 2–10%) khả năng rút nội khí quản thành công cao hơn và, nếu kết quả của một thử nghiệm ngoại lệ được loại trừ, có 6% (CI 95% 1–12%) khả năng thành công trong SBT cao hơn. Các thử nghiệm trong tương lai nên điều tra những bệnh nhân có kết quả SBT và rút nội khí quản không chắc chắn và so sánh các kỹ thuật tối đa hóa sự khác biệt trong hỗ trợ.

Từ khóa

#thử thở tự phát #rút nội khí quản #kỹ thuật điều trị #phân tích tổng hợp #bệnh nhân nội khí quản

Tài liệu tham khảo

Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group. Chest. 1994;106:1188–93. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002;287(3):345–55. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:1864–9. Blackwood B, Burns K, Cardwell C, et al. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: an updated Cochrane systematic review and meta-analysis. Cochrane Database Syst Rev. 2014;11:CD006904. Kuhlen R, Max M, Dembinski R, et al. Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. Eur J Anaesthesiol. 2003;20(1):10–6. Oulette DR, et al. Liberation from mechanical ventilation in critically ill adults: an Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Inspiratory pressure augmentation during spontaneous breathing trials, protocols minimizing sedation, and noninvasive ventilation immediately after extubation. Chest. 2017;151(1):166–80. Ladeira MT, Vital FM, Andriolo RB, et al. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev. 2014;5:CD006056. Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ. 1994;309(6964):1286–91. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 (updated September 2008). The Cochrane Collaboration. 2011. www.cochrane-handbook.org. Accessed 16 May 2017. Robinson KA, Dickersin K. Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. Int J Epidemiol. 2002;31(1):150–3. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0. The Cochrane Collaboration. 2008. http://handbook.cochrane.org. Accessed 16 May 2017. Review manger (RevMan) Version 5.3.0. The Cochrane Collaboration. Copenhagen: The Nordic Cochrane Centre; 2011. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration. 2011. http://handbook.cochrane.org. Accessed 16 May 2017. Borenstein M, Higgins JP. Meta-analysis and subgroups. Prev Sci. 2013;14:134–43. Guyatt G, Oxman AD, Kunz R, for the GRADE Working Group, et al. What is “Quality of Evidence” and why is it important to clinicians? BMJ. 2008;336:995–8. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ (Clinical Research Ed). 1997;315(7109):629–34. Feeley TW, Saumarez R, Klick JM, et al. Positive end-expiratory pressure in weaning patients from controlled ventilation. Lancet. 1975;2(7938):725–8. Hastings PR, Bushnell L, Skillman JJ, et al. Cardiorespiratory dynamics during weaning with IMV versus spontaneous ventilation in good-risk cardiac-survey patients. Anesthesiology. 1980;53:429–31. Prakash O, Meij S, Van Der Borden B. Spontaneous ventilation test vs intermittent mandatory ventilation. Chest. 1982;81:403–6. Koller W, Spiss C, Fina U, Duma S. Entwohnung nach postoperativer Beatmung Kardiochirurgischer Patienten, CPAP versus ZEEP [German]. Der Anesthesist. 1983;32:483–7. Jones DP, Byrne P, Morgan C, et al. Positive end-expiratory pressure vs. T-piece. Extubation after mechanical ventilation. Chest. 1991;100:1655–59. Abalos A, Leibowitz AB, Distafanco D, et al. Myocardial ischemia during the weaning period. Crit Care. 1992;3:32–6. Bailey CR, Jones RM, Kelleher AA. The role of continuous positive airway pressure during weaning from mechanical ventilation in cardiac surgical patients. Anaesthesia. 1995;50:677–81. Schinco MA, Whitman GJR, Weiman DS, et al. Pressure support ventilation in combination with continuous positive airway pressure is a better weaning trial in the post coronary bypass patient. Crit Care Med. 1995;23:A236. Esteban A, Alia I, Gordo F, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Am J Respir Crit Care Med. 1997;56:459–65. Holanda MA, Rocha EM, Bandeira RM, et al. Pressure support ventilation (PSV) versus T-tube as pre-extubation spontaneous breathing trials (SBT). Am J Respir Crit Care Med. 2000;161:A559. Farias JA, Retta A, Olazarri F, et al. A comparison of two methods to perform a breathing trial before extubation in pediatric intensive care patients. Intensive Care Med. 2001;27:1649–54. Haberthur C, Mols G, Elsasser S, et al. Extubation after breathing trials with automatic tube compensation, T-tube, or pressure support ventilation. Acta Anaesthesiol Scand. 2002;46:973–9. Koksal GM, Sayilgan C, Sen O, et al. The effects of different weaning modes on the endocrine stress response. Crit Care. 2004;8:R31–4. Matic I, Majeric-Kogler V. Comparison of pressure support and T-tube weaning from mechanical ventilation: randomized prospective study. Croat Med J. 2004;45:162–6. Cohen JD, Shapiro M, Grozovski E, et al. Extubation outcome following a spontaneous breathing trial with automatic tube compensation versus continuous positive airway pressure. Crit Care Med. 2006;34:682–6. Liang CY, Chen CW, Lin WJ, et al. A prospective, randomized comparison of automated tube compensation (ATC) and T-piece in the weaning of mechanically ventilated patients. Am J Respir Crit Care Med. 2006;173:A41. Colombo T, Boldrini AF, Juliano SRR, et al. Implementation, assessment and comparison of the T-tube and pressure-support weaning protocols applied to the intensive care unit patients who had received mechanical ventilation for more than 48 hours [Portugese]. Rev Bras Ter Intensiva. 2007;19:31–7. Matic I, Danic D, Majeric-Kogler V, et al. Chronic obstructive pulmonary disease and weaning of difficult-to-wean patients from mechanical ventilation: randomized prospective study. Croat Med J. 2007;48:51–8. Fayed AM, El Feky IL. Adding automatic tube compensation to continuous positive airway pressure in weaning patients with chronic obstructive pulmonary disease, is it worth trying? Crit Care Med. 2008;36:A137. Cohen J, Shapiro M, Grozovki E, et al. Prediction of extubation outcome: a randomized, controlled trial with automatic tube compensation vs. pressure support ventilation. Crit Care. 2009;13:R21. Zhang B, Qin YZ. A clinical study of rapid-shallow breathing index in spontaneous breathing trial with pressure support ventilation and T-piece [Chinese]. Chinese Crit Care Med. 2009;21:397–401. Figueroa-Casas J, Montoya R, Arzabala A, et al. Comparison between automatic tube compensation and continuous positive airway pressure during spontaneous breathing trials. Respir Care. 2010;55:549–54. Molina-Saldarriaga FJ, Fonseca-Ruiz NJ, Castro C, et al. Study of spontaneous breathing in patients with chronic obstructive pulmonary disease: continuous positive airway pressure (CPAP) versus T-Tube [Portuguese]. Med Intensiva. 2010;34:453–8. Cekman N, Erdemli O. The comparison of the effects of T-piece and CPAP on hemodynamic parameters, arterial blood gases and success of weaning. Bratisl Lek Listy. 2011;112:512–16. Vats N, Singh J, Kaira S. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Indian J Physiother Occup Ther. 2012;6:86–9. El-beleidy ASE, Khattab AAE, El-Sherbini SA, et al. Automatic tube compensation versus pressure support ventilation and extubation outcome in children; a randomized controlled study. ISRN Pediatr. 2013;871376:1–6. Lourenco IS, Franco AM, Bassetto S, et al. Pressure support ventilation versus spontaneous breathing with T-tube for interrupting the ventilation after cardiac operations. Rev Bras Cir Cardiovasc. 2013;28:455–61. Sherif AA, Atalaah HA. Prediction of weaning outcome, feasibility of automatic tube compensation (ATC) for weaning of chronic obstructive pulmonary disease (COPD) patients from mechanical ventilation. Anesth Analg. 2013;116:S-108. Bilan N, Ganji S. Comparison of CPAP with humidifier, blender, and T-piece on the outcome of weaning in patients with neurologic disorders. Iran J Child Neurol. 2015;9:42–5. Chittawatanarat K, Orrapin S, Orrapin S. An open label randomized control trial between low pressure support and T-piece method for discontinuation from mechanical ventilation and extubation in general surgical intensive care units. Crit Care. 2015;19:P268. Teixeira SN, Osaku EF, Costa CRLM, et al. Comparison of proportional assist ventilation plus, T-tube ventilation and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015;60:1527–35. Zhang B, Qin YZ. Comparison of pressure support ventilation and T-piece in determining rapid shallow breathing index in spontaneous breathing trials. Am J Med Sci. 2014;348:300–5. Bilan N, Gangi S. Weaning from ventilator and effect of blender-humidifier on outcome. Int J Pediatr. 2014;2 Suppl 6:39–45. Pellegrini JAS, Moraes RB, Maccari JG, et al. Spontaneous breathing trials with T-piece or pressure-support ventilation: a systematic review and meta-analysis of RCTs. Respir Care. 2016;61(12):1693–703. Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med. 1994;150:896–903. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med. 1995;332:345–50. Koh Y, Hong SB, Lim CM, et al. Effect of an additional 1-hour T-piece trial on weaning outcome at minimal pressure support. J Crit Care. 2000;15:41–5. Vitacca M, Vianello A, Colombo D, et al. Comparison of two methods for weaning patients with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15 days. Am J Respir Crit Care Med. 2001;164:225–30. Jubran A, Grant BJ, Duffner LA, et al. Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA. 2013;309(7):671–7. Sklar MC, Burns K, Rittayamai N, et al. Effort to breathe with various spontaneous breathing trial techniques: a systematic review and physiological meta-analysis. Am J Respir Crit Care Med. 2016.[Epub ahead of print]. Tobin MJ, Jubran A. Variable performance of weaning-predictor tests: role of Bayes’ theorem and spectrum and test-referral bias. Intensive Care Med. 2006;32:2002–12. Thille AW, Richard JC, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care Med. 2013;187:1294–302. Afessa B, Hogans L, Murphy R. Predicting 3-day and 7-day outcomes of weaning from mechanical ventilation. Chest. 1999;116:456–61. Stroetz RW, Hubmayr RD. Tidal volume maintenance during weaning with pressure support. Am J Respir Crit Care Med. 1995;152:1034–40. Burns KEA, Karottaiyamvelil Jacob S, Aguirre V, et al. Stakeholder engagement in trial design: a survey of citizen’s preference for outcomes and treatment options during weaning. Ann Am Thorac Soc. 2016;13(11):1962–8. Esteban A, Alia I, Tobin MJ, Gil A, Gordo F, Vallverdu I, Blanch L, Bonet A, Vazquez A, de Pablo R, Torres A, de al Cal MA, Macias S, for the Spanish Lung Failure Collaborative Group. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. AJRCCM. 1999;159:512–8. Perren A, Domenighetti G, Mauri S, Genini F, Vizzardi N. Protocol-directed weaning from mechanical ventilation: clinical outcome in patients randomized for a 30-min or 120-min trial with pressure support ventilation. Intens Care Med. 2002;28:1058–63. Fernandez MM, Fernandez R, Magret M, González-Castro A, Bouza MT, Ibañez M, García C, Balerdi B, Mas A, Arauzo V, Añón JM, Ruis F, Ferreres J, Tomás R, Alabert M, Tizón AI, Altaba S, Llamas N. Reconnection to mechanical ventilation for one hour after a successful spontaneous breathing trial reduces extubation failure and reintubation in critically ill patients: a multicenter randomized controlled trial. Intens Care Med Exp. 2016;4 Suppl 1:A470.