目的 评价允许性高碳酸血症通气法应用于新生儿机械通气的有效性及安全性.方法 检索PubMed、Embase、Cochrane图书馆、中国期刊全文数据库、万方数据库和中国生物医学文献数据库从建库至201 3年3月31日的文献.纳入文献同时满足以下条件:随机对照研究;研究对象为使用机械通气的新生儿;研究依据动脉血二氧化碳分压(partial pressure of carbon dioxide,PCO2)水平分为允许性高碳酸血症(permissive hypercapnia,PHC)组和血碳酸正常(normocapnia,NC)组.主要结局指标包括呼吸机相关性肺损伤(ventilator associated lung injury,VALI)、支气管肺发育不良(bronchopulmonary dysplasia,BPD)、脑室内出血、脑室周围白质软化、动脉导管未闭、坏死性小肠结肠炎、神经发育损伤的发生率和住院期间病死率;次要结局指标包括机械通气时间和住院时间.采用Cochrane评价手册5.1.0推荐的标准对纳入文献进行质量评价.Meta分析采用Revman 5.1软件,根据文献的异质性采用固定效应模型或随机效应模型分析. 结果 (1)一般情况:检索到325篇文献,筛选出8篇文献进入meta分析,共纳入605例新生儿,其中PHC组305例,NC组300例.7篇文献均控制PCO2＜65 mmHg(1 mmHg=0.133 kPa)且pH≥7.2,1篇文献PHC组PCO2未设定具体上限,仅控制PCO2＞52 mmHg且pH＞7.2.(2)文献质量评价结果:4篇文献描述了随机分配方法,3篇文献描述了分配方案隐藏,8篇文献均对研究对象采用盲法,2篇文献对研究结果测量者采用盲法,8篇文献均有完整数据结果且均无选择性报告结果,3篇文献描述了其他偏倚.(3) Meta分析结果:8篇文献报道了VALI发生率,文献间具有异质性(I2=56％,P=0.03),采用随机效应模型分析,2组VALI发生率差异有统计学意义(RR=0.52,95％CI:0.29～0.93,P=0.03).进一步根据胎龄分为2个亚组,3篇平均胎龄25周的文献为同质性研究(I2=0％,P=0.46),2组VALI发生率差异无统计学意义(RR=1.05,95％CI:0.72～1.54,P=0.78);5篇胎龄＞27周的文献为同质性研究(I2=0％,P=0.68),2组VALI发生率差异有统计学意义(RR=0.27,95％CI:0.14～0.50,P＜0.01).住院期间的病死率及机械通气时间均为同质性研究(I2值均为0％,P值均＞0.10),2组比较差异均有统计学意义(住院期间病死率:RR=0.40,95％CI:0.22～0.74,P＜0.01;机械通气时间:均数差=-0.75,95％CI:-1.04～-0.46,P＜0.01).支气管肺发育不良、脑室内出血、脑室周围白质软化、动脉导管未闭、坏死性小肠结肠炎以及神经发育损伤的发生率比较,差异均无统计学意义(P值均＞0.05). 结论 目前的证据显示,允许性高碳酸血症通气法应用于新生儿机械通气,可以减少患儿VALI的发生率、住院期间的病死率以及机械通气时间,但对BPD无明显预防作用.控制PCO2＜65 mmHg且pH≥7.2,不会增加脑室内出血、脑室周围白质软化、动脉导管未闭、坏死性小肠结肠炎以及神经发育损伤的风险.
目的 評價允許性高碳痠血癥通氣法應用于新生兒機械通氣的有效性及安全性.方法 檢索PubMed、Embase、Cochrane圖書館、中國期刊全文數據庫、萬方數據庫和中國生物醫學文獻數據庫從建庫至201 3年3月31日的文獻.納入文獻同時滿足以下條件:隨機對照研究;研究對象為使用機械通氣的新生兒;研究依據動脈血二氧化碳分壓(partial pressure of carbon dioxide,PCO2)水平分為允許性高碳痠血癥(permissive hypercapnia,PHC)組和血碳痠正常(normocapnia,NC)組.主要結跼指標包括呼吸機相關性肺損傷(ventilator associated lung injury,VALI)、支氣管肺髮育不良(bronchopulmonary dysplasia,BPD)、腦室內齣血、腦室週圍白質軟化、動脈導管未閉、壞死性小腸結腸炎、神經髮育損傷的髮生率和住院期間病死率;次要結跼指標包括機械通氣時間和住院時間.採用Cochrane評價手冊5.1.0推薦的標準對納入文獻進行質量評價.Meta分析採用Revman 5.1軟件,根據文獻的異質性採用固定效應模型或隨機效應模型分析. 結果 (1)一般情況:檢索到325篇文獻,篩選齣8篇文獻進入meta分析,共納入605例新生兒,其中PHC組305例,NC組300例.7篇文獻均控製PCO2＜65 mmHg(1 mmHg=0.133 kPa)且pH≥7.2,1篇文獻PHC組PCO2未設定具體上限,僅控製PCO2＞52 mmHg且pH＞7.2.(2)文獻質量評價結果:4篇文獻描述瞭隨機分配方法,3篇文獻描述瞭分配方案隱藏,8篇文獻均對研究對象採用盲法,2篇文獻對研究結果測量者採用盲法,8篇文獻均有完整數據結果且均無選擇性報告結果,3篇文獻描述瞭其他偏倚.(3) Meta分析結果:8篇文獻報道瞭VALI髮生率,文獻間具有異質性(I2=56％,P=0.03),採用隨機效應模型分析,2組VALI髮生率差異有統計學意義(RR=0.52,95％CI:0.29～0.93,P=0.03).進一步根據胎齡分為2箇亞組,3篇平均胎齡25週的文獻為同質性研究(I2=0％,P=0.46),2組VALI髮生率差異無統計學意義(RR=1.05,95％CI:0.72～1.54,P=0.78);5篇胎齡＞27週的文獻為同質性研究(I2=0％,P=0.68),2組VALI髮生率差異有統計學意義(RR=0.27,95％CI:0.14～0.50,P＜0.01).住院期間的病死率及機械通氣時間均為同質性研究(I2值均為0％,P值均＞0.10),2組比較差異均有統計學意義(住院期間病死率:RR=0.40,95％CI:0.22～0.74,P＜0.01;機械通氣時間:均數差=-0.75,95％CI:-1.04～-0.46,P＜0.01).支氣管肺髮育不良、腦室內齣血、腦室週圍白質軟化、動脈導管未閉、壞死性小腸結腸炎以及神經髮育損傷的髮生率比較,差異均無統計學意義(P值均＞0.05). 結論 目前的證據顯示,允許性高碳痠血癥通氣法應用于新生兒機械通氣,可以減少患兒VALI的髮生率、住院期間的病死率以及機械通氣時間,但對BPD無明顯預防作用.控製PCO2＜65 mmHg且pH≥7.2,不會增加腦室內齣血、腦室週圍白質軟化、動脈導管未閉、壞死性小腸結腸炎以及神經髮育損傷的風險.
목적 평개윤허성고탄산혈증통기법응용우신생인궤계통기적유효성급안전성.방법 검색PubMed、Embase、Cochrane도서관、중국기간전문수거고、만방수거고화중국생물의학문헌수거고종건고지201 3년3월31일적문헌.납입문헌동시만족이하조건:수궤대조연구;연구대상위사용궤계통기적신생인;연구의거동맥혈이양화탄분압(partial pressure of carbon dioxide,PCO2)수평분위윤허성고탄산혈증(permissive hypercapnia,PHC)조화혈탄산정상(normocapnia,NC)조.주요결국지표포괄호흡궤상관성폐손상(ventilator associated lung injury,VALI)、지기관폐발육불량(bronchopulmonary dysplasia,BPD)、뇌실내출혈、뇌실주위백질연화、동맥도관미폐、배사성소장결장염、신경발육손상적발생솔화주원기간병사솔;차요결국지표포괄궤계통기시간화주원시간.채용Cochrane평개수책5.1.0추천적표준대납입문헌진행질량평개.Meta분석채용Revman 5.1연건,근거문헌적이질성채용고정효응모형혹수궤효응모형분석. 결과 (1)일반정황:검색도325편문헌,사선출8편문헌진입meta분석,공납입605례신생인,기중PHC조305례,NC조300례.7편문헌균공제PCO2＜65 mmHg(1 mmHg=0.133 kPa)차pH≥7.2,1편문헌PHC조PCO2미설정구체상한,부공제PCO2＞52 mmHg차pH＞7.2.(2)문헌질량평개결과:4편문헌묘술료수궤분배방법,3편문헌묘술료분배방안은장,8편문헌균대연구대상채용맹법,2편문헌대연구결과측량자채용맹법,8편문헌균유완정수거결과차균무선택성보고결과,3편문헌묘술료기타편의.(3) Meta분석결과:8편문헌보도료VALI발생솔,문헌간구유이질성(I2=56％,P=0.03),채용수궤효응모형분석,2조VALI발생솔차이유통계학의의(RR=0.52,95％CI:0.29～0.93,P=0.03).진일보근거태령분위2개아조,3편평균태령25주적문헌위동질성연구(I2=0％,P=0.46),2조VALI발생솔차이무통계학의의(RR=1.05,95％CI:0.72～1.54,P=0.78);5편태령＞27주적문헌위동질성연구(I2=0％,P=0.68),2조VALI발생솔차이유통계학의의(RR=0.27,95％CI:0.14～0.50,P＜0.01).주원기간적병사솔급궤계통기시간균위동질성연구(I2치균위0％,P치균＞0.10),2조비교차이균유통계학의의(주원기간병사솔:RR=0.40,95％CI:0.22～0.74,P＜0.01;궤계통기시간:균수차=-0.75,95％CI:-1.04～-0.46,P＜0.01).지기관폐발육불량、뇌실내출혈、뇌실주위백질연화、동맥도관미폐、배사성소장결장염이급신경발육손상적발생솔비교,차이균무통계학의의(P치균＞0.05). 결론 목전적증거현시,윤허성고탄산혈증통기법응용우신생인궤계통기,가이감소환인VALI적발생솔、주원기간적병사솔이급궤계통기시간,단대BPD무명현예방작용.공제PCO2＜65 mmHg차pH≥7.2,불회증가뇌실내출혈、뇌실주위백질연화、동맥도관미폐、배사성소장결장염이급신경발육손상적풍험.
Objective To evaluate the efficacy and safety of permissive hypercapnia ventilation in mechanically ventilated newborns.Methods PubMed,Embase,the Cochrane Library,China National Knowledge Infrastructure (CKNI),Wanfang Data and Chinese BioMedical Literature Database (CBM) were searched up until March 31,2013.Randomized controlled trials (RCTs) comparing permissive hypercapnia (PHC) group with normocapnia (NC) group in mechanically ventilated newborns were included.The primary outcomes included the incidence of ventilator associated lung injury (VALI),bronchopulmonary dysplasia (BPD),intraventricular hemorrhage (IVH),periventricular leukomalacia (PVL),patent ductus arteriosus (PDA),neonatal necrotizing enterocolitis (NEC),neurodevelopmental injury and the mortality rate.Secondary outcomes included the duration of ventilatory support and the length of hospital stay.The Cochrane Handbook 5.1.0 was used to evaluate the methodological quality and RevMan 5.1 software from Cochrane Collaboration was used for meta-analysis.The fixed effects model or the random effects model was adopted according to the result of heterogeneity.Results (1) A total of 325 articles were searched,and eight RCTs involving 605 newborns (302 newborns in PHC group while 300 newborns in NC group) which met the inclusion criteria were selected.In seven studies,the partial pressure of carbon dioxide (PCO2) was controlled at ＜ 65 mmHg (1 mmHg=0.133 kPa) and pH at ≥ 7.2 in PHC group.In one study,PCO2 was ＞ 52 mmHg and pH＞7.2,without descripition of the upper limit of PCO2.(2) Four articles described the method of random allocation in detail; three described allocation concealment; all eight studies used blinding method for research subjects; two used blinding method for outcome assessment; all eight studies reported complete data; and three articles described the source of other bias.(3) All eight studies reported the incidence of VALI (I2=56％,P=0.03).The random effects model was used for the meta-analysis,and there was significant difference between PHC group and NC group (RR=0.52,95％CI:0.29-0.93,P=0.03).According to the gestational age,the eight studies were divided into two subgroups.One subgroup,including three studies with an average gestational age of 25 weeks (I2=0％,P=0.46),showed no significant difference in the incidence of VALI between PHC and NC group (RR=1.05,95％CI:0.72-1.54,P=0.78).The other subgroup,including five studies with gestational age of ＞27 weeks (I2=0％,P=0.68),showed significant difference in the incidence of VALI between the two groups (RR=0.27,95％CI:0.14-0.50,P＜0.01).The in-hospital mortality and duration of ventilation showed significant difference between the two groups (in-hospital mortality:RR=0.40,95％CI:0.22-0.74,P＜0.01; duration of ventilation:difference in means=-0.75,95％CI:-1.04--0.46,P＜0.01).There was no significant difference in the incidence of BPD,IVH,PVL,PDA,NEC and neurodevelopmental impairment between the two groups (all P＞0.05).Conclusions PHC ventilation in mechanically ventilated newborns can decrease the incidence of VALI,the in-hospital mortality and the duration of ventilation,while its protective efficacy against BPD is not remarkable.It does not increase the risk of IVH,PVL,PDA,NEC and neurodevelopmental injury,when the PCO2 is ＜ 65 mmHg and pH ≥ 7.2.
