急性肺损伤和急性呼吸窘迫征(ARDS)非药物治疗的卫生技术评估(一)  

Health technology assessment of non-drugs intervention for acute lung injury and ARDS

作　　者：邹燕[1] 李幼平[1] 杨小东[2] 卢军 杜亮 陈霖 

机构地区：[1]卫生部中国循证医学中心 [2]四川大学华西医院 [3]四川大学华西临床医学院

出　　处：《中国循证医学杂志》2003年第2期128-134,共7页Chinese Journal of Evidence-based Medicine

基　　金：美国纽约中华医学会基金资助~~

摘　　要：目的　 12 .9% - 5 0 %的SARS病人需要短暂的机械通气挽救生命。现已公布的治疗原则和指南基于SARS治疗经验和不很完全的事实 ,尚无前瞻性随机对照临床试验和其它高质量证据。通过对全世界有关机械通气的临床指南、系统评价、Meta分析、经济学评价和严重不良反应的回顾性总结和分析 ,辅以SARS抢救资料 ,寻求安全、合理的非药物干预。方法　检索MEDLINE ,Cochrane图书馆 ,根据纳入和排除标准确定纳入的文献 ,进行文献质量评价和数据提取至少 2遍 ,无异质性的文献作Meta分析。结果　纳入 14篇 ,由于纳入的文献间异质性明显 ,无法进一步作Meta分析 ,只对原作者的结论作描述性分析。结论　PPV的通气模式优于VPV ,PPV者死亡率更低。但要注意容积伤 ,采用低潮气量和适当的PEEP ,降低FiO2 ,允许高碳酸血症可能降低死亡率和缩短住院时间。无创机械通气 (NIMV)对血流动力学稳定和有自主呼吸的病人有效 ,且减少副作用和医务人员感染 ;但严重呼吸困难、PaO2 /FiO2 <2 0 0、无创通气效果不佳或病人不能耐受者需要气管插管通气。采用俯卧位可明显改善动脉血PaO2 /FiO2 。NO可提高肺血流量 ,改善肺V/Q比值和提高血氧 ,且间断吸入更好。有证据表明按计划撤机比按医生经验撤机好。Objectives About 12.9-50% patients of SARS(Severe Acute Respiratory Syndrome),require brief mechanical ventilation (MV) to save life. All the reported principles and guidelines for therapy SARS were based on experiences from clinical treatments and facts of inadequacy.Neither prospective randomized controlled trials (RCT) nor other high quality evidences were in dealing with SARS. Our objective is to seek safe and rational non-drugs interventions for patients with severe SARS by retrospectively reviewing clinical studies about MV all over the world, which include clinical guidelines, systematic reviews (SR), Meta-analysis, economic researches and adverse events .Methods To search MEDLINE and Cochrane Library with computer. According to the standards of inclucion or exclusion,the quality of the article which as assessed, and relevant data which were extracted double checked. The Meta-analysis was conducted if the studies had no heterogeneity. Results14 papers were eligible. Due to the significant heterogeneity between these studies, further Meta-analysis could not be conducted, and the authors' conclusions were described only.Conclusions The outcome of PPV is better than that of VPV. Patients who underwent PPV had a significantly lower mortality than that of VPV. Of course, the volutrauma should be watched. With low tidal volume and proper PEEP, or decreased FiO 2, even permissive hypercapnia, the mortality and length of stay were cut down. Non-invasive mechanical ventilation (NIMV) was effective in treating haemodynamical stable patients, minimizing complications and reducing medical staff infection. Patients with serious dyspnea with PaO 2/FiO 2 <200, no profit of NIMV, or couldn't tolerance hypoxaemia were unlikely to benefit from this technique and needed ventilation with endotracheal intubation. Prone position could improve PaO 2/FiO 2, NO maybe increased pulmonary perfusion, improved V/Q, and raised oxygenation. Furthermore, Inhaled NO sequentially (SQA) was better than Inhaled NO continuouly (CTA). S

关 键 词：急性肺损伤 急性呼吸窘迫征 ARDS 非药物治疗 卫生技术评估 机械通气 循证医学 SARS 

分 类 号：R511.9[医药卫生—内科学]