背景:自主呼吸试验(SBT)技术在成功拔管与再插管风险之间的最佳平衡尚不清楚。我们试图确定替代SBT技术的比较疗效和安全性。
方法:我们搜索了Medline,EMBASE,和Cochrane中央对照试验注册从开始到2023年2月,用于比较SBT技术在危重成人和儿童中的随机或准随机试验,并报告最初的SBT成功,成功拔管,再插管(主要结果)和死亡率(ICU,医院,最持久的;次要结果)比率。两名审稿人筛选,审查全文,和抽象的数据。我们进行了频繁随机效应网络荟萃分析。
结果:我们纳入了40个RCTs(6716例患者)。压力支持(PS)与T型SBT是最常见的比较。初始成功SBT率随着PS[风险比(RR)1.08,95%置信区间(CI)(1.05-1.11)]而增加,PS/自动管补偿(ATC)[1.12(1.01-1.25),高流量鼻插管(HFNC)[1.07(1.00-1.13)(均为中等确定性),和ATC[RR1.11,(1.03-1.20);低确定性]SBT与T型SBT相比。同样,最初的成功SBT率随着PS的增加而增加,ATC,与持续气道正压通气(CPAP)SBT相比,PS/ATCSBT。成功拔管率随着PS[RR1.06,(1.03-1.09);高确定性]而增加,ATC[RR1.13,(1.05-1.21);中等确定性],和HFNC[RR1.06,(1.02-1.11);高确定性]SBT,与T型SBT相比。PS的再插管率几乎没有差异(与T形件)SBT[RR1.05,(0.91-1.21);低确定性],但与HFNCSBT相比,PS[RR2.84,(1.61-5.03);中等确定性]和ATC[RR2.95(1.57-5.56);中等确定性]SBT的再插管率增加。
结论:通过压力增加进行的SBT(PS,ATC,PS/ATC)与不带(T形,CPAP)增加初始成功SBT和成功拔管率。尽管使用PS或ATC与HFNC进行的SBT增加了再插管率,PS与T型SBT的情况并非如此。
The spontaneous breathing
trial (SBT) technique that best balance successful
extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques.
We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful
extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis.
We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05-1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 -1.25), high flow nasal cannulae (HFNC) [1.07 (1.00-1.13) (all moderate certainty), and ATC [RR 1.11, (1.03-1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful
extubation rates were increased with PS [RR 1.06, (1.03-1.09); high certainty], ATC [RR 1.13, (1.05-1.21); moderate certainty], and HFNC [RR 1.06, (1.02-1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91-1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61-5.03); moderate certainty] and ATC [RR 2.95 (1.57-5.56); moderate certainty] SBTs compared to HFNC SBTs.
SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful
extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs.