背景:胃管通常用于无法吞咽的人的药物和管饲。通过错误放置在气管中的管喂养会导致严重的肺炎。因此,在插入管子后,确认管子在胃中的放置是重要的。最近的研究报道,超声检查在确认适当的导管放置方面提供了良好的诊断准确性估计。因此,超声可以提供一个有希望的替代X射线在确认管的放置,尤其是在X射线设施不可用或难以接近的环境中。
目的:评估超声单独或与其他方法结合用于儿童和成人胃管放置确认的诊断准确性。
方法:本系统综述是对先前发表的Cochrane综述的更新。对于此更新,我们搜索了Cochrane图书馆(2021年,第6期),MEDLINE(至2023年4月),Embase(至2023年4月),其他五个数据库(至2021年7月),和参考文章列表,并联系了研究作者。
方法:我们纳入了评估鼻胃和口胃管放置的诊断准确性的研究,这些研究通过使用X射线可视化作为参考标准的超声可视化证实。我们纳入了横断面研究和病例对照研究。我们排除了病例系列或病例报告。如果X射线可视化不是参考标准,或者放置的管子是胃造口术或肠管,我们将其排除在外。
方法:两位综述作者独立评估了方法学质量,并从每个纳入的研究中提取了数据。我们联系了纳入研究的作者,以获取缺失的数据。特异性数据稀疏。因此,我们使用单变量随机效应逻辑回归模型,对使用相同方法和回波窗口的研究数据进行了仅敏感性的荟萃分析.
结果:除了本综述早期版本中包含的10项研究外,我们还确定了12项新研究,共有1939名参与者和1944年的试管插入。总的来说,我们认为纳入研究的偏倚风险较低或不明确.没有研究在每个QUADAS-2领域都存在低偏倚风险或对适用性的低关注。由于错位发生率低,错位检测(特异性)的数据有限(152名参与者)。超声对颈部和腹部回声窗口的总敏感性为:空气注射为0.96(95%置信区间(CI)0.92至0.98;中度确定性证据),生理盐水注射为0.98(95%CI0.83至1.00;中度确定性证据)。超声对腹部回声窗口的总敏感性对于空气注射为0.96(95%CI0.65至1.00;非常低的确定性证据),对于不注射的程序为0.97(95%CI0.95至0.99;中等确定性证据)。由于样本量非常小,所有方法的特异性证据的确定性非常低。对于不容易获得X射线的设置,参与者接受了胃管插入引流(8项研究,552名参与者),超声联合其他验证性试验的敏感性估计值为0.86~0.98,宽CI的特异性估计值为1.00.对于单独的超声研究(9项研究,782名参与者),敏感性估计值为0.77~0.98,特异性估计值为1.00,且CI较宽或由于未发生错位而无法估计.
结论:在评估胃管放置诊断准确性的22项研究中,少数研究的偏倚风险较低.基于有限的证据,超声没有足够的准确性作为一个单一的测试来确认胃管放置。然而,在X射线不容易获得的环境中,超声可能是有用的检测放错了胃管。当超声用于确认导管放置时,需要更大的研究来确定不良事件的可能性。
BACKGROUND: Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access.
OBJECTIVE: To assess the diagnostic accuracy of ultrasound alone or in combination with other methods for gastric tube placement confirmation in children and adults.
METHODS: This systematic review is an update of a previously published Cochrane review. For this update, we searched the Cochrane Library (2021, Issue 6), MEDLINE (to April 2023), Embase (to April 2023), five other databases (to July 2021), and reference lists of articles, and contacted study authors.
METHODS: We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies and case-control studies. We excluded case series or case reports. We excluded studies if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube.
METHODS: Two review authors independently assessed the methodological quality and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. There were sparse data for specificity. Therefore, we performed a meta-analysis of only sensitivity using a univariate random-effects logistic regression model to combine data from studies that used the same method and echo window.
RESULTS: We identified 12 new studies in addition to 10 studies included in the earlier version of this review, totalling 1939 participants and 1944 tube insertions. Overall, we judged the risk of bias in the included studies as low or unclear. No study was at low risk of bias or low concern for applicability in every QUADAS-2 domain. There were limited data (152 participants) for misplacement detection (specificity) due to the low incidence of misplacement. The summary sensitivity of ultrasound on neck and abdomen echo windows were 0.96 (95% confidence interval (CI) 0.92 to 0.98; moderate-certainty evidence) for air injection and 0.98 (95% CI 0.83 to 1.00; moderate-certainty evidence) for saline injection. The summary sensitivity of ultrasound on abdomen echo window was 0.96 (95% CI 0.65 to 1.00; very low-certainty evidence) for air injection and 0.97 (95% CI 0.95 to 0.99; moderate-certainty evidence) for procedures without injection. The certainty of evidence for specificity across all methods was very low due to the very small sample size. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (8 studies, 552 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide CIs. For studies of ultrasound alone (9 studies, 782 participants), sensitivity estimates ranged from 0.77 to 0.98 and specificity estimates were 1.00 with wide CIs or not estimable due to no occurrence of misplacement.
CONCLUSIONS: Of 22 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.