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中华危重症医学杂志(电子版)

中华危重症医学杂志(电子版) ›› 2022, Vol. 15 ›› Issue (04) : 312 -317. doi: 10.3877/cma.j.issn.1674-6880.2022.04.010

荟萃分析

俯卧位通气对静脉-静脉体外膜肺氧合支持的急性呼吸窘迫综合征患者病死率影响的Meta分析
童洪杰1, 陈琨1, 潘飞艳1, 倪红英1,†()   
  1. 1. 321000　浙江金华，浙江大学医学院附属金华医院重症医学科
  • 收稿日期:2022-02-09 出版日期:2022-08-31
  • 通信作者: 倪红英
  • 基金资助:
    金华市科学技术局新型冠状病毒感染肺炎疫情应急防治科研攻关项目(2020XG-03)

Effect of prone position ventilation on mortality in patients with acute respiratory distress syndrome supported by veno-venous extracorporeal membrane oxygenation: a meta-analysis

Hongjie Tong1, Kun Chen1, Feiyan Pan1, Hongying Ni1,†()   

  1. 1. Department of Intensive Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, China
  • Received:2022-02-09 Published:2022-08-31
  • Corresponding author: Hongying Ni
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童洪杰, 陈琨, 潘飞艳, 倪红英. 俯卧位通气对静脉-静脉体外膜肺氧合支持的急性呼吸窘迫综合征患者病死率影响的Meta分析[J]. 中华危重症医学杂志(电子版), 2022, 15(04): 312-317.

Hongjie Tong, Kun Chen, Feiyan Pan, Hongying Ni. Effect of prone position ventilation on mortality in patients with acute respiratory distress syndrome supported by veno-venous extracorporeal membrane oxygenation: a meta-analysis[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2022, 15(04): 312-317.

目的

系统评价俯卧位通气对静脉-静脉体外膜肺氧合（VV-ECMO）支持的急性呼吸窘迫综合征（ARDS）患者病死率的影响。

方法

计算机检索Medline、荷兰医学文摘Embase、Cochrane临床试验数据库、万方数据库及中国知网数据库从2002年1月至2022年1月关于VV-ECMO支持ARDS期间使用俯卧位通气的随机对照研究或观察性研究。试验组为俯卧位通气患者，对照组为仰卧位通气患者。由2名研究人员独立进行筛选文献、提取文献资料及评估方法学质量后，采用RevMan 5.3软件进行Meta分析。

结果

最终纳入14项研究，共计1 880例患者，其中试验组869例，对照组1 011例。Meta分析显示，与对照组比较，试验组VV-ECMO支持的ARDS患者的28 d病死率[相对危险度（RR）=0.59，95%置信区间（CI）（0.43，0.80），Z = 3.41，P = 0.000 7]及住院病死率[RR = 0.73，95%CI（0.66，0.81），Z = 5.86，P < 0.000 01]均显著降低；但两组患者间其他病死率（30 d、60 d、90 d、ICU、6个月病死率）的比较，差异无统计学意义[RR = 0.80，95%CI（0.61，1.05），Z = 1.60，P = 0.11]。

结论

俯卧位通气能够降低VV-ECMO支持的ARDS患者28 d病死率以及住院病死率。

关键词: 呼吸窘迫综合征, 俯卧位通气, 体外膜肺氧合作用, 病死率, Meta分析
Objective

To systematically evaluate the effect of prone position ventilation on mortality in patients with acute respiratory distress syndrome (ARDS) supported by veno-venous extracorporeal membrane oxygenation (VV-ECMO).

Methods

Randomized controlled studies or observational studies concerning prone position ventilation for ARDS patients supported by VV-ECMO published from January 2002 to January 2022 in Medline, Embase, Cochrane Library, Wangfang and CNKI databases were searched comprehensively and systematically. Two reviewers independently screened articles, extracted data and evaluated methodological quality. Then meta-analysis was performed using the RevMan 5.3.

Results

A total of 14 articles with 1 880 patients were enrolled in this study, 869 patients in the experimental group (prone position ventilation) and 1 011 patients in the control group (supine position ventilation). Meta-analysis showed that the 28-day mortality [relative risk (RR) = 0.59, 95% confidence interval (CI) (0.43, 0.80), Z = 3.41, P = 0.000 7] and in-hospital mortality [RR = 0.73, 95%CI (0.66, 0.81), Z = 5.86,P < 0.000 01] in the experimental group were much lower than those in the control group. However, the other mortality (30-day, 60-day, 90-day, ICU and 6-month mortality) was not significantly different between the two groups [RR = 0.80, 95%CI (0.61, 1.05), Z = 1.60, P = 0.11].

Conclusion

Prone position ventilation can reduce the 28-day mortality and in-hospital mortality in ARDS patients supported by VV-ECMO.

Key words: Respiratory distress syndrome, Prone position ventilation, Extracorporeal membrane oxygenation, Mortality, Meta-analysis
表1 纳入文献的临床资料与Grade分级情况
文献 研究对象 样本量（试验组/对照组） 年龄[岁，±s或M（P25，P75）] 结局指标 Grade分级
Guervilly等[5] ARDS患者 91/77 49 ± 15 ①②③④⑤ 高
Rilinger等[7] ARDS患者 38/120 51.5（38.5，64.0） ①②③⑥ 中
Garcia等[8] ARDS患者 14/11 59（48，63） ①⑥ 低
Kimmoun等[9] ARDS患者 17/27 45（36，55） ② 低
Giani等[10] ARDS患者 107/133 48 ± 13 ② 高
Chaplin等[11] ARDS患者 13/59 45（33.5，48.0） ⑦ 低
Combes等[12] ARDS患者 17/107 - ①② 高
Jozwiak等[13] ARDS患者 6/5 - ①② 极低
Le Breton等[14] ARDS患者 7/6 47 ± 6 ①② 极低
Lebreton等[15] ARDS患者 193/109 - ①② 高
Petit等[16] ARDS患者 64/234 53（45，61） ①② 高
Schmidt等[17] ARDS患者 67/16 - ①② 中
Yang等[18] ARDS患者 51/22 - ② 中
COVID-ICU[19] ARDS患者 184/85 - ①② 高
图1 两种通气方法对VV-ECMO支持的ARDS患者28 d病死率影响的森林图注：VV-ECMO.静脉-静脉体外膜肺氧合；ARDS.急性呼吸窘迫综合征；试验组为俯卧位通气患者，对照组为仰卧位通气患者；RR.相对危险度；CI.置信区间
图2 两种通气方法对VV-ECMO支持的ARDS患者住院病死率影响的森林图注：VV-ECMO.静脉-静脉体外膜肺氧合；ARDS.急性呼吸窘迫综合征；试验组为俯卧位通气患者，对照组为仰卧位通气患者；RR.相对危险度；CI.置信区间
图3 两种通气方法对VV-ECMO支持的ARDS患者其它病死率影响的森林图注：VV-ECMO.静脉-静脉体外膜肺氧合；ARDS.急性呼吸窘迫综合征；试验组为俯卧位通气患者，对照组为仰卧位通气患者；RR.相对危险度；CI.置信区间
1
杨茂宪，姚明，徐龙生，等.姜黄素对急性呼吸窘迫综合征大鼠肺组织及气道重塑的影响[J/CD].中华危重症医学杂志（电子版），2021，14（5）：368-373.
2
Combes A, Peek GJ, Hajage D, et al. ECMO for severe ARDS: systematic review and individual patient data meta-analysis[J]. Intensive Care Med, 2020, 46 (11): 2048-57.
3
岳伟岗，向飞，张莹，等.急性呼吸窘迫综合征患者早期应用气道压力释放通气的疗效[J/CD].中华危重症医学杂志（电子版），2020，13（2）：93-99.
4
Scholten EL, Beitler JR, Prisk GK, et al. Treatment of ARDS with prone positioning[J]. Chest, 2017, 151 (1): 215-224.
5
Guervilly C, Prud'homme E, Pauly V, et al. Prone positioning and extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: time for a randomized trial?[J]. Intensive Care Med, 2019, 45 (7): 1040-1042.
6
Shekar K, Ramanathan K, Brodie D. Prone positioning of patients during venovenous extracorporeal membrane oxygenation[J]. Ann Am Thorac Soc, 2021, 18 (3): 421-423.
7
Rilinger J, Zotzmann V, Bemtgen X, et al. Prone positioning in severe ARDS requiring extracorporeal membrane oxygenation[J]. Crit Care, 2020, 24 (1): 397.
8
Garcia B, Cousin N, Bourel C, et al. Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome[J]. Crit Care, 2020, 24 (1): 428.
9
Kimmoun A, Roche S, Bridey C, et al. Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and respiratory compliance[J]. Ann Intensive Care, 2015, 5 (1): 35.
10
Giani M, Martucci G, Madotto F, et al. Prone positioning during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome. A multicenter cohort study and propensity-matched analysis[J]. Ann Am Thorac Soc, 2021, 18 (3): 495-501.
11
Chaplin H, McGuinness S, Parke R. A single-centre study of safety and efficacy of prone positioning for critically ill patients on veno-venous extracorporeal membrane oxygenation[J]. Aust Crit Care, 2021, 34 (5): 446-451.
12
Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome[J]. N Engl J Med, 2018, 378 (21): 1965-1975.
13
Jozwiak M, Chiche JD, Charpentier J, et al. Use of venovenous extracorporeal membrane oxygenation in critically-ill patients with COVID-19[J]. Front Med (Lausanne), 2020 (7): 614569.
14
Le Breton C, Besset S, Freita-Ramos S, et al. Extracorporeal membrane oxygenation for refractory COVID-19 acute respiratory distress syndrome[J]. J Crit Care, 2020 (60): 10-12.
15
Lebreton G, Schmidt M, Ponnaiah M, et al. Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study[J]. Lancet Respir Med, 2021, 9 (8): 851-862.
16
Petit M, Fetita C, Gaudemer A, et al. Prone-positioning for severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation[J]. Crit Care Med, 2022, 50 (2): 264-274.
17
Schmidt M, Hajage D, Lebreton G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study[J]. Lancet Respir Med, 2020, 8 (11): 1121-1131.
18
Yang X, Hu M, Yu Y, et al. Extracorporeal membrane oxygenation for SARS-CoV-2 acute respiratory distress syndrome: a retrospective study from Hubei, China[J]. Front Med (Lausanne), 2021 (7): 611460.
19
COVID-ICU Group on behalf of the REVA Network and the COVID-ICU Investigators. Clinical characteristics and day-90 outcomes of 4 244 critically ill adults with COVID-19: a prospective cohort study[J]. Intensive Care Med, 2021, 47 (1): 60-73.
20
Gattinoni L, Busana M, Giosa L, et al. Prone positioning in acute respiratory distress syndrome[J]. Semin Respir Crit Care Med, 2019, 40 (1): 94-100.
21
Ding L, Wang L, Ma W, et al. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study[J]. Crit Care, 2020, 24 (1): 28.
22
Hadaya J, Benharash P. Prone positioning for acute respiratory distress syndrome (ARDS)[J]. JAMA, 2020, 324 (13): 1361.
23
Liu X, Liu H, Lan Q, et al. Early prone positioning therapy for patients with mild COVID-19 disease[J]. Med Clin (Barc), 2021, 156 (8): 386-389.
24
Guérin C, Albert RK, Beitler J, et al. Prone position in ARDS patients: why, when, how and for whom[J]. Intensive Care Med, 2020, 46 (12): 2385-2396.
25
Kim WY, Kang BJ, Chung CR, et al. Prone positioning before extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: a retrospective multicenter study[J]. Med Intensiva (Engl Ed), 2019, 43 (7): 402-409.
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