柳叶刀的META分析：接受呼吸机治疗的重症患者，早切与晚切利弊分析

蓝鱼o_0

关于接受呼吸机支持治疗的重症患者，早切与晚切的争论一直存在。在2015年，柳叶刀子刊发表一篇META分析，系统评价了这个论点。

Lancet Respir Med. 2015 Feb;3(2):150-8. doi: 10.1016/S2213-2600(15)00007-7.

Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis.

[size=0.92em]Siempos II1, Ntaidou TK2, Filippidis FT3, Choi AM4.

Author information

AbstractBACKGROUND:

Delay of tracheostomy for roughly 2 weeks after translaryngeal intubation of critically ill patients is the presently recommended practice and is supported by findings from large trials. However, these trials were suboptimally powered to detect small but clinically important effects on mortality. We aimed to assess the benefit of early versus late or no tracheostomy on mortality and pneumonia in critically ill patients who need mechanical ventilation.

METHODS:

We systematically searched PubMed, CINAHL, Embase, Web of Science, DOAJ, the Cochrane Library, references of relevant articles, scientific conference proceedings, and grey literature up to Aug 31, 2013, to identify randomised controlled trials comparing early tracheostomy (done within 1 week after translaryngeal intubation) with late (done any time after the first week of mechanical ventilation) or no tracheostomy and reporting on mortality or incidence of pneumonia in critically ill patients under mechanical ventilation. Our primary outcomes were all-cause mortality during the stay in the intensive-care unit and incidence of ventilator-associated pneumonia. Mortality during the stay in the intensive-care unit was a composite endpoint of definite intensive-care-unit mortality, presumed intensive-care-unit mortality, and 28-day mortality. We calculated pooled odds ratios (OR), pooled risk ratios (RR), and 95% CIs with a random-effects model. All but complications analyses were done on an intention-to-treat basis.

FINDINGS:

Analyses of 13 trials (2434 patients, 648 deaths) showed that all-cause mortality in the intensive-care unit was not significantly lower in patients assigned to the early versus the late or no tracheostomy group (OR 0·80, 95% CI 0·59-1·09; p=0·16). This result persisted when we considered only trials with a low risk of bias (511 deaths; OR 0·80, 95% CI 0·59-1·09; p=0·16; eight trials with 1934 patients). Incidence of ventilator-associated pneumonia was lower in mechanically ventilated patients assigned to the early versus the late or no tracheostomy group (691 cases; OR 0·60, 95% CI 0·41-0·90; p=0·01; 13 trials with 1599 patients). There was no evidence of a difference between the compared groups for 1-year mortality (788 deaths; RR 0·93, 95% CI 0·85-1·02; p=0·14; three trials with 1529 patients).

INTERPRETATION:

The synthesised evidence suggests that early tracheostomy is not associated with lower mortality in the intensive-care unit than late or no tracheostomy. However, early, compared with late or no, tracheostomy might be associated with a lower incidence of pneumonia; a finding that could question the present practice of delaying tracheostomy beyond the first week after translaryngeal intubation in mechanically ventilated patients. Nevertheless, the scarcity of a beneficial effect on long-term mortality and the potential complications associated with tracheostomy need careful consideration; thus, further studies focusing on long-term outcomes are warranted.

吴晓梅

语水平太差，看不懂啊！

蓝鱼o_0

文章说了，早切与晚切不影响重症患者死亡率。但是早切可以降低肺炎发病的风险。这是对指南的一个很好的补充。但是不能忽略的伦理问题，尤其是在我国医患关系比较敏感的情况下，需要很好的规避这类风险。

反过来，我也思考：既然有伦理的风险，那么会不会导致这篇META分析存在偏倚。即所有的试验本身设计就存在一定的选择偏倚。导致最后：GARBAGE IN , GARBAGE OUT

小浅的心

章说了，早切与晚切不影响重症患者死亡率。但是早切可以降低肺炎发病的风险。这是对指南的一个很好的补充 ...[/quote]
老师思维敏锐，个人也感觉样本就可能存在偏倚

杰子

有的降低风险的方法，都应该一分为二的看问题，利大于弊就是一种好的方法。