【Cochrane简语概要】高流量鼻插管对成年重症监护患者的呼吸支持

背景 

进入重症监护室（ intensive care unit, ICU）的一个常见原因是，需要呼吸（或呼吸系统）支持。高流量鼻插管（High-flow nasal cannulae, HFNC）是插入鼻孔的小塑料管，给需要呼吸支持的病人高流量速率地输送加热的空气和氧气混合物。它们在ICU被频繁使用，尽管没有明显证据显示它们是否给患者带来长期好处，例如减少ICU停留时间或增加生存可能。

（图片来源于网络）

研究特征 

证据检索截止到2016年3月。本综述纳入了11项研究，共1972名受试者。大多患者有呼吸衰竭，或刚刚停止使用自动呼吸机。纳入的研究比较了，HFNC和通过面具、低流量插管或轻度压力仪器进行低流量给氧。我们在2016年12月重新进行了检索，并且，当我们更新综述时，会讨论所有相关的有意义的研究。

主要结局 

我们没有找到证据证明，相比于低流量氧气设备，HFNC降低了治疗失败率或死亡风险。我们没有找到证据证明HFNC可以带来任何好处，关于不良事件发生率、ICU停留时长或呼吸系统支持时长。我们未观测到受试者血氧水平或血液中二氧化碳水平的任何差别，并且，我们注意到呼吸速率的任何差别都很小而无临床意义。研究未报告任何舒适度测量的患者评分差异。只有一项研究证明，HFNC的使用能减少口干。

证据质量 

大多研究未充分报告方法，我们不知道偏倚风险是否影响研究结局。我们确认了一些符合的研究，并注意到我们纳入的研究中，受试者之间存在一些差异，尤其是关于需要呼吸系统支持的原因。我们使用GRADE方法评估每一结局的证据，我们判定所有证据为低质量或非常低质量。

结论 

我们无法从高质量研究中收集足够的证据来确定HFNC是否为ICU中的成年人提供了安全有效的呼吸系统支持。

结论: 

我们无法证明，相比于其他氧气设备，HFNC是否是ICU成年患者更高效或安全的输氧设备。Meta分析可以用于一些研究的每一结局，与 CPAP或BiPAP的比较资料非常有限。另外，我们发现纳入研究存在偏倚风险，患者组间差异，和一些结局的高级别统计学异质性，导致我们的分析结果存在不确定性。因此，证据不能充分显示，HFNC是否为ICU成年患者提供安全有效的呼吸系统支持。

译者：张子萱，北京中医药大学志愿者；审校：刘雪寒，北京中医药大学循证医学中心；编辑排版：张晓雯，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】High-flow nasal cannulae for breathing support in adult intensive care patients

Background

A common reason for intensive care unit (ICU) admission is the need for breathing (or respiratory) support. HFNC are small plastic tubes that sit inside the nostrils and deliver a heated mix of air and oxygen at high flow rates to patients requiring breathing support. They are used frequently in the ICU, yet no clear evidence shows whether they provide patients with long-term benefits such as reduced ICU stay or improved chances of survival.

Study characteristics

The evidence is current to March 2016. We included in the review 11 studies with 1972 participants. Most participants had respiratory failure, or had just been taken off an artificial breathing machine. Included studies compared HFNC with low-flow oxygen given through face masks, through low-flow cannulae, or through devices that use mild pressure to aid oxygen delivery. We reran the search in December 2016 and will deal with any studies of interest when we update the review.

Key results

We found no evidence that HFNC reduced the rate of treatment failure or risk of death compared with low-flow oxygen devices. We found no evidence of any advantages for HFNC in terms of adverse event rates, ICU length of stay, or duration of respiratory support. We observed no differences in participants' blood oxygen levels or carbon dioxide blood levels, and we noted that any differences in breathing rates were small and were not considered clinically important. Studies reported no differences in patient-rated measures of comfort. Only one study found evidence of less dry mouth when HFNC was used. 

Quality of evidence

Most studies had reported methods inadequately, and we did not know whether risk of bias may have affected study results. We identified few eligible studies and noted some differences among participants within our included studies, particularly in reasons for requiring respiratory support. We used the GRADE system to rate the evidence for each of our outcomes, and we judged all evidence to be of low or very low quality.

Conclusion

We were not able to collect sufficient evidence from good quality studies to determine whether HFNC offer a safe and effective way of delivering respiratory support for adults in the ICU.

Authors' conclusions: 

We were unable to demonstrate whether HFNC was a more effective or safe oxygen delivery device compared with other oxygenation devices in adult ICU patients. Meta-analysis could be performed for few studies for each outcome, and data for comparisons with CPAP or BiPAP were very limited. In addition, we identified some risks of bias among included studies, differences in patient groups, and high levels of statistical heterogeneity for some outcomes, leading to uncertainty regarding the results of our analysis. Consequently, evidence is insufficient to show whether HFNC provides safe and efficacious respiratory support for adult ICU patients.

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