哮喘急性加重期的无创通气治疗：系统回顾
2025/01/26
摘要
背景：由于证据不足，多份临床实践指南都缺乏与哮喘急性加重期无创通气 (NIV) 相关的建议。然而，这些指南的证据综述都是在多年前进行的，而且最近发表了更多的随机对照试验（RCT）和观察性研究。更新以前指南中的证据综述，进一步明确 NIV 对哮喘急性加重的影响。
方法：对 Medline、Embase 和 Cochrane 图书馆进行系统检索，采用先验选择标准筛选出在成人哮喘急性加重患者中比较 NIV联合标准药物治疗与单纯标准药物治疗的研究，并提取相关数据。对研究效果进行加权汇总（荟萃分析），并采用 GRADE（建议、评估、发展和评价分级）方法对研究效果进行评估。
结果：共筛选出 8 项 RCT 研究和 5 项观察性研究。NIV 可降低插管率（RCTs RR 0.46，CI 0.16-1.29 和观察性研究 RR 0.55，CI 0.45-0.68）、入院率（RR 0.57，CI 0.34-0.98）和辅助肌使用改善时间（平均差-1.13 小时，CI -1.28 -0.99）。其他结果（包括呼吸困难测量和肺活量测量）均优于 NIV联合标准药物疗法，但未达到统计学意义。死亡人数太少，无法对死亡率进行可靠评估。所有结果的证据质量从低到极低不等。
结论：在哮喘急性加重的成人患者中，所有具有统计学意义的结果均显示 NIV联合标准药物治疗优于单纯的标准药物治疗。我们的综合数据表明，使用 NIV 加 SMT 可降低插管率，但证据的总体质量较低。如果这是一个真实的效果，那么它可能具有重要的临床意义，因为在多项观察性试验中，插管已被证明与死亡率相关。鉴于这些研究结果，哮喘急性加重期患者除了接受标准的药物治疗外，还可从 NIV 试验中获益。
Non-Invasive Ventilation in Acute Asthma Exacerbations: A Systematic Review
Homer-Bouthiette, C., & Wilson, K. C
Abstract
Background:Multiple clinical practice guidelines lack recommendations pertaining to non-invasive ventilation (NIV) in acute asthma exacerbations due to a paucity of evidence. However, the evidence syntheses for these guidelines were performed years ago and more recent randomized controlled trials (RCTs) and observational studies have been published. Update the evidence syntheses from previous guidelines to further clarify the effects of NIV in acute asthma exacerbations.
METHODS:A systematic search of Medline, Embase and the Cochrane Library was conducted, studies comparing NIV plus standard medical therapy to standard medical therapy alone in adults with acute asthma exacerbation were selected using a priori selection criteria, and relevant data were extracted. Weighted aggregation (meta-analysis) was performed to summarize effects, which were appraised using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.
Results:Eight RCTs and five observational studies were selected. NIV was associated with a reduced intubation rate (RCTs RR 0.46, CI 0.16-1.29 and observational studies RR 0.55, CI 0.45-0.68), admission rate (RR 0.57, CI 0.34-0.98), and time to improvement in accessory muscle use (Mean difference -1.13 hours, CI -1.28 - -0.99). Additional outcomes favored NIV plus standard medical therapy but didn't reach statistical significance including dyspnea measures and spirometry measures. There were too few deaths to reliably assess mortality. The quality of evidence ranged from low to very low for all outcomes.
Conclusion:All statistically significant outcomes favored NIV plus standard medical therapy over standard medical therapy alone in adults with acute asthma exacerbation. Our aggregate data suggests that intubation rate may be reduced with NIV plus SMT, though the overall quality of the evidence is low. If this is a true effect, it may be clinically important because intubation has been shown to correlate with mortality in multiple observational trials. Given these findings, patients with acute asthma exacerbations may benefit from a trial of NIV in addition to standard medical therapy.
背景：由于证据不足，多份临床实践指南都缺乏与哮喘急性加重期无创通气 (NIV) 相关的建议。然而，这些指南的证据综述都是在多年前进行的，而且最近发表了更多的随机对照试验（RCT）和观察性研究。更新以前指南中的证据综述，进一步明确 NIV 对哮喘急性加重的影响。
方法：对 Medline、Embase 和 Cochrane 图书馆进行系统检索，采用先验选择标准筛选出在成人哮喘急性加重患者中比较 NIV联合标准药物治疗与单纯标准药物治疗的研究，并提取相关数据。对研究效果进行加权汇总（荟萃分析），并采用 GRADE（建议、评估、发展和评价分级）方法对研究效果进行评估。
结果：共筛选出 8 项 RCT 研究和 5 项观察性研究。NIV 可降低插管率（RCTs RR 0.46，CI 0.16-1.29 和观察性研究 RR 0.55，CI 0.45-0.68）、入院率（RR 0.57，CI 0.34-0.98）和辅助肌使用改善时间（平均差-1.13 小时，CI -1.28 -0.99）。其他结果（包括呼吸困难测量和肺活量测量）均优于 NIV联合标准药物疗法，但未达到统计学意义。死亡人数太少，无法对死亡率进行可靠评估。所有结果的证据质量从低到极低不等。
结论：在哮喘急性加重的成人患者中，所有具有统计学意义的结果均显示 NIV联合标准药物治疗优于单纯的标准药物治疗。我们的综合数据表明，使用 NIV 加 SMT 可降低插管率，但证据的总体质量较低。如果这是一个真实的效果，那么它可能具有重要的临床意义，因为在多项观察性试验中，插管已被证明与死亡率相关。鉴于这些研究结果，哮喘急性加重期患者除了接受标准的药物治疗外，还可从 NIV 试验中获益。
(中日友好医院呼吸与危重症医学科 沈焜路 摘译 林江涛 审校)
(Ann Am Thorac Soc. 2024 Dec 6; DOI: 10.1513/AnnalsATS.202407-799OC)
(Ann Am Thorac Soc. 2024 Dec 6; DOI: 10.1513/AnnalsATS.202407-799OC)
Non-Invasive Ventilation in Acute Asthma Exacerbations: A Systematic Review
Homer-Bouthiette, C., & Wilson, K. C
Abstract
Background:Multiple clinical practice guidelines lack recommendations pertaining to non-invasive ventilation (NIV) in acute asthma exacerbations due to a paucity of evidence. However, the evidence syntheses for these guidelines were performed years ago and more recent randomized controlled trials (RCTs) and observational studies have been published. Update the evidence syntheses from previous guidelines to further clarify the effects of NIV in acute asthma exacerbations.
METHODS:A systematic search of Medline, Embase and the Cochrane Library was conducted, studies comparing NIV plus standard medical therapy to standard medical therapy alone in adults with acute asthma exacerbation were selected using a priori selection criteria, and relevant data were extracted. Weighted aggregation (meta-analysis) was performed to summarize effects, which were appraised using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.
Results:Eight RCTs and five observational studies were selected. NIV was associated with a reduced intubation rate (RCTs RR 0.46, CI 0.16-1.29 and observational studies RR 0.55, CI 0.45-0.68), admission rate (RR 0.57, CI 0.34-0.98), and time to improvement in accessory muscle use (Mean difference -1.13 hours, CI -1.28 - -0.99). Additional outcomes favored NIV plus standard medical therapy but didn't reach statistical significance including dyspnea measures and spirometry measures. There were too few deaths to reliably assess mortality. The quality of evidence ranged from low to very low for all outcomes.
Conclusion:All statistically significant outcomes favored NIV plus standard medical therapy over standard medical therapy alone in adults with acute asthma exacerbation. Our aggregate data suggests that intubation rate may be reduced with NIV plus SMT, though the overall quality of the evidence is low. If this is a true effect, it may be clinically important because intubation has been shown to correlate with mortality in multiple observational trials. Given these findings, patients with acute asthma exacerbations may benefit from a trial of NIV in addition to standard medical therapy.
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