英国伦敦大学学院医院Peter M Odor课题组宣布他们的最新研究对围手术期干预措施预防术后肺部并发症进行了荟萃分析。这一研究成果于2020年3月11日发表在《英国医学杂志》上。

为了鉴定、评估和综合非心脏手术成年患者接受围手术期干预来降低术后肺部并发症（PPC）的最佳证据，研究组对1990年1月至2017年12月Medline数据库中非心脏手术围手术期进行医学干预的随机对照试验进行系统评价和荟萃分析。

荟萃分析共纳入95项随机对照试验，招募了18062名参与者，涉及11种医学干预措施。未发现干预措施可降低PPC发生率的高质量证据。7项干预措施有中低度的质量证据表明有可能降低PPC发生率，分别为增强恢复途径（风险比为0.35）、预防性粘液溶解剂（0.40）、术后持续气道正压通气（0.49）、术中肺保护通气（0.52）、预防性呼吸物理疗法（0.55）、硬膜外镇痛（0.77）和针对性的血液动力疗法（0.87）。

中等质量的证据表明，激励性肺活量测定法不能预防PPC。试验顺序分析校正支持预防性呼吸物理治疗、硬膜外镇痛、增强恢复途径和针对性的血流动力学疗法可将PPC的相对风险降低25％。但没有足够的数据来支持或反对其他干预措施的等效相对风险降低。

总之，支持多种围手术期方案降低PPC的证据质量偏低。

附：英文原文

Title: Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Author: Peter M Odor, Sohail Bampoe, David Gilhooly, Benedict Creagh-Brown, S Ramani Moonesinghe

Issue&Volume: 2020/03/11

Abstract: AbstractObjective To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery.Design Systematic review and meta-analysis of randomised controlled trials.Data sources Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017.Eligibility criteria Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded.Data extraction and synthesis Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared.Results 117 trials enrolled 21940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions.Conclusions Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions.

DOI: 10.1136/bmj.m540

Source: https://www.bmj.com/content/368/bmj.m540