护理预防脑卒中相关性肺炎临床效果的Meta分析
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摘要
[目的]了解集束化护理对脑卒中相关性肺炎的预防及临床疗效,为其探索更科学和适宜的护理决策。[方法]计算机检索建库以来到2017年10月前全文发表于Cochrane Library、PubMed、EMbase、CBM、CNKI、WanFang Data中的有关集束化护理预防脑卒中相关性肺炎的随机对照试验(RCT),筛选出符合纳入标准的文献及其参考文献,另手工检索进行补充,由2名研究者同时对文献质量进行评鉴和提取,并用RevMan 5.3软件对纳入的研究进行Meta分析,随后运用定量系统评价证据分级工具(GRADE)profiler3.6.1软件对其证据质量进行分级。[结果]共纳入14篇RCT共3 668例病人。Meta分析结果显示:使用集束化护理能有效预防脑卒中后相关性肺炎的发生[RR=0.53,95%CI(0.45,0.63),P<0.000 01],减少误吸发生率[RR=0.28,95%CI(0.17,0.46),P<0.000 01],从而改善病人临床结局。进行敏感性分析对原结果无本质改变;其死亡率无统计学意义;住院天数合并存在较大异质性,故放弃Meta分析,漏斗图不对称考虑存在发表性偏倚。GRADE分级系统显示:集束化护理对脑卒中相关性肺炎的预防疗效证据等级为极低级。[结论]对于脑卒中后病人实施集束化护理可在一定程度上预防脑卒中相关性肺炎和误吸的发生,但由于偏倚因素影响和研究质量普遍偏低的问题,证据质量为极低级,对于研究结果还需开展多中心、大样本的高质量RCT证实后方能推广于临床使用。
Objective:To understand the prevention and clinical efficacy of clustering nursing for stroke-associated pneumonia,and to explore more scientific and appropriate nursing decisions.Methods:Literature and its references of randomized controlled trials(RCTs)on cluster nursing in the prevention of stroke-associated pneumonia were retrieved in Cochrane Library,PubMed,EMbase,CBM,China National Knowledge Infrastructure(CNKI),and WanFang Database from the establishment of the database to October2017;with supplement by hand.Two researchers simultaneously evaluated and extracted the quality of the literature,and used the RevMan 5.3 software was used to conduct a meta-analysis of the included studies.The quality of the evidence was then graded using the Grading of Recommendations Assessment,Development,and Evaluation(GRADE)profiler 3.6.1 software.Results:A total of 14 RCTs involving 3 668 patients were included in this study.Meta-analysis results showed that the use of clustering nursing could effectively prevent pneumonia[RR = 0.53,95% CI(0.45,0.63),P<0.000 01],reduce the incidence of aspiration[RR = 0.28,95 %CI(0.17,0.46),P<0.000 01],and thus improve the clinical outcome.The sensitivity analysis did not change the original results;the mortality rate was not statistically significant;the hospitalization stays combination had a large heterogeneity,so give up the meta-analysis;the funnel plot asymmetry considered the existence of publication bias.The GRADE grading system showed that the level of evidence for the prevention of stroke-related pneumonia was extremely low.Conclusions:The implementation of clustering nursing for post-stroke patients could prevent the occurrence of stroke-related pneumonia and aspiration in a certain degree,while the quality of evidence was extremely low due to the influence of bias factors and the low quality of research.The results still required a large multicenter sample of high-quality RCTs to be validated for clinical application.
Objective:To understand the prevention and clinical efficacy of clustering nursing for stroke-associated pneumonia,and to explore more scientific and appropriate nursing decisions.Methods:Literature and its references of randomized controlled trials(RCTs)on cluster nursing in the prevention of stroke-associated pneumonia were retrieved in Cochrane Library,PubMed,EMbase,CBM,China National Knowledge Infrastructure(CNKI),and WanFang Database from the establishment of the database to October2017;with supplement by hand.Two researchers simultaneously evaluated and extracted the quality of the literature,and used the RevMan 5.3 software was used to conduct a meta-analysis of the included studies.The quality of the evidence was then graded using the Grading of Recommendations Assessment,Development,and Evaluation(GRADE)profiler 3.6.1 software.Results:A total of 14 RCTs involving 3 668 patients were included in this study.Meta-analysis results showed that the use of clustering nursing could effectively prevent pneumonia[RR = 0.53,95% CI(0.45,0.63),P<0.000 01],reduce the incidence of aspiration[RR = 0.28,95 %CI(0.17,0.46),P<0.000 01],and thus improve the clinical outcome.The sensitivity analysis did not change the original results;the mortality rate was not statistically significant;the hospitalization stays combination had a large heterogeneity,so give up the meta-analysis;the funnel plot asymmetry considered the existence of publication bias.The GRADE grading system showed that the level of evidence for the prevention of stroke-related pneumonia was extremely low.Conclusions:The implementation of clustering nursing for post-stroke patients could prevent the occurrence of stroke-related pneumonia and aspiration in a certain degree,while the quality of evidence was extremely low due to the influence of bias factors and the low quality of research.The results still required a large multicenter sample of high-quality RCTs to be validated for clinical application.
引文
[1]中国脑梗死急性期康复专家共识组.中国脑梗死急性期康复专家共识[J].实用心脑肺血管病杂志,2016,24(2):1-24.
[2]中华医学会神经病学分会.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志,2015,48(4):246-257.
[3]SMITH C J,KISHORE A K,VAIL A,et al.Diagnosis of strokeassociated pneumonia:recommendations from the pneumonia in stroke consensus group[J].Stroke-Associated Pneumonia Consensus Statement,2015,46(8):2335-2340.
[4]卒中相关性肺炎诊治中国专家共识组.卒中相关性肺炎诊治中国专家共识[J].中华内科杂志,2010,49(12):1075-1078
[5]DIRNAGL U,KLEHMET J,BRAUN JS,et al.Stroke-induced immunodepression:experimental evidence and clinical relevance[J].Stroke,2007,38(2):770-773.
[6]MARTIOO R,FOLEY N,AHOGAL S,et al.Dysphgia after stroke:incidence,diagnosis,and pulmonary complications[J].Stroke,2005,36:2756-2763.
[7]刘瑞雪,刘影.集束化护理方案预防卒中相关性肺炎的效果观察[J].全科护理,2017,15(19):2347-2348.
[8]王洁.集束化护理干预在重症监护室脑卒中患者中的应用效果[J].医学理论与实践,2017,30(9):1373-1374.
[9]吴丽花.集束化护理策略在脑卒中患者吞咽困难中的应用[J].中国康复,2017,32(2):112.
[10]张筱诗,梁红丽,蓝永贞,等.集束化护理在卒中相关性肺炎预防中的应用[J].中国实用医药,2016,11(30):276-278.
[11]王志华.预防重症出血性脑卒中患者反流、误吸的集束化护理及体会[J].大家健康(学术版),2016,10(7):34-35.
[12]欧阳少凤.集束化护理干预在预防脑卒中病人相关性肺炎中的应用效果研究[J].中国冶金工业医学杂志,2016,33(1):122-123.
[13]邓秋霞,高岚,王宇娇,等.集束化护理干预在预防脑卒中病人相关性肺炎中的应用[J].护理研究,2015,29(7A):2416-2418.
[14]韩丽丽,贾锐.集束化护理在预防卒中相关性肺炎患者中的应用[J].大家健康(学术版),2014,8(10):296-297.
[15]苏善英.集束化护理在预防卒中相关性肺炎中的应用[J].护理实践与研究,2011,8(15):31-32.
[16]柳春霞,周建梅.集束干预策略管理在卒中相关性肺炎预防与控制中的应用[J].中国医院药学杂志,2016(10):10.
[17]孙芳,李红军,刘茹,等.集束化护理在干预与控制卒中相关性肺炎中的临床疗效[J].中国保健营养,2016,26(22):140-141.
[18]陆继彩,朱孔平.集束化护理在脑梗塞患者并发肺部感染中的应用效果[J].当代护士,2015(9):20-22.
[19]吴娜.预防卒中相关性肺炎中集束化护理的应用效果探析[J].医学信息,2014,27(4):401-402.
[20]苏芳,沈梅芬.脑卒中病人沉默性误吸的集束化护理[J].护理研究,2014,28(5C):1889-1891.
[21]HAN G S,BYUNG-MO O,TAI R H.Swallowing kinematics and factors associated with laryngeal penetration and aspiration in stroke survivors with dysphagia[J].Dysphagia,2015,21(11):1502-1511.
[22]李胜利.言语治疗学[M].北京:人民卫生出版社,2014:217-229.
[23]CATHERINE M,ANNE R,MAUREEN M,et al.Nasogastric feeding for stroke patients:practice and education[J].Br J Nurs,2015,24(6):319-325.
[24]SILVESTRI L,VAN SAENE H K,WEIR I,et al.Survival benefit of the full selective digestive decontamination regimen[J].JCrit Care,2009,24:474.
[25]DE SMET A M,KHYTMANS J A,COOPER B S,et al.Decontamination of the digestive tract and oropharynx in ICU patients[J].N Engl J Med,2009,360:20-31.
[26]GOSNEY M,MARTIN M V,WRIT A E.Role of selective decontamination of the digestive tract in acute stroke[J].Age Ageing,2006,35:42-47.
[27]邹玉凤.预防脑卒中患者并发坠积性肺炎的观察和护理[J].世界最新医学信息文摘,2016,16(35):212-213.
[2]中华医学会神经病学分会.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志,2015,48(4):246-257.
[3]SMITH C J,KISHORE A K,VAIL A,et al.Diagnosis of strokeassociated pneumonia:recommendations from the pneumonia in stroke consensus group[J].Stroke-Associated Pneumonia Consensus Statement,2015,46(8):2335-2340.
[4]卒中相关性肺炎诊治中国专家共识组.卒中相关性肺炎诊治中国专家共识[J].中华内科杂志,2010,49(12):1075-1078
[5]DIRNAGL U,KLEHMET J,BRAUN JS,et al.Stroke-induced immunodepression:experimental evidence and clinical relevance[J].Stroke,2007,38(2):770-773.
[6]MARTIOO R,FOLEY N,AHOGAL S,et al.Dysphgia after stroke:incidence,diagnosis,and pulmonary complications[J].Stroke,2005,36:2756-2763.
[7]刘瑞雪,刘影.集束化护理方案预防卒中相关性肺炎的效果观察[J].全科护理,2017,15(19):2347-2348.
[8]王洁.集束化护理干预在重症监护室脑卒中患者中的应用效果[J].医学理论与实践,2017,30(9):1373-1374.
[9]吴丽花.集束化护理策略在脑卒中患者吞咽困难中的应用[J].中国康复,2017,32(2):112.
[10]张筱诗,梁红丽,蓝永贞,等.集束化护理在卒中相关性肺炎预防中的应用[J].中国实用医药,2016,11(30):276-278.
[11]王志华.预防重症出血性脑卒中患者反流、误吸的集束化护理及体会[J].大家健康(学术版),2016,10(7):34-35.
[12]欧阳少凤.集束化护理干预在预防脑卒中病人相关性肺炎中的应用效果研究[J].中国冶金工业医学杂志,2016,33(1):122-123.
[13]邓秋霞,高岚,王宇娇,等.集束化护理干预在预防脑卒中病人相关性肺炎中的应用[J].护理研究,2015,29(7A):2416-2418.
[14]韩丽丽,贾锐.集束化护理在预防卒中相关性肺炎患者中的应用[J].大家健康(学术版),2014,8(10):296-297.
[15]苏善英.集束化护理在预防卒中相关性肺炎中的应用[J].护理实践与研究,2011,8(15):31-32.
[16]柳春霞,周建梅.集束干预策略管理在卒中相关性肺炎预防与控制中的应用[J].中国医院药学杂志,2016(10):10.
[17]孙芳,李红军,刘茹,等.集束化护理在干预与控制卒中相关性肺炎中的临床疗效[J].中国保健营养,2016,26(22):140-141.
[18]陆继彩,朱孔平.集束化护理在脑梗塞患者并发肺部感染中的应用效果[J].当代护士,2015(9):20-22.
[19]吴娜.预防卒中相关性肺炎中集束化护理的应用效果探析[J].医学信息,2014,27(4):401-402.
[20]苏芳,沈梅芬.脑卒中病人沉默性误吸的集束化护理[J].护理研究,2014,28(5C):1889-1891.
[21]HAN G S,BYUNG-MO O,TAI R H.Swallowing kinematics and factors associated with laryngeal penetration and aspiration in stroke survivors with dysphagia[J].Dysphagia,2015,21(11):1502-1511.
[22]李胜利.言语治疗学[M].北京:人民卫生出版社,2014:217-229.
[23]CATHERINE M,ANNE R,MAUREEN M,et al.Nasogastric feeding for stroke patients:practice and education[J].Br J Nurs,2015,24(6):319-325.
[24]SILVESTRI L,VAN SAENE H K,WEIR I,et al.Survival benefit of the full selective digestive decontamination regimen[J].JCrit Care,2009,24:474.
[25]DE SMET A M,KHYTMANS J A,COOPER B S,et al.Decontamination of the digestive tract and oropharynx in ICU patients[J].N Engl J Med,2009,360:20-31.
[26]GOSNEY M,MARTIN M V,WRIT A E.Role of selective decontamination of the digestive tract in acute stroke[J].Age Ageing,2006,35:42-47.
[27]邹玉凤.预防脑卒中患者并发坠积性肺炎的观察和护理[J].世界最新医学信息文摘,2016,16(35):212-213.