呼气末闭塞试验预测容量反应性价值的系统回顾及Meta分析:基于国际数据库的结果
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摘要
目的通过系统回顾以及Meta分析评价呼气末闭塞试验(EEOT)判定容量反应性的临床价值。方法通过计算机检索PubMed、Embase、Cochrane Library数据库,收集自建库至2017年10月所有应用EEOT评价容量反应性的临床研究,由2位研究员独立进行文献筛选、资料提取及方法学质量评价。采用双变量混合效应模型对其敏感度、特异度、阳性似然比、阴性似然比及诊断比值比进行合并分析,同时绘制受试者工作特征曲线图,并计算曲线下面积(AUC);绘制Fagan图,评价其临床应用价值。此外,进一步筛选同时采用EEOT与脉压变异性(PPV)分别判断容量反应性的研究,计算相对诊断比值比,评价两种方法对容量反应性的预测价值。结果共纳入7篇文献,共计270次容量评估,均以液体负荷试验作为评价容量反应性的金标准。EEOT判断容量反应性的合并敏感度和特异度分别为0.93(95%CI:0.86～0.96)、0.90(95%CI:0.81～0.95),ROC的AUC为0.97(95%CI:0.95～0.98)。7篇文献中共4篇同时比较EEOT、PPV的容量预测价值,EEOT与PPV的相对诊断比值比为3.13(P=0.24)。结论 EEOT预测容量反应性有较高的敏感度以及特异度,其预测价值可能不低于PPV,但仍需要前瞻性的大样本研究进一步证实。
Objective To determine the predictive value of the end-expiratory occlusion test(EEOT) in ?uid responsiveness evaluation by performing a systematic review and meta-analysis of studies.Methods Databases including PubMed, Embase and Cochrane Database were searched for relevant clinical trials before October 2017. Two independent investigators extracted data and study characteristics. Bivariate mixed-effects regression model was used to estimate the pooled sensitivity, speci?city, positive and negative likelihood ratio and diagnostic odds ratio with 95% CIs. The SROC curve and Fagan graphs were produced,and the area under the curve was also calculated. Meanwhile, we calculated relative diagnostic odds ratio(RDOR) to compare diagnostic value of EEOT and PPV. Results Seven studies(260 adult patients, 270 ?uid challenges) were included. Fluid challenge test was used as standard reference in all studies. For the EEOTinduced changes in CO or its surrogate, the pooled sensitivity was 0.93(95%CI: 0.86-0.96) and the pooled speci?city was 0.90(95%CI: 0.81-0.95). The area under the ROC curve was 0.97(95%CI: 0.95-0.98). Four studies which compared EEOT and PPV at the same time, the RDOR was 3.13(P=0.24). Conclusion EEOTinduced changes in CO or its surrogate can very reliably predict the response of CO to volume expansion in adult patients. There is no signi?cant difference between the diagnostic value of EEOT and PPV.
Objective To determine the predictive value of the end-expiratory occlusion test(EEOT) in ?uid responsiveness evaluation by performing a systematic review and meta-analysis of studies.Methods Databases including PubMed, Embase and Cochrane Database were searched for relevant clinical trials before October 2017. Two independent investigators extracted data and study characteristics. Bivariate mixed-effects regression model was used to estimate the pooled sensitivity, speci?city, positive and negative likelihood ratio and diagnostic odds ratio with 95% CIs. The SROC curve and Fagan graphs were produced,and the area under the curve was also calculated. Meanwhile, we calculated relative diagnostic odds ratio(RDOR) to compare diagnostic value of EEOT and PPV. Results Seven studies(260 adult patients, 270 ?uid challenges) were included. Fluid challenge test was used as standard reference in all studies. For the EEOTinduced changes in CO or its surrogate, the pooled sensitivity was 0.93(95%CI: 0.86-0.96) and the pooled speci?city was 0.90(95%CI: 0.81-0.95). The area under the ROC curve was 0.97(95%CI: 0.95-0.98). Four studies which compared EEOT and PPV at the same time, the RDOR was 3.13(P=0.24). Conclusion EEOTinduced changes in CO or its surrogate can very reliably predict the response of CO to volume expansion in adult patients. There is no signi?cant difference between the diagnostic value of EEOT and PPV.
引文
1 Michard F,Teboul JL.Predicting fluid responsiveness in ICU patients:a critical analysis of the evidence[J].Chest,2002,121(6):2000-2008.
2 Monnet X,Marik PE,Teboul JL.Prediction of fluid responsiveness:an update[J].Ann Intensive Care,2016,6(1):111.
3 Marik PE,Cavallazzi R,Vasu T,et al.Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients:a systematic review of the literature[J].Crit Care Med,2009,37(9):2642-2647.
4 Monnet X,Osman D,Ridel C,et al.Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients[J].Crit Care Med,2009,37(3):951-956.
5吴景玲,葛龙,张俊华,等.多个诊断性试验准确性的比较:网状Meta分析方法介绍[J].中国循证医学杂志,2017,17(8):987-992.
6 Biais M,Larghi M,Henriot J,et al.End-expiratory occlusion test predicts fluid responsiveness in patients with protective ventilation in the operating room[J].Anesth Analg,2017,125(6):1889-1895.
7 Guinot PG,Godart J,de Broca B,et al.End-expiratory occlusion manoeuvre does not accurately predict fluid responsiveness in the operating theatre[J].Br J Anaesth,2014,112(6):1050-1054.
8 Jozwiak M,Depret F,Teboul JL,et al.Predicting fluid responsiveness in critically ill patients by using combined end-expiratory and endinspiratory occlusions with echocardiography[J].Crit Care Med,2017,45(11):e1131-e1138.
9 Monnet X,Bleibtreu A,Ferre A,et al.Passive leg-raising and endexpiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance[J].Crit Care Med,2012,40(1):152-157.
10 Monnet X,Dres M,Ferre A,et al.Prediction of fluid responsiveness by a continuous non-invasive assessment of arterial pressure in critically ill patients:comparison with four other dynamic indices[J].Br J Anaesth,2012,109(3):330-338.
11 Myatra SN,Prabu NR,Divatia JV,et al.The changes in pulse pressure variation or stroke volume variation after a″tidal volume challenge″reliably predict fluid responsiveness during low tidal volume ventilation[J].Crit Care Med,2017,45(3):415-421.
12 Boyd JH,Forbes J,Nakada TA,et al.Fluid resuscitation in septic shock:a positive fluid balance and elevated central venous pressure are associated with increased mortality[J].Crit Care Med,2011,39(2):259-265.
13 Acheampong A,Vincent JL.A positive fluid balance is an independent prognostic factor in patients with sepsis[J].Crit Care,2015,19:251.
14 Muller L,Louart G,Bousquet PJ,et al.The influence of the airway driving pressure on pulsed pressure variation as a predictor of fluid responsiveness[J].Intensive Care Med,2010,36(3):496-503.
15 De Backer D,Heenen S,Piagnerelli M,et al.Pulse pressure variations to predict fluid responsiveness:influence of tidal volume[J].Intensive Care Med,2005,31(4):517-523.
16 Heenen S,De Backer D,Vincent JL.How can the response to volume expansion in patients with spontaneous respiratory movements be predicted?[J].Crit Care,2006,10(4):R102.
17 Monnet X,Rienzo M,Osman D,et al.Passive leg raising predicts fluid responsiveness in the critically ill[J].Crit Care Med,2006,34(5):1402-1407.
18 Cavallaro F,Sandroni C,Marano C,et al.Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults:systematic review and meta-analysis of clinical studies[J].Intensive Care Med,2010,36(9):1475-1483.
2 Monnet X,Marik PE,Teboul JL.Prediction of fluid responsiveness:an update[J].Ann Intensive Care,2016,6(1):111.
3 Marik PE,Cavallazzi R,Vasu T,et al.Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients:a systematic review of the literature[J].Crit Care Med,2009,37(9):2642-2647.
4 Monnet X,Osman D,Ridel C,et al.Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients[J].Crit Care Med,2009,37(3):951-956.
5吴景玲,葛龙,张俊华,等.多个诊断性试验准确性的比较:网状Meta分析方法介绍[J].中国循证医学杂志,2017,17(8):987-992.
6 Biais M,Larghi M,Henriot J,et al.End-expiratory occlusion test predicts fluid responsiveness in patients with protective ventilation in the operating room[J].Anesth Analg,2017,125(6):1889-1895.
7 Guinot PG,Godart J,de Broca B,et al.End-expiratory occlusion manoeuvre does not accurately predict fluid responsiveness in the operating theatre[J].Br J Anaesth,2014,112(6):1050-1054.
8 Jozwiak M,Depret F,Teboul JL,et al.Predicting fluid responsiveness in critically ill patients by using combined end-expiratory and endinspiratory occlusions with echocardiography[J].Crit Care Med,2017,45(11):e1131-e1138.
9 Monnet X,Bleibtreu A,Ferre A,et al.Passive leg-raising and endexpiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance[J].Crit Care Med,2012,40(1):152-157.
10 Monnet X,Dres M,Ferre A,et al.Prediction of fluid responsiveness by a continuous non-invasive assessment of arterial pressure in critically ill patients:comparison with four other dynamic indices[J].Br J Anaesth,2012,109(3):330-338.
11 Myatra SN,Prabu NR,Divatia JV,et al.The changes in pulse pressure variation or stroke volume variation after a″tidal volume challenge″reliably predict fluid responsiveness during low tidal volume ventilation[J].Crit Care Med,2017,45(3):415-421.
12 Boyd JH,Forbes J,Nakada TA,et al.Fluid resuscitation in septic shock:a positive fluid balance and elevated central venous pressure are associated with increased mortality[J].Crit Care Med,2011,39(2):259-265.
13 Acheampong A,Vincent JL.A positive fluid balance is an independent prognostic factor in patients with sepsis[J].Crit Care,2015,19:251.
14 Muller L,Louart G,Bousquet PJ,et al.The influence of the airway driving pressure on pulsed pressure variation as a predictor of fluid responsiveness[J].Intensive Care Med,2010,36(3):496-503.
15 De Backer D,Heenen S,Piagnerelli M,et al.Pulse pressure variations to predict fluid responsiveness:influence of tidal volume[J].Intensive Care Med,2005,31(4):517-523.
16 Heenen S,De Backer D,Vincent JL.How can the response to volume expansion in patients with spontaneous respiratory movements be predicted?[J].Crit Care,2006,10(4):R102.
17 Monnet X,Rienzo M,Osman D,et al.Passive leg raising predicts fluid responsiveness in the critically ill[J].Crit Care Med,2006,34(5):1402-1407.
18 Cavallaro F,Sandroni C,Marano C,et al.Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults:systematic review and meta-analysis of clinical studies[J].Intensive Care Med,2010,36(9):1475-1483.