| 摘要: | 研究目的:
高碳酸性的呼吸衰竭常見於急重症單位，其可能會引發高碳酸血
症後的代謝性鹼中毒，進而抑制中樞的呼吸驅動，延長呼吸器的使用
時間及加護病房的住院天數，造成發病率及死亡率的上升。研究顯示
Acetazolamide 對於此類患者可以減少機械式呼吸器的使用時間，但對
於孩童及使用非侵入式呼吸器的成人患者尚未有定論。因此針對相關
研究採取統合分析的方法，探討Acetazolamide 用於呼吸衰竭引發的
高碳酸血症併代謝性鹼中毒之患者的效果及安全性。
研究方法:
搜尋Cochrane library 、Embase、PubMed、Web of science 及
Clinicaltrial.gov 等資料庫直至2021 年3 月，並將納入文獻的結果，以
隨機效應模式進行統合分析。主要測量結果為使用機械式呼吸器或非
侵入式呼吸器的時間、住院天數及住加護病房天數，次級測量結果為
動脈血液氣體參數、致死率及不良事件。
研究結果:
總共納入12篇研究，包含4篇隨機對照試驗、1篇類實驗設計研
究 、3篇病例系列研究及4篇病例對照研究，結果顯示呼吸衰竭引發
的高碳酸血症併代謝性鹼中毒之成人患者，Acetazolamide能減少使用
機械式呼吸器的時間 (MD，-1.22天; 95% CI: -2.129, -0.31)及非侵入式
呼吸器的時間 (MD，-13天; 95% CI: -25.813, -0.817)，並改善動脈血
液氣體參數: PaCO2 (MD，-4.215 mmHg; 95% CI: -6.738, -1.691)、PaO2
(MD，9.011 mmHg; 95%CI: 3.489, 14.532)、pH (MD，-0.04; 95% CI:
-0.063, -0.017)及HCO3- (MD，-5.626 mmol/L; 95%CI: -9.285, -1.967)。
進一步從次族群分析中，呈現每日投予Acetazolamide
500mg~1000mg，經腸胃道或靜脈注射，可改善pH及HCO3-。但於住
院天數、住加護病房天數及致死率，Acetazolamide與安慰劑間並無顯
著差異，且Acetazolamide有較高的機率發生不良事件 (RR: 1.438，
95%CI: 0.806, 2.565)。對孩童患者，Acetazolamide也可改善動脈血液
氣體參數: PaCO2 (MD，-2.792 mmHg; 95% CI: -4.704, -0.88)、pH
(MD，-0.052; 95% CI: -0.088, -0.016)及HCO3- (MD，-2.548 mmol/L;
95%CI: -3.304, -1.791)。
結論:
Acetazolamide用於呼吸衰竭引發的高碳酸血症併代謝性鹼中毒之
患者，可改善呼吸器的使用時間，且可調控成人及孩童患者的動脈血
液氣體參數。但其它臨床效果，如住院天數、住加護病房天數及致死
率，尚未有一致性的答案，未來仍需有大樣本數、設計嚴謹的研究去
繼續探詢上述的結果。
Objective:
Hypercapnic respiratory failure occurs among patients in the
emergency department. It leads to posthypercapnic metabolic alkalosis,
which may depress central respiratory drive, lead to longer duration of the
ventilation, longer stay of intensive cure unity (ICU), and increase
morbidity and mortality. Based on previous studies, acetazolamide could
shorten the duration of mechanical ventilation (MV) for such patients, but
there is no conclusion on children and noninvasive ventilation (NIV)
adult’s patients. Therefore, we conducted a systematic review with meta-
analysis to evaluate the efficacy and safety of acetazolamide in these
patients.
Methods:
We searched Cochrane library, Embase, PubMed, Web of science and
Clinicaltrial.gov until March 2021. The results of each study were pooled
by random-effects model. Primary outcomes were duration of ventilation,
length of hospital stay and length of ICU stay. Secondary outcomes were
arterial blood gas (ABG) parameters, mortality and adverse events.
Results:
A total of 12 studies were included (4 randomized controlled trials, 1
quasi-experimental study, 3 case series and 4 case-control studies). For
adult patients in hypercapnic respiratory failure with metabolic alkalosis,
acetazolamide may shorten duration of MV (MD, -1.22 days; 95% CI:
-2.129, -0.31) and duration of NIV (MD, -13 days; 95% CI: -25.813,
-0.817), and then it could improve ABG parameters - PaCO2 (MD, -4.215
mmHg; 95% CI: -6.738, -1.691), PaO2 (MD, 9.011 mmHg; 95%CI: 3.489,
14.532), pH (MD, -0.04; 95% CI: -0.063, -0.017) and HCO3-(MD, -5.626
mmol/L; 95%CI: -9.285, -1.967). Moreover, dosage of acetazolamide from
500mg~1000mg by either enteral route or intravenous injection could
improve pH and HCO3- from subgroup analysis. But, length of hospital
stay, length of ICU stay and mortality did not differ between acetazolamide
and placebo. And there was a higher risk of adverse events for
acetazolamide (RR: 1.438, 95%CI: 0.806, 2.565). As for children patients,
acetazolamide still improves ABG parameters - PaCO2 (MD, -2.792
mmHg; 95% CI: -4.704, -0.88), pH (MD, -0.052; 95% CI: -0.088, -0.016)
and HCO3-(MD, -2.548 mmol/L; 95%CI: -3.304, -1.791).
Conclusion
Acetazolamide in hypercapnic respiratory failure with metabolic
alkalosis patients may relieve duration of ventilation and could improve
ABG parameters either adult or children. But there is no consistence in
length of hospital stay, length of ICU stay and mortality. Further large and
well-design trials are needed to answer this question. |
