小剂量甲泼尼龙对中重度急性呼吸窘迫综合征患者肺容积及氧合影响的临床分析_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

梁壮 , 邸兴伟 , 李晓东 , 张晓玉 , 徐博 , 柳知含 ,  胡占升

锦州医科大学附属第一医院重症医学科（辽宁锦州 121000）;

Corresponding author：

胡占升, Email: ICUHZS@163.com

Keywords：

甲泼尼龙; 急性呼吸窘迫综合征; 功能残气量

DOI：

10.7507/1671-6205.202007029

Video：

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目的探讨小剂量甲泼尼龙对中重度急性呼吸窘迫综合征（ARDS）患者肺容积及氧合的影响。方法收集 2019 年 6 月至 2020 年 6 月锦州医科大学附属第一医院重症医学科收治的 50 例中重度 ARDS 机械通气患者，按照随机数字表法将患者分为甲泼尼龙试验组和常规治疗对照组，观察患者治疗前后的功能残气量（FRC）、氧合指数（PaO₂/FiO₂）、血清乳酸（cLac）及超敏 C 反应蛋白（hs-CRP）变化及患者预后相关指标；采用 Pearson 法分析 FRC 与 PaO₂/FiO₂ 的相关性。采用受试者工作特征（ROC）曲线评估 FRC 和 PaO₂/FiO₂ 对 ARDS 患者 28 天病死率的预测价值。结果两组患者治疗后第 4、7 天的 FRC、PaO₂/FiO₂、PaO₂、PaCO₂、cLac 及 hs-CRP 均较治疗前改善（均 P<0.05），而且试验组在治疗后的第 4、7 天的 FRC、PaO₂/FiO₂、PaO₂ 显著高于对照组，cLac、hs-CRP 及 PaCO₂ 显著低于对照组（均 P<0.05）。试验组呼吸机使用时间、住院时间、28 天病死率等均低于对照组（均 P<0.05）。FRC 与 PaO₂/FiO₂ 存在显著相关性（r=0.731，P<0.05）。ROC 曲线分析显示，FRC 和 PaO₂/FiO₂ 对中重度 ARDS 患者 28 天病死率均有预测价值，其 ROC 曲线下面积分别为 0.841 和 0.802（均 P<0.05）。结论早期应用小剂量甲泼尼龙可以显著改善中重度 ARDS 患者 FRC 和 PaO₂/FiO₂，降低 28 天病死率，疗效确切、安全性高，并且通过动态监测 FRC 对于中重度 ARDS 患者预后预测具有较好参考价值。

Citation： 梁壮, 邸兴伟, 李晓东, 张晓玉, 徐博, 柳知含, 胡占升. 小剂量甲泼尼龙对中重度急性呼吸窘迫综合征患者肺容积及氧合影响的临床分析. Chinese Journal of Respiratory and Critical Care Medicine, 2021, 20(6): 427-431. doi: 10.7507/1671-6205.202007029 Copy

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3.	许红阳, 姜淑云, 臧芝栋, 等. 糖皮质激素对早期 ARDS 患者的治疗效果. 江苏医药, 2014, 40(21): 2618-2619.
4.	肖贞良, 周菁, 陈章, 等. 糖皮质激素治疗对急性呼吸窘迫综合征患者预后的影响. 中国中西医结合急救杂志, 2015, 22(1): 83-85.
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10.	Umberto Meduri G, Bell W, Sinclair S, et al. Pathophysiology of acute respiratory distress syndrome. Glucocorticoid receptor-mediated regulation of inflammation and response to prolonged glucocorticoid treatment. Presse Med, 2011, 40(12): 543-560.
11.	Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med, 2017, 43(12): 1751-1763.
12.	Vichyanond P, Irvin CG, Larsen GL, et al. Penetration of corticosteroids into the lung: evidence for a difference between methylprednisolone and prednisolone. J Allergy Clin Immunol, 1989, 84(6): 867-873.
13.	Greos LS, Vichyanond P, Bloedow DC, et al. Methylprednisolone achieves greater concentrations in the lung than prednisolone. A pharmacokinetic analysis. Am Rev Respir Dis, 1991, 144(3): 586-592.
14.	Braude AC, Rebuck AS. Prednisone and methylprednisolone disposition in the lung. Lancet, 1983, 2(8357): 995-997.
15.	张春元, 宋元林, 胡兆燕, 等. 肺功能残气量的测定方法及临床意义研究进展. 生物医学工程与临床, 2019, 23(4): 487-492.
16.	Chen H, Ruan S, Huang C, et al. Pre-extubation functional residual capacity and risk of extubation failure among patients with hypoxemic respiratory failure. Sci Rep, 2020, 10(1): 937.
17.	Sun S, Liu D, Zhang H, et al. Effect of different doses and time-courses of corticosteroid treatment in patients with acute respiratory distress syndrome: A meta-analysis. Exp Ther Med, 2019, 18(6): 4637-4644.
18.	Zayed Y, Barbarawi M, Ismail E, et al. Use of glucocorticoids in patients with acute respiratory distress syndrome: a meta-analysis and trial sequential analysis. J Intensive Care, 2020, 8: 43.
19.	Kido T, Muramatsu K, Asakawa T, et al. The relationship between high-dose corticosteroid treatment and mortality in acute respiratory distress syndrome: a retrospective and observational study using a nationwide administrative database in Japan. BMC Pulm Med, 2018, 18(1): 28.
20.	Wang Y, Jiang W, He Q, et al. A retrospective cohort study of methylprednisolone therapy in severe patients with COVID-19 pneumonia. Signal Transduct Target Ther, 2020, 5(1): 57.
21.	Annane D, Pastores SM, Arlt W, et al. Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Crit Care Med, 2017, 45(12): 2089-2098.
22.	Hapgood J P, Avenant C, Moliki J M. Glucocorticoid-independent modulation of GR activity: Implications for immunotherapy. Pharmacol Ther, 2016, 165: 93-113.
23.	周秀芳, 刘梦, 胡克. 长疗程糖皮质激素治疗与急性呼吸窘迫综合征. 中国呼吸与危重监护杂志, 2014, 13(1): 101-105.

1. Cherian SV, Anupam K, Karunakar A, et al. Salvage therapies for refractory hypoxemia in ARDS. Respir Med, 2018, 141: 150-158.
2. Gouda MM, Shaikh SB, Bhandary YP. Inflammatory and fibrinolytic system in acute respiratory distress syndrome. Lung, 2018, 196(5): 609-616.
3. 许红阳, 姜淑云, 臧芝栋, 等. 糖皮质激素对早期 ARDS 患者的治疗效果. 江苏医药, 2014, 40(21): 2618-2619.
4. 肖贞良, 周菁, 陈章, 等. 糖皮质激素治疗对急性呼吸窘迫综合征患者预后的影响. 中国中西医结合急救杂志, 2015, 22(1): 83-85.
5. 李丽, 杨延杰, 宋元林. 功能残气量和肺一氧化碳弥散量测定的技术规范和质量控制. 中华结核和呼吸杂志, 2012, 35(10): 794-796.
6. 吴爱萍, 王金柱, 韩芳, 等. 基于柏林标准诊断的急性呼吸窘迫综合征患者预后影响因素研究. 中国全科医学, 2019, 22(18): 2176-2181.
7. Huppert L, Matthay M, Ware L. Pathogenesis of acute respiratory distress syndrome. Semin Respir Crit Care Med, 2019, 40(1): 31-39.
8. Mcnicholas BA, Rooney GM, Laffey JG. Lessons to learn from epidemiologic studies in ARDS. Curr Opin Crit Care, 2018, 24(1): 41-48.
9. 罗红, 丁水姿, 张秀瑞. 急性呼吸窘迫综合征的药物及生物治疗问题. 中华医学杂志, 2018, 98(34): 2712-2714.
10. Umberto Meduri G, Bell W, Sinclair S, et al. Pathophysiology of acute respiratory distress syndrome. Glucocorticoid receptor-mediated regulation of inflammation and response to prolonged glucocorticoid treatment. Presse Med, 2011, 40(12): 543-560.
11. Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med, 2017, 43(12): 1751-1763.
12. Vichyanond P, Irvin CG, Larsen GL, et al. Penetration of corticosteroids into the lung: evidence for a difference between methylprednisolone and prednisolone. J Allergy Clin Immunol, 1989, 84(6): 867-873.
13. Greos LS, Vichyanond P, Bloedow DC, et al. Methylprednisolone achieves greater concentrations in the lung than prednisolone. A pharmacokinetic analysis. Am Rev Respir Dis, 1991, 144(3): 586-592.
14. Braude AC, Rebuck AS. Prednisone and methylprednisolone disposition in the lung. Lancet, 1983, 2(8357): 995-997.
15. 张春元, 宋元林, 胡兆燕, 等. 肺功能残气量的测定方法及临床意义研究进展. 生物医学工程与临床, 2019, 23(4): 487-492.
16. Chen H, Ruan S, Huang C, et al. Pre-extubation functional residual capacity and risk of extubation failure among patients with hypoxemic respiratory failure. Sci Rep, 2020, 10(1): 937.
17. Sun S, Liu D, Zhang H, et al. Effect of different doses and time-courses of corticosteroid treatment in patients with acute respiratory distress syndrome: A meta-analysis. Exp Ther Med, 2019, 18(6): 4637-4644.
18. Zayed Y, Barbarawi M, Ismail E, et al. Use of glucocorticoids in patients with acute respiratory distress syndrome: a meta-analysis and trial sequential analysis. J Intensive Care, 2020, 8: 43.
19. Kido T, Muramatsu K, Asakawa T, et al. The relationship between high-dose corticosteroid treatment and mortality in acute respiratory distress syndrome: a retrospective and observational study using a nationwide administrative database in Japan. BMC Pulm Med, 2018, 18(1): 28.
20. Wang Y, Jiang W, He Q, et al. A retrospective cohort study of methylprednisolone therapy in severe patients with COVID-19 pneumonia. Signal Transduct Target Ther, 2020, 5(1): 57.
21. Annane D, Pastores SM, Arlt W, et al. Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Crit Care Med, 2017, 45(12): 2089-2098.
22. Hapgood J P, Avenant C, Moliki J M. Glucocorticoid-independent modulation of GR activity: Implications for immunotherapy. Pharmacol Ther, 2016, 165: 93-113.
23. 周秀芳, 刘梦, 胡克. 长疗程糖皮质激素治疗与急性呼吸窘迫综合征. 中国呼吸与危重监护杂志, 2014, 13(1): 101-105.

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Chinese Journal of Respiratory and Critical Care Medicine

小剂量甲泼尼龙对中重度急性呼吸窘迫综合征患者肺容积及氧合影响的临床分析

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