小劑量甲潑尼龍對中重度急性呼吸窘迫綜合征患者肺容積及氧合影響的臨床分析_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

梁壯 , 邸興偉 , 李曉東 , 張曉玉 , 徐博 , 柳知含 ,  胡占升

錦州醫科大學附屬第一醫院重癥醫學科（遼寧錦州 121000）;

Corresponding?author：

胡占升, Email: ICUHZS@163.com

Keywords：

甲潑尼龍; 急性呼吸窘迫綜合征; 功能殘氣量

DOI：

10.7507/1671-6205.202007029

Video：

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目的探討小劑量甲潑尼龍對中重度急性呼吸窘迫綜合征（ARDS）患者肺容積及氧合的影響。方法收集 2019 年 6 月至 2020 年 6 月錦州醫科大學附屬第一醫院重癥醫學科收治的 50 例中重度 ARDS 機械通氣患者，按照隨機數字表法將患者分為甲潑尼龍試驗組和常規治療對照組，觀察患者治療前后的功能殘氣量（FRC）、氧合指數（PaO₂/FiO₂）、血清乳酸（cLac）及超敏 C 反應蛋白（hs-CRP）變化及患者預后相關指標；采用 Pearson 法分析 FRC 與 PaO₂/FiO₂ 的相關性。采用受試者工作特征（ROC）曲線評估 FRC 和 PaO₂/FiO₂ 對 ARDS 患者 28 天病死率的預測價值。結果兩組患者治療后第 4、7 天的 FRC、PaO₂/FiO₂、PaO₂、PaCO₂、cLac 及 hs-CRP 均較治療前改善（均 P<0.05），而且試驗組在治療后的第 4、7 天的 FRC、PaO₂/FiO₂、PaO₂ 顯著高于對照組，cLac、hs-CRP 及 PaCO₂ 顯著低于對照組（均 P<0.05）。試驗組呼吸機使用時間、住院時間、28 天病死率等均低于對照組（均 P<0.05）。FRC 與 PaO₂/FiO₂ 存在顯著相關性（r=0.731，P<0.05）。ROC 曲線分析顯示，FRC 和 PaO₂/FiO₂ 對中重度 ARDS 患者 28 天病死率均有預測價值，其 ROC 曲線下面積分別為 0.841 和 0.802（均 P<0.05）。結論早期應用小劑量甲潑尼龍可以顯著改善中重度 ARDS 患者 FRC 和 PaO₂/FiO₂，降低 28 天病死率，療效確切、安全性高，并且通過動態監測 FRC 對于中重度 ARDS 患者預后預測具有較好參考價值。

Citation： 梁壯, 邸興偉, 李曉東, 張曉玉, 徐博, 柳知含, 胡占升. 小劑量甲潑尼龍對中重度急性呼吸窘迫綜合征患者肺容積及氧合影響的臨床分析. Chinese Journal of Respiratory and Critical Care Medicine, 2021, 20(6): 427-431. doi: 10.7507/1671-6205.202007029 Copy

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.	許紅陽, 姜淑云, 臧芝棟, 等. 糖皮質激素對早期 ARDS 患者的治療效果. 江蘇醫藥, 2014, 40(21): 2618-2619.
4.	肖貞良, 周菁, 陳章, 等. 糖皮質激素治療對急性呼吸窘迫綜合征患者預后的影響. 中國中西醫結合急救雜志, 2015, 22(1): 83-85.
5.	李麗, 楊延杰, 宋元林. 功能殘氣量和肺一氧化碳彌散量測定的技術規范和質量控制. 中華結核和呼吸雜志, 2012, 35(10): 794-796.
6.	吳愛萍, 王金柱, 韓芳, 等. 基于柏林標準診斷的急性呼吸窘迫綜合征患者預后影響因素研究. 中國全科醫學, 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.	羅紅, 丁水姿, 張秀瑞. 急性呼吸窘迫綜合征的藥物及生物治療問題. 中華醫學雜志, 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.	張春元, 宋元林, 胡兆燕, 等. 肺功能殘氣量的測定方法及臨床意義研究進展. 生物醫學工程與臨床, 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, 劉夢, 胡克. 長療程糖皮質激素治療與急性呼吸窘迫綜合征. 中國呼吸與危重監護雜志, 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. 許紅陽, 姜淑云, 臧芝棟, 等. 糖皮質激素對早期 ARDS 患者的治療效果. 江蘇醫藥, 2014, 40(21): 2618-2619.
4. 肖貞良, 周菁, 陳章, 等. 糖皮質激素治療對急性呼吸窘迫綜合征患者預后的影響. 中國中西醫結合急救雜志, 2015, 22(1): 83-85.
5. 李麗, 楊延杰, 宋元林. 功能殘氣量和肺一氧化碳彌散量測定的技術規范和質量控制. 中華結核和呼吸雜志, 2012, 35(10): 794-796.
6. 吳愛萍, 王金柱, 韓芳, 等. 基于柏林標準診斷的急性呼吸窘迫綜合征患者預后影響因素研究. 中國全科醫學, 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. 羅紅, 丁水姿, 張秀瑞. 急性呼吸窘迫綜合征的藥物及生物治療問題. 中華醫學雜志, 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. 張春元, 宋元林, 胡兆燕, 等. 肺功能殘氣量的測定方法及臨床意義研究進展. 生物醫學工程與臨床, 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, 劉夢, 胡克. 長療程糖皮質激素治療與急性呼吸窘迫綜合征. 中國呼吸與危重監護雜志, 2014, 13(1): 101-105.

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Chinese Journal of Respiratory and Critical Care Medicine

小劑量甲潑尼龍對中重度急性呼吸窘迫綜合征患者肺容積及氧合影響的臨床分析

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