临床证据：皮质醇激素治疗急性肺损伤和急性呼吸窘迫综合征的有效性

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Use of corticosteroids in acute lung injury and acute respiratory distress syndrome: a systematic review and meta-analysis. 系统性回顾和meta分析证实皮质醇激素治疗急性肺损伤和急性呼吸窘迫综合征的有效性 出处：Crit Care Med   2009  May  37(5) :1594-603 作者：Tang BM;Craig JC;Eslick GD;Seppelt I;McLean AS

摘自医脉互通《pubmed精华文摘译讯》

OBJECTIVE: Controversy remains as to whether low-dose corticosteroids can reduce the mortality and morbidity of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) without increasing the risk of adverse reactions. We aimed to evaluate all studies investigating prolonged corticosteroids in low-to-moderate dose in ALI or ARDS. DATA SOURCES: MEDLINE, EMBASE, Current Content, and Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles. STUDY SELECTION: Randomized controlled trials (RCTs) and observational studies reported in any language that used 0.5-2.5 mg.kg.d of methylprednisolone or equivalent to treat ALI/ARDS. DATA EXTRACTION: Data were extracted independently by two reviewers and included study design, patient characteristics, interventions, and mortality and morbidity outcomes. DATA SYNTHESIS: Both cohort studies (five studies, n = 307) and RCTs (four trials, n = 341) showed a similar trend toward mortality reduction (RCTs relative risk 0.51, 95% CI 0.24-1.09; p = 0.08; cohort studies relative risk 0.66, 95% CI 0.43-1.02; p = 0.06). The overall relative risk was 0.62 (95% CI 0.43-0.91; p = 0.01). There was also improvement in length of ventilation-free days, length of intensive care unit stay, Multiple Organ Dysfunction Syndrome Score, Lung Injury Scores, and improvement in Pao2/Fio2. There was no increase in infection, neuromyopathy, or any major complications. There was significant heterogeneity in the pooled studies. Subgroup and meta-regression analyses showed that heterogeneity had minimal effect on treatment efficacy; however, these findings were limited by the small number of studies used in the analyses. CONCLUSION: The use of low-dose corticosteroids was associated with improved mortality and morbidity outcomes without increased adverse reactions. The consistency of results in both study designs and all outcomes suggests that they are an effective treatment for ALI or ARDS. The mortality benefits in early ARDS should be confirmed by an adequately powered randomized trial.
目的：在不增加副作用的情况下，应用小剂量皮质醇激素是否可以降低急性肺损伤（ALI）或急性呼吸窘迫综合征（ARDS）的死亡率和发病率仍有争议。我们研究给予ALI或ARDS患者长时间应用中小剂量皮质醇激素的效果。数据来源：MEDLINE数据库、MBASE数据库、Current Content数据库、Cochrane Central Register of Controlled Trials数据库和bibliographies of retrieved articles数据库。研究选择：应用0.5-2.5/mg.kg.d甲强龙或等当量其它激素治疗急性肺损伤/急性呼吸窘迫综合征进行随机对照试验（RCTs）和观察报告研究。数据抽取：由两名实验人员分别提取数据，包括研究设计、病人特征、干预性措施、死亡率和发病率。数据综合：队列研究（5组，每组307例）和随机对照试验（ 4组，每组341例 ）都表明了死亡率的降低趋势（随机对照试验的相对危险度是0.51, 95%置信区间为0.24-1.09，p = 0.08; 队列研究的相对危险度是0.66, 95%置信区间为0.43-1.02，p = 0.06；总相对危险度是0.62，95 ％置信区间为0.43-0.91，P=0.01）。可以缩短机械通气的时间和重症监护时间，改善多器官功能障碍综合征评分和肺损伤评分，提高了血氧分压/吸入气体氧含量比值。并没有增加感染、神经肌病或其它严重并发症的风险，并表现出明显的异质性。亚组分析和meta回归分析表明，异质性对治疗效果的评价具有较小的影响。但是该实验结果也受小样本实验对象的影响。结论：应用小剂量皮质醇激素可以显著降低死亡率和发病率，并且不增加严重不良反应的风险。该试验的研究结果符合研究设计目标，该方法可有效应用于治疗急性肺损伤或急性呼吸窘迫综合征。大样本随机试验应该可以证实治疗早期急性呼吸窘迫综合征可以降低死亡率。
专家评价：
Herwig Gerlach
with Susanne Toussaint
Vivantes - Klinikum Neukoelln, Germany
Critical Care & Emergency Medicine
By reading this most interesting article, the reader learns that using corticosteroids in low doses improves the outcome of patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Mortality as well as morbidity was lowered as indicated by several variables. This article is a ‘must read’ for every intensivist.Two reviewers independently extracted study data in order to investigate prolonged corticosteroids in low-to-moderate dose in ALI or ARDS. The authors included study design, patient characteristics, interventions, and mortality and morbidity outcomes in their meta-analysis. The overall relative risk of death when using corticosteroids was significantly lower. The meta-analysis showed improvement in length of ventilation-free days, Lung Injury Scores and several additional parameters. Importantly, there was no increase in infection, neuromyopathy, or any other major complication. The consistency of results of the studies and RCTs in both design and outcomes suggest that corticosteroids are an effective treatment for ALI and ARDS. In severe ALI or ARDS, the use of low-dose steroids should be implemented into standard therapy

评价翻译：

ivylinshuying

嗯，有的主任是这么用的，但是我本人不爱用