Division of Pulmonary and Critical Care, Virginia Commonwealth University Health System, Medical College of Virginia Hospitals, Richmond, Virginia 23298, USA.
Respir Care. 2010 Jan;55(1):43-55.
The acute respiratory distress syndrome (ARDS) is characterized by intense inflammation and alveolar-capillary disruption that can progress to a state of unresolving inflammation and disordered fibrosis, referred to as fibroproliferative, late-stage, or persistent ARDS. These pathophysiologic features may be responsive to corticosteroids, but early high-dose, short-duration therapy was proven ineffective. More recently, several small and one moderate-size multicenter randomized controlled trial (RCT) investigated low-to-moderate-dose prolonged corticosteroid treatment. The RCT and meta-analysis consistently demonstrated improved oxygenation and shorter duration of mechanical ventilation with methylprednisolone. The largest RCT also revealed less pneumonia and shock, and shorter intensive care unit (ICU) stay, but more cases of severe myoneuropathy, with methylprednisolone. There were virtually identical 60-day and 180-day mortality rates for methylprednisolone and placebo in the largest RCT. Sub-group analysis of that study showed significantly higher mortality with methylprednisolone than with placebo when enrollment occurred > 13 days after onset of ARDS, but small sample size and differences in subject characteristics probably confound those results. Most meta-analyses demonstrated trends toward better survival with methylprednisolone, and, when restricted to patients enrolled in RCTs who received prolonged administration of methylprednisolone that was initiated within the first 14 days of ARDS, one meta-analysis demonstrated better survival with corticosteroids. Importantly, the aforementioned studies have methodological limitations, and the number of subjects enrolled was small. Experts differ in their recommendations regarding corticosteroids for late-stage ARDS, although one consensus group supported a "weak" recommendation of low-to-moderate-dose corticosteroids for ARDS of < 14 days duration. If corticosteroids are administered, infection surveillance, avoidance of neuromuscular blockers, and gradual taper of corticosteroids are recommended.
急性呼吸窘迫综合征（ARDS）的特征是强烈的炎症和肺泡毛细血管破坏，可进展为无法解决的炎症和紊乱的纤维化，称为纤维增生性、晚期或持续性 ARDS。这些病理生理特征可能对皮质类固醇有反应，但早期高剂量、短疗程的治疗已被证明无效。最近，几项小型和一项中型多中心随机对照试验（RCT）研究了低至中等剂量延长皮质类固醇治疗。RCT 和荟萃分析一致表明，使用甲泼尼龙可改善氧合并缩短机械通气时间。最大的 RCT 还显示肺炎和休克较少，重症监护病房（ICU）入住时间较短，但严重肌神经病的病例更多，使用甲泼尼龙。最大的 RCT 中，甲泼尼龙和安慰剂的 60 天和 180 天死亡率几乎相同。该研究的亚组分析表明，当 ARDS 发病后 > 13 天开始招募时，与安慰剂相比，甲泼尼龙的死亡率显著更高，但由于样本量小和受试者特征的差异，这些结果可能存在混淆。大多数荟萃分析表明，使用甲泼尼龙的生存率有提高趋势，并且当仅限于在 ARDS 发病后 14 天内接受甲泼尼龙延长治疗的 RCT 中入组的患者时，一项荟萃分析表明皮质类固醇具有更好的生存率。重要的是，上述研究存在方法学局限性，并且入组的受试者数量较少。尽管有一个共识小组支持对持续时间<14 天的 ARDS 给予低至中等剂量皮质类固醇的“弱”建议，但专家在皮质类固醇治疗晚期 ARDS 的建议上存在分歧。如果给予皮质类固醇，建议进行感染监测、避免使用神经肌肉阻滞剂和逐渐减少皮质类固醇的剂量。
