Landzberg Elizabeth, Keim Garrett, Yehya Nadir
Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA.
Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, the Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
CHEST Crit Care. 2024 Jun;2(2). doi: 10.1016/j.chstcc.2024.100058. Epub 2024 Feb 27.
Systemic corticosteroid use in acute respiratory failure has yielded uncertain benefits, partially because of off-target side effects. Inhaled corticosteroids (ICSs) confer localized antiinflammatory benefits and may protect adults with direct lung injury (DLI) from developing respiratory failure. To our knowledge, this relationship has not been studied in children.
Do children with DLI who are prescribed ICSs before hospitalization have lower odds of progressing to respiratory failure?
This retrospective, single-center cohort identified children seeking treatment at the ED with DLI and medication records before hospitalization. The primary outcome was intubation; secondary outcomes included noninvasive respiratory support (NRS). We tested the association of ICSs with intubation and NRS, adjusting for confounders. We stratified analyses on history of asthma and performed a sensitivity analysis adjusting for systemic corticosteroid use to account for status asthmaticus.
Of 35,220 patients, 17,649 patients (50%) were prescribed ICSs. Intubation occurred in 169 patients (73 patients receiving ICSs) and NRS was used in 3,582 patients (1,336 patients receiving ICS). ICS use was associated with lower intubation (adjusted OR, 0.46; 95% CI, 0.31-0.67) and NRS (aOR, 0.45; 95% CI, 0.40-0.49). The association between ICS and NRS differed according to history of asthma ( = .04 for interaction), with ICS exposure remaining protective only for patients with a history of asthma. Results held true in sensitivity analyses.
ICS use prior to hospitalization may protect children with DLI from progressing to respiratory failure, with possible differential efficacy according to history of asthma.
在急性呼吸衰竭中使用全身性皮质类固醇的益处尚不明确，部分原因是存在非靶向副作用。吸入性皮质类固醇（ICS）具有局部抗炎作用，可能保护患有直接肺损伤（DLI）的成年人不发生呼吸衰竭。据我们所知，这种关系在儿童中尚未得到研究。
住院前开具ICS处方的DLI儿童进展为呼吸衰竭的几率是否更低？
这项回顾性单中心队列研究确定了在急诊科因DLI就诊且有住院前用药记录的儿童。主要结局是插管；次要结局包括无创呼吸支持（NRS）。我们测试了ICS与插管及NRS之间的关联，并对混杂因素进行了调整。我们根据哮喘病史进行分层分析，并进行了敏感性分析，对全身性皮质类固醇的使用进行调整以考虑哮喘持续状态。
在35220例患者中，17649例患者（50%）开具了ICS处方。169例患者发生插管（73例接受ICS治疗），3582例患者使用了NRS（1336例接受ICS治疗）。使用ICS与较低的插管率（校正比值比，0.46；95%置信区间，0.31 - 0.67）和NRS使用率（校正比值比，0.45；95%置信区间，0.40 - 0.49）相关。ICS与NRS之间的关联根据哮喘病史而有所不同（交互作用P = 0.04），ICS暴露仅对有哮喘病史的患者具有保护作用。敏感性分析结果依然成立。
住院前使用ICS可能保护患有DLI的儿童不进展为呼吸衰竭，根据哮喘病史可能存在不同的疗效。
