糖皮质激素在重症社区获得性肺炎致急性呼吸窘迫综合征综合救治中的价值探讨

Evaluation of glucocorticoid in treatment for patients with acute respiratory distress syndrome as a result of serious community-acquired pneumonia

目的 :探讨糖皮质激素 (GC)在重症社区获得性肺炎 (SCAP)致急性呼吸窘迫综合征 (ARDS)综合救治中的价值。方法 :收集 2 0 0 0年 5月— 2 0 0 3年 2月所有因 SCAP致 ARDS入住 ICU患者的临床资料 ,分析年龄、性别、急性生理学与慢性健康状况评分 (APACHE )、氧合指数 (Pa O2 /Fi O2 )、肺内分流 (Qs/Qt)、肺部感染严重程度、机械通气、呼气末正压 (PEEP)水平、ICU停留时间、肺炎吸收指数、氧合改善率、病死率及直接死亡原因等 ,评价应用 GC对缺氧与休克纠正和预后的影响。结果 :2 4例患者中 ,未接受 GC治疗 7例 ,痊愈 5例(71.4 % ) ,死亡 2例 (2 8.6 % ) ,直接死亡原因分别为 ARDS(拒绝接受机械通气治疗 )和多脏器功能障碍综合征(MODS) ;接受 GC治疗 17例 ,仅痊愈 5例 (2 9.4 % ) ,死亡 12例 (70 .6 % ) ,主要死亡原因为 MODS(6例 ,75 .0 % ) ,少数为 ARDS与休克 (各 1例 ,12 .5 % )。痊愈患者肺部感染严重程度等临床参数与死亡者无显著差异(P>0 .0 5 ) ,但治疗后除 Pa O2 /Fi O2 和 Qs/Qt改善、休克纠正明显外 ,肺部感染有效率高 (P<0 .0 0 1)。结论 :GC能协助机械通气等常规治疗纠正 SCAP等肺内性 ARDS的顽固性缺氧和休克 ,为原发病治疗赢得时间。

Objective: To evaluate the usage of glucocorticoid(GC) in treatment for patients with acute respiratory distress syndrome (ARDS) resulting from serious community-acquired pneumonia (SCAP). Methods: The clinical data from all patients with ARDS resulting from SCAP in medical ICU (MICU) from May 2000 to Feb. 2003 were collected. Their age, sex, acute physiology and chronic health evaluation (APACHEⅡ) score, PaO 2/FiO 2 and Qs/Qt, the severity of SCAP, mechanical ventilation (MV) and the level of positive end-expiratory pressure(PEEP), time of stay in ICU, improvement of SCAP and oxygenation, as well as mortality and reasons of death were analyzed, respectively. So was did the influence of administration of GC on hypoxemia, septic shock, and their prognosis. Results: There were 24 cases totally, among them 7 patients had not taken GC, and 5 patients were cured (71.4 percent), and the other 2 cases died ( 28.6 percent). Their direct cause of death were multiple organ dysfunction syndrome(MODS) and ARDS, respectively. In 17 cases GC was given because hypoxemia and septic shock could not be alleviated with ordinary therapy, including MV.Among them only 5 patients (29.4 percent) were cured, and all others ( 12 cases, 70.6 percent) died, and the major direct cause of death was MODS(6 cases,75.0 percent). A few of them died of ARDS and septic shock(1 case,12.5 percent, respectively). The severity of SCAP, as well as other clinical data of the survivors, showed no significant difference compared with the nonsurvivors (P>0.05). But except for their PaO 2/FiO 2, Qs/Qt and shock, their pulmonary infection was better controlled than deaths (P<0.001). Conclusion: Refractory hypoxemia and septic shock of patients with pulmonary ARDS might be alleviated by GC when they are treated with routine methods, including MV, thus it enabled to win the time for other effective treatments.