糖皮质激素治疗ARDS的系统评价及Meta分析
发布时间：2018-12-17 22:49
【摘要】：急性呼吸窘迫综合症(Acute respiratory distress syndrome,ARDS)依旧是一个困扰临床医师的难题,临床主要表现为非心源性肺水肿导致的顽固性进行性低氧血症,其死亡率为40%-60%。当前,ARDS诊疗面对的问题主要有:定义未清、机制不明、治疗手段无统一标准。2012年,最新颁布了柏林标准,但是依旧存在许多不足。由于其发病机制不清,导致治疗手段没有统一的标准。虽然机械通气等取得了一定的疗效,但是,在药物治疗方面,依旧没有药物证明对ARDS存在疗效。糖皮质激素因为其潜在的消炎作用,为ARDS研究人员所关注。现在,我们通过对既往临床研究进行系统回顾及评价,探索糖皮质激素在ARDS中的疗效及探讨分析研究中存在高度异质性的原因。通过检索 PUBMED、Embase、WEB of Knowledge、Cochrane Library,时间范围为1994～2016年,根据纳入及筛除标准,筛选文献、评价质量、提取资料。其中,根据cochmae量表对纳入文献进行质量评价,并通过STATA软件进行统计学分析。根据I2检验检测不同临床研究结果的异质性,选择固定效应模型或随机效应模型进行分析。计量资料采取计算均数差表示,计数资料采用相对危险度表示,采用95%可信区间表示疗效效应量。P0.05为差异有统计学意义。此次回顾分析从4024篇临床研究中,筛选出7篇临床随机对照试验研究。其中,患者总共550例,其中激素组296例,安慰剂组254例。根据分析结果,糖皮质激素对ARDS患者的住院死亡率具有改善效果,合并RR值为0.454,95%CI(0.244,0.845),Z=2.49(p=0.013);糖皮质激素可增加患者使用辅助装置(assisted breath,AB)呼吸时间,合并 WMD 值为 4.176,95%CI(1.174,7.179),Z=2.736,P=0.006;ARDS患者通过糖皮质激素治疗可提高其氧合指数合并WMD值为 123.566,95%CI(62.147,184.985),Z=3.94,P=0.000。糖皮质激素对于 ICU死亡率、副作用均无统计学差异,P值分别为P=0.150、P=0.377。我们得出结论:(1)糖皮质激素可以改善ARDS患者的住院死亡率;(2)糖皮质激素可以延长患者的UAB时间;(3)小剂量糖皮质激素可改善患者氧合状态;(4)小剂量糖皮质激素短时间使用不能增加ARDS患者院内感染的机率。此外,根据结果,我们给出建议:(1)ARDS患者不同的病因在对皮质醇治疗具有不同的反应,应该针对不同的病原学进行研究。(2)研究终点应该在更长的时间内进行,此次纳入文献只有一组涉及到了患者的60天死亡率及180天死亡率;(3)实验对象纳入的时间也应保持一致,探索不同时间段内首次给予糖皮质激素治疗,ARDS患者是否可能有不同的获益;(4)应该设定更加明确的研究终点:死亡率、脱机时间、副作用等。
[Abstract]:Acute respiratory distress syndrome (Acute respiratory distress syndrome,ARDS) is still a difficult problem for clinicians. The main clinical manifestation is refractory progressive hypoxemia caused by non-cardiogenic pulmonary edema, with a mortality rate of 40 to 60. At present, the main problems facing ARDS diagnosis and treatment are: unclear definition, unclear mechanism, no unified standard of treatment. In 2012, the latest Berlin standard was promulgated, but there are still many shortcomings. Because its pathogenesis is unclear, there is no uniform standard of treatment. Although mechanical ventilation has achieved some curative effect, there is still no drug to prove the efficacy of ARDS in drug therapy. Glucocorticoids are of concern to ARDS researchers for their potential anti-inflammatory effects. Now, by reviewing and evaluating the previous clinical studies, we explore the efficacy of glucocorticoid in ARDS and explore the reasons for the high heterogeneity in the analysis of the effects of glucocorticoids. By searching the time range of PUBMED,Embase,WEB of Knowledge,Cochrane Library, from 1994 to 2016, according to the criteria of inclusion and screening, the literature was screened, the quality was evaluated and the data were extracted. The quality of the literature was evaluated according to the cochmae scale, and the statistical analysis was carried out by STATA software. According to I 2 test, fixed effect model or random effect model were selected to analyze the heterogeneity of different clinical results. The measurement data were expressed by the calculated mean difference, the counting data were expressed by relative risk and the 95% confidence interval was used to represent the therapeutic effect quantity. The difference was statistically significant (P0.05). In this retrospective analysis, 7 clinical randomized controlled trial studies were selected out of 4024 clinical studies. Of the 550 patients, 296 were in the hormone group and 254 in the placebo group. According to the analysis results, glucocorticoid can improve the inpatient mortality rate of ARDS patients, the combined RR value is 0.45495 CI (0.244 卤0.845), Zu 2.49 (p 0.013); Glucocorticoid could increase the breathing time of patients with assisted breath,AB. The combined WMD value was 4.176 卤9.179 (CI 1.174 卤7.179). ARDS patients treated with glucocorticoid could improve the oxygenation index combined with WMD value (CI = 123.566N95, CI = 62.147184.985), ZH = 3.94, P = 0.000. There was no significant difference in the side effects of glucocorticoid on ICU mortality (P = 0.150, P = 0.377). We concluded that: (1) glucocorticoid can improve the inpatient mortality of ARDS; (2) glucocorticoid can prolong the UAB time of the patients; (3) low dose glucocorticoid can improve the oxygenation state of the patients; (4) Short-term use of low dose glucocorticoid did not increase the risk of nosocomial infection in patients with ARDS. In addition, based on the results, we suggest that: (1) different etiologies of ARDS patients have different responses to cortisol therapy and should be studied for different etiology. (2) the end point of the study should be carried out over a longer period of time. Only one group of patients was included in the literature, with a 60-day mortality rate and a 180-day mortality rate. (3) the participants should be included in the same time to explore the first time to give glucocorticoid treatment in different time periods, ARDS patients may have different benefits; (4) A more specific study endpoint should be set: mortality, offline time, side effects, etc.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R563.8
，
本文编号：2384907
[Abstract]:Acute respiratory distress syndrome (Acute respiratory distress syndrome,ARDS) is still a difficult problem for clinicians. The main clinical manifestation is refractory progressive hypoxemia caused by non-cardiogenic pulmonary edema, with a mortality rate of 40 to 60. At present, the main problems facing ARDS diagnosis and treatment are: unclear definition, unclear mechanism, no unified standard of treatment. In 2012, the latest Berlin standard was promulgated, but there are still many shortcomings. Because its pathogenesis is unclear, there is no uniform standard of treatment. Although mechanical ventilation has achieved some curative effect, there is still no drug to prove the efficacy of ARDS in drug therapy. Glucocorticoids are of concern to ARDS researchers for their potential anti-inflammatory effects. Now, by reviewing and evaluating the previous clinical studies, we explore the efficacy of glucocorticoid in ARDS and explore the reasons for the high heterogeneity in the analysis of the effects of glucocorticoids. By searching the time range of PUBMED,Embase,WEB of Knowledge,Cochrane Library, from 1994 to 2016, according to the criteria of inclusion and screening, the literature was screened, the quality was evaluated and the data were extracted. The quality of the literature was evaluated according to the cochmae scale, and the statistical analysis was carried out by STATA software. According to I 2 test, fixed effect model or random effect model were selected to analyze the heterogeneity of different clinical results. The measurement data were expressed by the calculated mean difference, the counting data were expressed by relative risk and the 95% confidence interval was used to represent the therapeutic effect quantity. The difference was statistically significant (P0.05). In this retrospective analysis, 7 clinical randomized controlled trial studies were selected out of 4024 clinical studies. Of the 550 patients, 296 were in the hormone group and 254 in the placebo group. According to the analysis results, glucocorticoid can improve the inpatient mortality rate of ARDS patients, the combined RR value is 0.45495 CI (0.244 卤0.845), Zu 2.49 (p 0.013); Glucocorticoid could increase the breathing time of patients with assisted breath,AB. The combined WMD value was 4.176 卤9.179 (CI 1.174 卤7.179). ARDS patients treated with glucocorticoid could improve the oxygenation index combined with WMD value (CI = 123.566N95, CI = 62.147184.985), ZH = 3.94, P = 0.000. There was no significant difference in the side effects of glucocorticoid on ICU mortality (P = 0.150, P = 0.377). We concluded that: (1) glucocorticoid can improve the inpatient mortality of ARDS; (2) glucocorticoid can prolong the UAB time of the patients; (3) low dose glucocorticoid can improve the oxygenation state of the patients; (4) Short-term use of low dose glucocorticoid did not increase the risk of nosocomial infection in patients with ARDS. In addition, based on the results, we suggest that: (1) different etiologies of ARDS patients have different responses to cortisol therapy and should be studied for different etiology. (2) the end point of the study should be carried out over a longer period of time. Only one group of patients was included in the literature, with a 60-day mortality rate and a 180-day mortality rate. (3) the participants should be included in the same time to explore the first time to give glucocorticoid treatment in different time periods, ARDS patients may have different benefits; (4) A more specific study endpoint should be set: mortality, offline time, side effects, etc.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R563.8
，
本文编号：2384907
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