糖皮質(zhì)激素治療ARDS的系統(tǒng)評(píng)價(jià)及Meta分析
發(fā)布時(shí)間：2018-12-17 22:49
【摘要】：急性呼吸窘迫綜合癥(Acute respiratory distress syndrome,ARDS)依舊是一個(gè)困擾臨床醫(yī)師的難題,臨床主要表現(xiàn)為非心源性肺水腫導(dǎo)致的頑固性進(jìn)行性低氧血癥,其死亡率為40%-60%。當(dāng)前,ARDS診療面對(duì)的問題主要有:定義未清、機(jī)制不明、治療手段無統(tǒng)一標(biāo)準(zhǔn)。2012年,最新頒布了柏林標(biāo)準(zhǔn),但是依舊存在許多不足。由于其發(fā)病機(jī)制不清,導(dǎo)致治療手段沒有統(tǒng)一的標(biāo)準(zhǔn)。雖然機(jī)械通氣等取得了一定的療效,但是,在藥物治療方面,依舊沒有藥物證明對(duì)ARDS存在療效。糖皮質(zhì)激素因?yàn)槠錆撛诘南鬃饔?為ARDS研究人員所關(guān)注。現(xiàn)在,我們通過對(duì)既往臨床研究進(jìn)行系統(tǒng)回顧及評(píng)價(jià),探索糖皮質(zhì)激素在ARDS中的療效及探討分析研究中存在高度異質(zhì)性的原因。通過檢索 PUBMED、Embase、WEB of Knowledge、Cochrane Library,時(shí)間范圍為1994～2016年,根據(jù)納入及篩除標(biāo)準(zhǔn),篩選文獻(xiàn)、評(píng)價(jià)質(zhì)量、提取資料。其中,根據(jù)cochmae量表對(duì)納入文獻(xiàn)進(jìn)行質(zhì)量評(píng)價(jià),并通過STATA軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。根據(jù)I2檢驗(yàn)檢測(cè)不同臨床研究結(jié)果的異質(zhì)性,選擇固定效應(yīng)模型或隨機(jī)效應(yīng)模型進(jìn)行分析。計(jì)量資料采取計(jì)算均數(shù)差表示,計(jì)數(shù)資料采用相對(duì)危險(xiǎn)度表示,采用95%可信區(qū)間表示療效效應(yīng)量。P0.05為差異有統(tǒng)計(jì)學(xué)意義。此次回顧分析從4024篇臨床研究中,篩選出7篇臨床隨機(jī)對(duì)照試驗(yàn)研究。其中,患者總共550例,其中激素組296例,安慰劑組254例。根據(jù)分析結(jié)果,糖皮質(zhì)激素對(duì)ARDS患者的住院死亡率具有改善效果,合并RR值為0.454,95%CI(0.244,0.845),Z=2.49(p=0.013);糖皮質(zhì)激素可增加患者使用輔助裝置(assisted breath,AB)呼吸時(shí)間,合并 WMD 值為 4.176,95%CI(1.174,7.179),Z=2.736,P=0.006;ARDS患者通過糖皮質(zhì)激素治療可提高其氧合指數(shù)合并WMD值為 123.566,95%CI(62.147,184.985),Z=3.94,P=0.000。糖皮質(zhì)激素對(duì)于 ICU死亡率、副作用均無統(tǒng)計(jì)學(xué)差異,P值分別為P=0.150、P=0.377。我們得出結(jié)論:(1)糖皮質(zhì)激素可以改善ARDS患者的住院死亡率;(2)糖皮質(zhì)激素可以延長(zhǎng)患者的UAB時(shí)間;(3)小劑量糖皮質(zhì)激素可改善患者氧合狀態(tài);(4)小劑量糖皮質(zhì)激素短時(shí)間使用不能增加ARDS患者院內(nèi)感染的機(jī)率。此外,根據(jù)結(jié)果,我們給出建議:(1)ARDS患者不同的病因在對(duì)皮質(zhì)醇治療具有不同的反應(yīng),應(yīng)該針對(duì)不同的病原學(xué)進(jìn)行研究。(2)研究終點(diǎn)應(yīng)該在更長(zhǎng)的時(shí)間內(nèi)進(jìn)行,此次納入文獻(xiàn)只有一組涉及到了患者的60天死亡率及180天死亡率;(3)實(shí)驗(yàn)對(duì)象納入的時(shí)間也應(yīng)保持一致,探索不同時(shí)間段內(nèi)首次給予糖皮質(zhì)激素治療,ARDS患者是否可能有不同的獲益;(4)應(yīng)該設(shè)定更加明確的研究終點(diǎn):死亡率、脫機(jī)時(shí)間、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 鹵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 鹵9.179 (CI 1.174 鹵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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R563.8
，
本文編號(hào)：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 鹵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 鹵9.179 (CI 1.174 鹵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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R563.8
，
本文編號(hào)：2384907
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