Ulinastatin for acute lung injury and acute respiratory distress syndrome: A systematic review and meta-analysis

AIM: To investigate the efficacy and safety of ulinastatin for patients with acute lung injury (ALI) and those with acute respiratory distress syndrome (ARDS).METHODS: A systematic review of randomized controlled trials (RCTs) of ulinastatin for ALI/ARDS was conducted. Oxygenation index, mortality rate [intensive care unit (ICU) mortality rate, 28-d mortality rate] and length of ICU stay were compared between ulinastatin group and conventional therapy group. Meta-analysis was performed by using Rev Man 5.1.RESULTS: Twenty-nine RCTs with 1726 participants were totally included, the basic conditions of which were similar. No studies discussed adverse effect. Oxygenation index was reported in twenty-six studies (1552 patients). Ulinastatin had a significant effect in improving oxygenation [standard mean difference (SMD) = 1.85, 95%CI: 1.42-2.29, P < 0.00001, I² = 92%]. ICU mortality and 28-d mortality were respectively reported in eighteen studies (987 patients) and three studies (196 patients). We found that ulinastatin significantly decreased the ICU mortality [I² = 0%, RR = 0.48, 95%CI: 0.38-0.59, number needed to treat (NNT) = 5.06, P < 0.00001], while the 28-d mortality was not significantly affected (I² = 0%, RR = 0.78, 95%CI: 0.51-1.19, NNT = 12.66, P = 0.24). The length of ICU stay (six studies, 364 patients) in the ulinastatin group was significantly lower than that in the control group (SMD = -0.97, 95%CI: -1.20--0.75, P < 0.00001, I² = 86%).CONCLUSION: Ulinastatin seems to be effective for ALI and ARDS though most trials included were of poor quality and no information on safety was provided.     

Meta-analysis of controlled trials of ventilator therapy in acute lung injury and acute respiratory distress syndrome: an alternative perspective

Objective The role of protective ventilation in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is controversial. Evidence was sought from published randomised trials for a consistent treatment effect of protective ventilation and any covariate modification.Design Meta-analysis of protective ventilation trials in ALI/ARDS and meta-regression of covariates on treatment effect (log odds ratio), with respect to 28-day mortality. Heterogeneity impact on the meta-analysis was assessed by the H statistic (substantial impact, >1.5) and graphical analysis. Five trials with a total of 1,202 patients were considered.Measurements and results Average 28-day mortality was 0.40 in the treatment group (protective ventilation, n=605) vs. 0.46 in the control group (control ventilation, n=597). The treatment effect (odds ratio) was: fixed-effects, 0.71 (95% CI 0.56–0.91, p=0.006; heterogeneity, p=0.06) and random effects: 0.80 (95% CI 0.49–1.31, p=0.37). Heterogeneity impact (H statistic=1.50) was adjudged as modest. The treatment effect was significant and (a) favoured protective ventilation for a tidal volume less than 7.7 ml/kg predicted (treatment group) and a mean plateau pressure of 30 cmH₂O or higher (control group) but was not influenced by plateau pressure 21–30 cmH₂O (treatment group) and (b) depended upon plateau pressure difference greater than 5–7 cmH₂O between protective ventilation and standard ventilation.Conclusions Overall treatment effect estimate favoured protective ventilation but did not achieve statistical significance. Protective ventilation depended upon threshold levels of tidal volume, plateau pressure, and plateau pressure difference.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at .     

无创正压通气治疗急性肺损伤/急性呼吸窘迫综合征的观察

目的 评价无创正压通气(NPPV)治疗急性肺损伤(ALI)／急性呼吸窘迫综合征(ARDS)患者的临床效果。方法 对18例ALI/ARDS患者实施NPPV治疗结果进行回顾性总结，分析NPPV治疗前后动脉血氧分压／吸氧浓度(PaO2／FiO2)、呼吸频率(RR)和心率(HR)的变化。结果 NPPV治疗成功率为55.6％(10／18)，8例NPPV治疗失败患者中7例改用气管插管有创通气。总死亡率为33．3％(6／18)。NPPV成功组50％(5／10)为ALI患者，治疗后1～2h PaO2／FiO2、RR和HR较治疗前有显著改善。NPPV失败组均为ARDS患者，治疗后1-2h PaO2／FiO2、RR和HR无明显变化。结论 NPPV对部分ALI／ARDS患者是有效的支持治疗手段，尤其是ARDS早期的ALI阶段可考虑选用NPPV。如NPPV治疗失败，应及时转换为气管插管有创通气。     

The effect of aspirin in preventing the acute respiratory distress syndrome/acute lung injury: A meta-analysis

Background

The effects of aspirin in preventing the occurrence of acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) among adult patients are controversial. We aimed to further determine the effectiveness of aspirin in reducing the rate of ARDS/ALI.

俯卧位通气对急性肺损伤和急性呼吸窘迫综合征临床疗效影响的Meta分析

目的 系统评价俯卧位通气(PPV)对我国急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)患者的短期临床疗效.方法 利用Cochrane系统评价法,全面检索2000年至2009年国内公开发表的所有ALI与ARDS患者PPV的临床研究资料.对纳入研究独立进行质量评价、资料提取、交叉核对后行Meta分析.结果 纳入研究8项共184例患者,PPV时患者动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)、呼吸系统总顺应性(C)均显著升高;动脉血二氧化碳分压(PaCO2)、中心静脉压(CVP)、呼吸道峰压(PIP)和呼吸系统总阻力(Raw)无显著的变化;心率(HR)与平均动脉压(MAP)显著升高. 结论 ALI与ARDS患者行PPV可增加呼吸系统总顺应性,改善患者低氧血症,相关临床研究结果基本一致.但因Meta分析的自身局限性,我们仍急需开展设计严谨的高质量大样本临床研究,明确PPV临床疗效、作用机制、科学的操作流程及PPV对患者血流动力学的影响等临床实际问题,改善国内ALI与ARDS患者的临床护理水平.     

Effects of dynamic ventilatory factors on ventilator-induced lung injury in acute respiratory distress syndrome dogs

BACKGROUND:

Mechanical ventilation is a double-edged sword to acute respiratory distress syndrome (ARDS) including lung injury, and systemic inflammatory response high tidal volumes are thought to increase mortality. The objective of this study is to evaluate the effects of dynamic ventilatory factors on ventilator induced lung injury in a dog model of ARDS induced by hydrochloric acid instillation under volume controlled ventilation and to investigate the relationship between the dynamic factors and ventilator-induced lung injuries (VILI) and to explore its potential mechanisms.

METHODS:

Thirty-six healthy dogs were randomly divided into a control group and an experimental group. Subjects in the experimental group were then further divided into four groups by different inspiratory stages of flow. Two mL of alveolar fluid was aspirated for detection of IL-8 and TNF-α. Lung tissue specimens were also extracted for total RNA, IL-8 by western blot and observed under an electronic microscope.

RESULTS:

IL-8 protein expression was significantly higher in group B than in groups A and D. Although the IL-8 protein expression was decreased in group C compared with group B, the difference was not statistically significant. The TNF-α ray degree of group B was significantly higher than that in the other groups (P<0.01), especially in group C (P>0.05). The alveolar volume of subjects in group B was significantly smaller, and cavity infiltration and cell autolysis were marked with a significant thicker alveolar septa, disorder of interval structures, and blurring of collagenous and elastic fiber structures. A large number of necrotic debris tissue was observed in group B.

CONCLUSION:

Mechanical ventilation with a large tidal volume, a high inspiratory flow and a high ventilation frequency can cause significant damage to lung tissue structure. It can significantly increase the expression of TNF-α and IL-8 as well as their mRNA expression. Furthermore, the results of our study showed that small tidal ventilation significantly reduces the release of pro-inflammatory media. This finding suggests that greater deterioration in lung injury during ARDS is associated with high inspiratory flow and high ventilation rate.KEY WORDS: Acute respiratory distress syndrome, Dynamic factors, Inspiratory flow, Ventilator-induced lung injury     

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients

Objective: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. Design: A prospective, multi-institutional, initial cohort study including 28-day follow-up. Settings: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). Patients: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO₂/FIO₂ ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F ≤ 300 mmHg and bilateral infiltrates) and group 3 to patients with P/F of 300 mmHg or less but having exclusion criteria from the previous groups. Results: Nine hundred seventy-six patients entered the ICUs during the study period, 43 % of them being mechanically ventilated and 213 (22 %) meeting the criteria for one of the three groups. Among all the ICU admissions, ARDS, ALI and group 3 patients amounted, respectively, to 6.9 % (67), 1.8 % (17) and 13.3 % (129) of the patients, and represented 31.5 %, 8.1 % and 60.2 % of the hypoxemic, ventilated patients. The overall mortality rate was 41 % and was significantly higher in ARDS patients than in the others (60 % vs 31 % p < 0.01). In group 3, 42 patients had P/F less than 200 mmHg associated with unilateral lung injury; mortality was significantly lower (40.5 %) than in the ARDS group. In the whole group of hypoxemic, ventilated patients, septic shock and severity indices but not oxygenation indices were significantly associated with mortality, while the association with immunosuppression revealed only a trend (p = 0.06). Conclusions: In this survey we found that very few patients fulfilled the ALI non-ARDS criteria and that the mortality of the group with ARDS was high. Received: 21 September 1998 Final revision received: 3 February 1999 Accepted: 3 May 1999     

促红细胞生成素在急性肺损伤与急性呼吸窘迫综合征中作用的研究进展

急性肺损伤（ALI）或急性呼吸窘迫综合征（ARDS）是临床常见急危重症。各种病因包括严重感染、创伤、休克、急性胰腺炎、肺炎等肺内或肺外因素均可导致ALI/ARDS,发病机制主要包括炎症反应、细胞凋亡、氧化应激和肺泡毛细血管膜的损害等,目前尚无特殊有效的治疗方法,临床上也无修复肺损伤的有效药物。促红细胞生成素（EPO）作为一种多功能的内源性调节因子对各种组织损伤有一定的细胞保护作用,尤其是肺组织〔1〕,成为治疗ALI/ARDS的研究热点,     

Acute respiratory distress syndrome and lung injury: Pathogenetic mechanism and therapeutic implication

To review possible mechanisms and therapeutics for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). ALI/ARDS causes high mortality. The risk factors include head injury, intracranial disorders, sepsis, infections and others. Investigations have indicated the detrimental role of nitric oxide (NO) through the inducible NO synthase (iNOS). The possible therapeutic regimen includes extracorporeal membrane oxygenation, prone position, fluid and hemodynamic management and permissive hypercapnic acidosis etc. Other pharmacological treatments are anti-inflammatory and/or antimicrobial agents, inhalation of NO, glucocorticoids, surfactant therapy and agents facilitating lung water resolution and ion transports. β-adrenergic agonists are able to accelerate lung fluid and ion removal and to stimulate surfactant secretion. In conscious rats, regular exercise training alleviates the endotoxin-induced ALI. Propofol and N-acetylcysteine exert protective effect on the ALI induced by endotoxin. Insulin possesses anti-inflammatory effect. Pentobarbital is capable of reducing the endotoxin-induced ALI. In addition, nicotinamide or niacinamide abrogates the ALI caused by ischemia/reperfusion or endotoxemia. This review includes historical retrospective of ALI/ARDS, the neurogenic pulmonary edema due to head injury, the detrimental role of NO, the risk factors, and the possible pathogenetic mechanisms as well as therapeutic regimen for ALI/ARDS.     

肺部超声引导下胸部物理治疗急性呼吸窘迫综合征的临床疗效观察

目的 对比肺部超声引导下胸部物理治疗与单纯胸部物理治疗对机械通气急性呼吸窘迫综合征(ARDS)患者的疗效,探讨肺部超声在ARDS胸部物理治疗中的应用价值.方法 选取在我院行机械通气的ARDS患者104例,根据ARDS限制性保护通气策略随机分为两组,对照组52例,常规治疗加机械辅助排痰;超声组52例,常规治疗加超声引导机...     

Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review

Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the “sponge lung” - and the “shape matching” -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients’ response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.     

The effect of high-frequency oscillatory ventilation combined with tracheal gas insufflation on extravascular lung water in patients with acute respiratory distress syndrome: A randomized,crossover, physiologic study

Purpose

High-frequency oscillation combined with tracheal gas insufflation (HFO-TGI) improves oxygenation in patients with acute respiratory distress syndrome (ARDS). There are limited physiologic data regarding the effects of HFO-TGI on hemodynamics and pulmonary edema during ARDS. The aim of this study was to investigate the effect of HFO-TGI on extravascular lung water (EVLW).

Materials and methods

We conducted a prospective, randomized, crossover study. Consecutive eligible patients with ARDS received sessions of conventional mechanical ventilation with recruitment maneuvers (RMs), followed by HFO-TGI with RMs, or vice versa. Each ventilatory technique was administered for 8 hours. The order of administration was randomly assigned. Arterial/central venous blood gas analysis and measurement of hemodynamic parameters and EVLW were performed at baseline and after each 8-hour period using the single-indicator thermodilution technique.

Results

Twelve patients received 32 sessions. Pao₂/fraction of inspired oxygen and respiratory system compliance were higher (P < .001 for both), whereas extravascular lung water index to predicted body weight and oxygenation index were lower (P = .021 and .029, respectively) in HFO-TGI compared with conventional mechanical ventilation. There was a significant correlation between Pao₂/fraction of inspired oxygen improvement and extravascular lung water index drop during HFO-TGI (Rs = − 0.452, P = .009).

Conclusions

High-frequency oscillation combined with tracheal gas insufflation improves gas exchange and lung mechanics in ARDS and potentially attenuates EVLW accumulation.     

N-terminal pro-brain natriuretic peptide as a marker of right ventricular dysfunction after open-lung approach in patients with acute lung injury/acute respiratory distress syndrome

Purpose

The purpose of the study was to evaluate the utility of N-terminal pro-brain natriuretic peptide (NT-proBNP) as a marker of right ventricular (RV) dysfunction after open-lung approach (OLA) in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS).

Materials and Methods

Twenty-seven patients with ALI/ARDS underwent OLA (2-minute steps of fixed pressure-controlled ventilation with progressive positive end-expiratory pressure levels up to 30 cm H₂O, followed by stepwise decrement of positive end-expiratory pressure level by 2 cm H₂O). Patients who showed a PaO₂/FiO₂ increase of more than 50% from baseline were defined as responders. Plasma NT-proBNP levels were taken immediately before OLA and 2 and 6 hours later. A minimum 30% increase in NT-proBNP level from baseline was considered significant.

Results

Right-over-left ventricular stroke work ratio and its percentage change did not differ between responders and nonresponders, whereas these values were higher in patients showing NT-proBNP increase (P < .05). The NT-proBNP percentage change correlated with right-over-left ventricular stroke work ratio percentage change (r = 0.83), pulmonary vascular resistance (r = 0.81), and RV ejection fraction (r = -0.79) and correlated with plateau pressure in nonresponders only (r = 0.82).

Conclusions

In patients with ALI/ARDS, intraindividual NT-proBNP changes correlated with RV afterload following OLA, thereby serving as a potential marker for RV dysfunction after OLA.     

血管外肺水与脓毒症相关性ALI/ARDS预后关系的Meta分析

目的 研究血管外肺水(EVLW)在预测脓毒症相关性急性肺损伤/急性呼吸窘迫综合征预后中的价值.方法 检索1991年到2011年国内外公开发表的关于血管外肺水与脓毒症相关性ALI/ARDS预后关系的中英文文献,通过Stata软件进行Meta分析.结果 根据纳入和剔除标准筛选出7篇文献,Meta分析表明脓毒症相关性急性肺损伤/急性呼吸窘迫综合征患者中死亡组3d内的EVLW均维持在较高水平,而存活组有明显下降趋势,两组EVLW差距日趋扩大(SMDd1＜SMDd2＜SMD.d3),首日:SMD d1=0.29,95％CI:0.047～0.532;次日:SMDd2=1.64,95％ CI:0.14-3.13;第3天:SMDd3 =1.83,95％ CI:0.56～3.10.结论 脓毒症相关性急性肺损伤/急性呼吸窘迫综合征发病早期EVLW水平及其动态变化可作为预后评估指标,持续高水平的EVLW将增加死亡风险.     

动态通气参数对急性呼吸窘迫综合征犬肺损伤的作用机制

目的 探讨机械通气动态通气参数对ARDS犬肺内肺炎症介质的影响及其作用途径.方法 取36条健康杂种犬,采用气管内盐酸吸入法建立ARDS模型,随机(随机数字法)分为对照组,ARDS模型组及实验犬组,实验犬组随机分成A,B,c,D四组,每组6条.A组:小潮气量(6 mL/kg),低吸气流速[6mL/kg·s)],高通气频率(30次/min);B组:大潮气量(20mL/kg),高吸气流速[20mL/(kg·s)],高通气频率(30次/min);C组:大潮气量(20 mL/kg),高吸气流速[17 mL/(kg·s)],低通气频率(15次/min);D组:大潮气量(20 mL/kg),低吸气流速[10 mL/(kg·s)],低通气频率(15次/min).机械通气4 h后处死动物,留取肺组织标本行免疫组化、Western blotting检测TNF-α,IL-8,p38 MAPK蛋白的变化,RT-PCR测定TNF-α,IL-8 mRNA的表达,流式细胞仪检测NF-κB活性.结果 B组IL-8蛋白表达明显较A,D组高,c组IL-8蛋白表达较B组有下降趋势,但B,C组之间差异无统计学意义;B组TNF-α的灰度比值明显较其他组高(P<0.01),但与C组比较差异无统计学意义(P>0.05);B组p38 MAPK表达明显较A,D组高(P<0.01);A,D组之间的p38 NAPK表达差异无统计学意义(P>0.05).B组NF-κB p65(33.56±2.85)%表达较A(10.35±0.6)%,D(7.11±0.47)%两组差异有统计学意义,B组与C组(30.87±1.16)%之间差异无统计学意义.结论 在相同的大潮气量基础上,高吸气流速和高通气频率可以激活肺组织p38 MAPK及NF-κB通道,炎症介质的释放增加,导致呼吸机相关性肺损伤,小潮气量机械通气可减轻炎症反应.     

高呼气末正压通气结合小潮气量对急性肺损伤/急性呼吸窘迫综合征患者预后影响的荟萃分析

目的 系统评价高呼气末正压(PEEP)与低PEEP机械通气对急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)患者预后的影响.方法 通过检索美国<医学索引>、荷兰<医学文摘>、Cochrane临床试验数据库、中国生物医学文献数据库(CBM)和中国期刊网全文数据库(CNKI)等文献数据库,全面收集全世界范围内高PEEP与低PEEP治疗ALI/ARDS患者的随机对照试验(RCT),提取文献中的相关资料和评估方法学质量,而后采用Cochrane协作网RevMan 5.0软件对资料进行荟萃分析(Meta分析).结果 最终纳入6个RCT共2484例ALI/ARDS患者.A亚组的3个RCT中试验组采用了高PEEP(相对于对照组),对照组采用了低PEEP(相对于试验组),两组均采用了小潮气量(6 ml/kg)通气;B亚组的3个RCT中试验组采用了高PEEP加小潮气量,对照组采用了低PEEP加传统潮气量通气.合并结果显示,B亚组中高PEEP加小潮气量通气策略可以降低患者的28 d病死率[Peto比值比(OR)=0.40,95%可信区间(95%CI)0.22～0.72,P=0.003]和气压伤发生率(OR=0.20,95%CI 0.05～0.82,P=0.02);A亚组中,两组患者的28 d病死率(OR=0.86,95%CI 0.72～1.02,P=0.08)和气压伤发生率(OR=1.19,95%CI 0.89～1.58,P=0.25)差异无统计学意义.结论 高PEEP加小潮气量通气可以改善ALI/ARDS患者的28 d病死率和气压伤发生率,单独高PEEP的作用需要进一步评价.

Abstract：

Objective To compare the effects of high and low positive end-expiratory pressure (PEEP) levels on prognosis of patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). Methods The data in PubMed, EMbase, Cochrane Library, CBM and CNKI were retrieved. All randomized controlled trials (RCTs) of treatment of ALI/ARDS with PEEP with high or low level were included. Study selection and assessment, data collection and analyses were undertaken by two independent reviewers. Meta-analyses were done using Cochrane Collaboration's RevMan 5.0 software.Results Six RCTs, involving a total of 2 484 patients of ALI/ARDS were included in the review. According to ventilation strategy, all trials were divided into subgroup A (high PEEP+low tidal volume of 6 ml/kg vs.low PEEP+low tidal volume) and subgroup B (high PEEP+low tidal volume vs. low PEEP+traditional tidal volume). In subgroup B, there were three RCTs, and high PEEP was found to be associated with a lower 28-day mortality [odds ratio (OR)=0. 40, 95% confidence interval (95%CI) 0.22 -0.72, P=0.003]and a lower barotraumas (OR = 0.20,95%CI 0.05 - 0.82, P = 0.02) in patients with ALI/ARDS. In subgroup A, there were three RCTs, and it was found that the differences in 28-day mortality (OR=0.86,95%CI 0.72 - 1.02, P = 0.08) and barotraumas (OR = 1.19, 95%CI 0.89 - 1.58, P= 0.25) were not significant. Conclusion As compared with conventional ventilation, high PEEP and low tidal volume ventilation are associated with improved survival and a lower rate of barotrauma in patients with ALI/ARDS.It is necessary to further confirm the role of high PEEP only in the ventilation strategy in patients with ALI/ARDS.     

Recovery from lung injury in survivors of acute respiratory distress syndrome: difference between pulmonary and extrapulmonary subtypes

Objective To determine whether long-term outcome differs between acute respiratory distress syndrome (ARDS) resulting from pulmonary (ARDSp) and extrapulmonary (ARDSexp) causes.Design Observational study.Setting Medical intensive care unit of a university hospital.Patients Twenty-nine ARDS patients (16 ARDSp and 13 ARDSexp) who survived over 6 months after diagnosis.Measurements and results The two groups did not differ according to demographic data and severity indices on admission. The duration of ICU stay (median 21 days [interquartile range, 12–43 days] vs 12 [6.5–20] days, p=0.097) tended to be longer and total ventilation time (360 [96–700] h vs 144 [42.5–216] h, p=0.045) were longer in the patients with ARDSp. The ARDSp patients showed more severe abnormalities on thin-section computed tomography (CT), including ground-glass opacity (GGO; 6 [3–16] vs 0 [0–2.5], p=0.002), reticular density (12 [8–14] vs 5 [2–9], p=0.033) and the sum of all four patterns of lesion (20 [11–27] vs 5 [2–12], p=0.006). There were no between-group differences in Spitzers Quality of Life index and the Chronic Respiratory Questionnaire.Conclusions These results suggest that ARDSp would leave more severe lung sequelae than ARDSexp, but the clinical relevance of their difference is questionable.This study was performed with the support of an Asan Medical Center Institutional fund.     

重度光气中毒致急性呼吸窘迫综合征患者的临床特点及救治策略

目的 探讨重度光气中毒所致急性呼吸窘迫综合征(ARDS)患者的临床特点及救治策略.方法 17例重度光气中毒患者采用个体化综合治疗;治疗前后进行血常规、电解质、动脉血气分析、肝肾功能和心肌酶学等检测.结果 治疗后,17例重度中毒患者的一般体征、水和电解质及酸碱平衡紊乱改善,与治疗前比较,白细胞计数(WBC,×109/L:12.18±4.76比21.93±6.21)、中性粒细胞比例(0.87±0.05比0.92±0.03)、血红蛋白(Hb,g/L:128.12±25.65比173.71±23.53)、血小板计数(PLT,×109/L:165.12±31.70比254.47±70.80)、丙氨酸转氨酶(ALT,U/L:70.71±46.70比212.71±141.34)、天冬氨酸转氨酶(AST,U/L:52.47±34.68比82.41±34.60)、血尿素氮(BUN,mmol/L:5.83±4.09比7.89±5.96)、血肌酐(SCr,μmol/L:48.13±14.97比67.25±24.29)、乳酸脱氢酶(LDH,U/L:280.10±81.77比586.35±186.71)、肌酸激酶(CK,U/L:199.12±106.75比683.00±323.31)、肌酸激酶同工酶(CK-MB,U/L:26.94±9.13比45.59±11.21)、血Na+(mmol/L:140.61±6.69比134.06±4.80)、血Cl-(mmol/L:95.88±6.06比102.29±7.28)、呼吸频率(RR,次/min:20.88±4.30比30.06±5.78)、心率(HR,次/min:82.76±17.16比113.35±16.90)、pH值(7.34±0.44比7.39±0.03)、血氧分压(PO2,mm Hg,1 mm Hg=0.133 kPa:84.41±30.58比59.88±15.19)、脉搏血氧饱和度(SPO2:0.91±0.08比0.78±0.15)差异均有统计学意义(P＜0.05或P＜0.01).17例重度中毒患者中16例完全康复,1例死亡,治愈率94.12％.结论 光气中毒的临床表现主要为呼吸系统损害,并发ARDS,在治疗上应早期采用皮质激素及呼吸支持等综合治疗措施.     

Clinical trial design—effect of prone positioning on clinical outcomes in infants and children with acute respiratory distress syndrome

PurposeThis paper describes the methodology of a clinical trial of prone positioning in pediatric patients with acute lung injury (ALI). Nonrandomized studies suggest that prone positioning improves oxygenation in patients with ALI/acute respiratory distress syndrome without the risk of serious iatrogenic injury. It is not known if these improvements in oxygenation result in improvements in clinical outcomes. A clinical trial was needed to answer this question.Materials and MethodsThe pediatric prone study is a multicenter, randomized, noncrossover, controlled clinical trial. The trial is designed to test the hypothesis that at the end of 28 days, children with ALI treated with prone positioning will have more ventilator-free days than children treated with supine positioning. Secondary end points include the time to recovery of lung injury, organ failure–free days, functional outcome, adverse events, and mortality from all causes. Pediatric patients, 42 weeks postconceptual age to 18 years of age, are enrolled within 48 hours of meeting ALI criteria. Patients randomized to the prone group are positioned prone within 4 hours of randomization and remain prone for 20 hours each day during the acute phase of their illness for a maximum of 7 days. Both groups are managed according to ventilator protocol, extubation readiness testing, and sedation protocols and hemodynamic, nutrition, and skin care guidelines.ConclusionsThis paper describes the process, multidisciplinary input, and procedures used to support the design of the clinical trial, as well as the challenges faced by the clinical scientists during the conduct of the clinical trial.     

Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis

BACKGROUND: There are conflicting results regarding whether corticosteroids have better efficacy than placebo in acute respiratory distress syndrome (ARDS) patients. Therefore, we aim to further evaluate the efficacy and safety of corticosteroids in adult ARDS patients.