中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

小中剂量糖皮质激素在人感染 H7N9 禽流感中的初步应用

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目的分析探讨小中剂量糖皮质激素在人感染 H7N9 禽流感中的初步临床应用效果,并探索激素使用的时机和疗程。方法收集遂宁市中心医院 2017 年 1 月 25 日至 2017 年 5 月 12 日收治的 8 例人感染 H7N9 禽流感患者资料,纳入 5 例使用激素的危重症患者。观察患者接受激素治疗后的疾病转归,包括临床表现,感染指标(血白细胞、C 反应蛋白、血清降钙素原),炎症指标(CK、HBDH、LDH),体温变化,氧合改善情况(SpO2/FiO2),呼吸机脱机情况,以及预后。结果5 例患者均为重症人感染 H7N9 禽流感患者,1 例女性,4 例男性,中位年龄 58.0 岁,2 例死亡,3 例存活。5 例患者发病至入院时间中位数 4 d;发病至确诊时间中位数 8 d,入传染病 ICU 时间为入院后第 3 d(中位数)。第 1 次接受系统性激素治疗在入院后第 11 d(中位数),持续时间 4 d(中位数)。在病情加重初期使用激素可以使 HBDH 和 LDH 下降,患者氧合状态好转。第 2 次接受系统性激素治疗在入院后第 26.5 d(中位数),持续时间 9 d(中位数),存活患者氧合状态有不同程度改善(SpO2/FiO2 比值有所升高),并在此阶段脱离呼吸机支持。结论对于人感染 H7N9 禽流感患者,小中剂量激素或可在一定程度上降低炎症水平,提高患者氧合指标,促进患者脱离呼吸机支持。小中剂量激素可在病情加重初期,炎症峰值过后或同期,急性呼吸窘迫综合征(ARDS)发病 10~14 d 以内开始使用;或可在患者氧合状态得不到明显提升时(难以用其他原因解释)加用,可在呼吸机脱机困难、脓毒性休克、难以解释的反复发热时使用,使用约 10~14 d 或使用至血清 HBDH、LDH 水平再次降低。以上推论还需进一步增加样本量或设立较大型对照研究来证实。

ObjectiveTo evaluate the effect of low-to-moderate doses of corticosteroids on human infections with avian influenza A (H7N9) virus, and explore when to initiate the treatment of corticosteroids and the duration of corticosteroids administration.MethodsThe study collected clinical data of 8 cases with avian influenza A (H7N9) virus infection admitted from January 25, 2017 to May 12, 2017. The final analysis included 5 severe patients who had received adjuvant corticosteroid treatment. The variation curves of WBC, CRP, PCT, CK, HBDH, LDH, temperature, ratio of SpO2/FiO2 were depicted and analyzed. The progress of clinical improvements, deterioration and prognosis were observed and discussed.ResultsThere were 1 female and 4 males in the 5 included patients with a median age of 58.0 years, among them 3 survived. The median time of illness onset to hospitalization and diagnosis confirmed were 4 days and 8 days respectively; the median duration of hospitalization to admission to infective ICU were 3 days. The first course of adjuvant corticosteroid treatment was initiated 11 days (median) after admission with a duration of 4 days (median), during which, the serum levels of HBDH and LDH decreased remarkably except the patient 3, and the oxygenation (SpO2/FiO2) improved except the patient 3. The second course of systemic administration of corticosteroid was given at a median of 26.5 days after admission with a duration of 9 days (median), during which, the patients survived with improved oxygenation (SpO2/FiO2), and weaned from mechanical ventilation.ConclusionsFor patients suffered severe human infection with avian influenza A (H7N9) virus, low-to-moderate doses of corticosteroids may decrease the level of inflammation, regulate the aberrant immune response, improve the oxygenation, make an early unassisted breathing. And corticosteroids treatment can be initiated at the time of disease deterioration, after/at the peak inflammatory response, and within 10-14 days of ARDS. Also, the adjuvant corticosteroids may be administered when oxygenation is dificult to be improved by other ways, or dificult to be liberated from mechanical ventilation, suffering severe septic shock, and refractory fever. And the duration of corticosteroids may be prolonged to 10-14 days, or until the higher level of HBDH and LDH decreased again.

关键词: 糖皮质激素; 人感染 H7N9 禽流感; 急性呼吸窘迫综合征

Key words: Corticosteroids; Human infections with avian influenza A (H7N9) virus; Acute respiratory distress syndrome

引用本文: 曹霖, 龚宇, 夏洪韬, 敬毅, 赵界, 李毅, 何洋, 刘涛, 骆华宇, 赵川, 何正光. 小中剂量糖皮质激素在人感染 H7N9 禽流感中的初步应用. 中国呼吸与危重监护杂志, 2018, 17(1): 33-41. doi: 10.7507/1671-6205.201708057 复制

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