大剂量甲强龙联合保护性通气策略治疗创伤性ARDS的疗效及机制探讨  

Effect and mechanism of high dose methylprednisolone combined with protective ventilation on traumatic acute respiratory distress syndrome

作　　者：单世民[1] 王鹏[1] 郝伟[1] 任立洁[1] 张军[1] 王志松[1] 

机构地区：[1]天津市第五中心医院,天津300450

出　　处：《山东医药》2014年第24期19-22,共4页Shandong Medical Journal

基　　金：天津市滨海新区卫生局科技项目(2012BWKY009);天津市塘沽科委科技兴区项目(2010XQ15-09)

摘　　要：目的观察大剂量甲强龙联合保护性通气策略治疗严重创伤性急性呼吸窘迫综合征（ARDS）的疗效,并探讨其机制。方法将60例创伤性ARDS患者随机分为A、B两组各30例,均行常规治疗;A组行容量控制通气（VCV）,潮气量10～15 mL/mg;B组VCV潮气量4～6 mL/mg,PEEP 5～12 cmH2O,静推甲强龙5 mg/（kg·h）。分别于入术室（T0）、治疗1 h（T1）、3 h（T2）,记录血流动力学指标并行血气分析;T1、T2时检测肺泡灌洗液（BALF）中的丙二醛（MDA）、NO、诱导型NO合成酶（iNOS）、超氧化物歧化酶（SOD）及髓过氧化物酶（MPO）及骨形态发生蛋白2（BMP-2）mRNA、蛋白。结果与T0时比较,两组SBP、心排血量、心脏指数、左心作功和左心作功指数均显著增高,而HR、外周血管阻力、外周血管阻力指数显著下降,且B组较A组变化更显著,P均〈0.05;与T0时比较,两组氧合指数、pH、SpO2升高,乳酸、PCO2降低,B组较A组氧合指数、SpO2、乳酸变化更明显,P均〈0.05;A组T1、T2时BALF中MDA、NO、iNOS、MPO、BMP-2 mRNA及其蛋白高于B组,而SOD下降,P均〈0.01。结论大剂量甲强龙联合保护性通气策略治疗创伤性ARDS可明显改善其血流动力学及血气指标,该作用与其增加BMP-2表达、抑制肺氧化损伤有关。Objective To observe the efficacy of high dose methylprednisolone combined with protective ventilation on traumatic acute respiratory distress syndrome（ ARDS） and to investigate the mechanism. Methods Sixty patients with severe traumatic ARDS were randomly divided into two groups,30 cases in each group： traditional tidal volume group（ group A,VT 10-15 mL /kg） and protective ventilation group（ group B,LVT 4-6 mL /kg ＋ positive end expiratory pressure 5-12cmH2O ＋ methylprednisolone 5 mg /kg /h）. Recording the hemodynamics index and conducting the blood gas analysis at the time of entering operation-room（ T0） and treatment for 1 hour（ T1） and treatment for 3 hour（ T2） in the two groups.Bronchoalveolar lavage fluid（ BALF） was extracted to measure MDA,NO,inducible nitric oxide synthase（ iNOS）,superoxide dismutase（ SOD） and myeloperoxidase（ MPO）. Meanwhile,the expression of bone morphogenetic protein-2（ BMP-2） was detected. Results Compared with T0,SBP,cardiac output,cardiac index,left ventricular function and left ventricular work indexes were significantly increased,while HR,peripheral vascular resistance,peripheral vascular resistance index decreased significantly,and the changes in group B was more significantly than in group A,all P〈 0. 05; compared with T0,the oxygenation index,pH,SpO2increased,but lactic acid and PCO2decreased; compared with group A,the index of oxygenation,SpO2and lactic acid changes more significantly in group B（ all P〈 0. 05）. However,MDA,NO,iNOS,MPO and BMP-2 mRNA and protein expression were higher in group A at T1and T2than those in group B（ all P〈 0. 01）. Conclusion High-dose methylprednisolone combined with protective ventilation can significantly change the hemodynamics and blood gas index in the treatment of severe traumatic ARDS,whose mechanism may be related to up-regulation of BMP-2 gene and inhibition of lung oxidative damage.

关 键 词：急性呼吸窘迫综合征 甲基氢化泼尼松 机械通气 血流动力学 氧自由基 骨形态发生蛋白2 

分 类 号：R563.8[医药卫生—呼吸系统]