El tratamiento con glucocorticoides en pacientes con síndrome de dificultad respiratoria aguda. Una revisión sistemática de la literatura y metaanálisis / Glucocorticoid treatment in patients with acute respiratory distress syndrome. A systematic review and meta-analysis

Introducción: el síndrome de dificultad respiratoria aguda (SDRA) es secundario a inflamación originada en una enfermedad pulmonar primaria o una afección extrínseca al pulmón. Es frecuente en cuidado intensivo y conlleva alta mortalidad. Objetivos: determinar la eficacia y seguridad de los glucocorticoides en dosis bajas en personas mayores de 18 años con SDRA, en términos de mortalidad, días libres de ventilación mecánica, incidencia de infecciones nosocomiales, neuromiopatía y sangrado digestivo. Metodología: se hizo una búsqueda sistemática de ensayos clínicos controlados que compararon glucocorticoides con placebo, en adultos con SDRA en los desenlaces descritos. También, búsqueda secundaria de ensayos clínicos referenciados en los artículos primarios. Resultados: se encontraron siete ensayos clínicos. Se demostró disminución de la mortalidad hospitalaria al día 28 (OR: 0,56 [0,38-0,81], ganancia de 3,5 días libres de ventilación mecánica, disminución en la incidencia de infecciones nosocomiales y neumonía adquirida en el hospital. No hubo diferencias en la neuromiopatía asociada con esteroides, pero sí una tendencia, no significativa, al aumento del sangrado digestivo. Conclusión: los esteroides en dosis bajas disminuyen la mortalidad al día 28 de los adultos con SDRA y aumentan los días libres de ventilación mecánica sin aumentar los efectos adversos significativos.

Background: The Acute Respiratory Distress Syndrome (ARDS) is a lung inflammation secondary to primary or extrinsic pulmonary pathology. It is a common disease in the intensive care unit and its mortality rate is high. Objectives: To determine the efficacy and safety of corticosteroids in patients with ARDS older than 18 years, in terms of mortality, mechanical ventilationfree days, and safety in regard to nosocomial infections, health-care related pneumonia, neuromiopathy, and gastrointestinal bleeding. Search methods: A systematic search of electronic and manual literature was done, without restriction of language, of controlled clinical trials involving adults with ARDS, randomized to placebo vs. steroids, and that measured the outcomes described. Results: Seven clinical trials were found showing a decrease in hospital mortality (OR 0.56 [0.38-0.81], 3.5 more days free from mechanical ventilation, a decrease in nosocomial infections and in hospitalacquired pneumonia. There were no differences in the presentation of steroid-associated neuromiopathy. There was a non-significant tendency to increase in bleeding from the digestive tract. Conclusion: Low-dose steroids seem to have a beneficial effect on mortality and ventilator-free days in adult patients with ARDS with no increase in adverse effects.

A Case of Vivax Malaria Complicated by Adult Respiratory Distress Syndrome and Successful Management with Extracorporeal Membrane Oxygenation

Complicated malaria is mainly caused by Plasmodium falciparum, but, increasingly, Plasmodium vivax is also being reported as a cause. Since the reemergence of indigenous vivax malaria in 1993, cases of severe malaria have been steadily reported in Korea. Herein, we report a case of vivax malaria complicated by adult respiratory distress syndrome (ARDS) that was successfully managed with extracorporeal membrane oxygenation (ECMO). A 59-year-old man presented at our hospital with fever and abdominal pain, which had persisted for 10 days. On admission, the patient had impaired consciousness, shock, hypoxia and haziness in both lungs, jaundice, thrombocytopenia and disseminated intravascular coagulation, metabolic acidosis, and acute kidney injury. A peripheral blood smear and a rapid diagnostic test verified P. vivax mono-infection. Ten hours after admission, hypoxia became more severe, despite providing maximal ventilatory support. The administration of antimalarial agents, ECMO, and continuous venovenous hemofiltration resulted in an improvement of his vital signs and laboratory findings. He was discharged from the hospital 7 weeks later, without any sequelae.

Duchenne muscular dystrophy in northeastern Thai children: a retrospective study

Background: Duchenne muscular dystrophy (DMD) is the most common hereditary neuromuscular disease. No curative treatment for DMD is known. Prednisone therapy is the first medical treatment that alters the course of DMD. Several studies about the doses and administrations of prednisone or prednisolone had been reported. Objectives: To review clinical features, laboratory findings, and the result of treatment of DMD. Methods: DMD patients who came to Srinagarind Hospital, Thailand from January, 1995 to January, 2007 were retrospectively analyzed. Results: Sixty-two patients fulfilled the study criteria. All patients were male (100 %). Mean age at onset was 4.9 years. Family history was found in 10 families (16 %). The most common symptoms were weakness, standing difficulty, and gait abnormality (100, 97, and 93 % respectively). The most common clinical signs were calf hypertrophy, weakness, and Gower sign (100, 100, and 94 % respectively). Serum creatine kinase (CK) was raised in all of the patients with mean serum CK 13,026 IU/L. Fifty patients received prednisolone. Twelve received only supportive treatments. The overall outcomes of prednisolone treatment were better, same, and worse in 37, 51, and 12 % respectively. Mean age at wheel chair was 10.8 years. Three patients with associate diseases; adult respiratory distress syndrome (ARDS), Sturge Weber syndrome, and autism were presented. To the best of our knowledge, this is the first report about DMD concomitant with ARDS and DMD with Sturge-Weber syndrome. DMD with autism, a very rare occurrence, is presented. Conclusion: Clinical features, laboratory findings, and the outcomes of treatments of 62 DMD patients were presented. Prednisolone treatment had some beneficial effects and had significant side effects. Starting with a low dose, and then increasing to high dose in the no response patient is recommended.

A Study on Pulmonary Extraction Rates of Biogenic Amines and Permeability of Serum Albumin in Dogs with Experimental Acute Respiratory Failure / 대한마취과학회지

The extraction rates of biogenic amines such as 5-hydroxytryptamine(5-HT) and norepinephrine(NE) in pulmonary endothelium, and the permeability of human serum albumin(HSA) to pulmonary epithelium were measured in experimental adult respiratory distress syndrome(ARDS), in order to evaluate their usefulness for the early recognition of ARDS. Sixteen mongrel dogs(body weight, 13+/-0.9 kg) were divided into 3 groups; Oleic acid 0.06 ml/kg was injected to 6 dogs(M group) and oleic acid 0.12 ml/kg to 6 dogs(S group). Four dogs were used as a control group. The extraction rates(%) of 14C-5-HT and 3H-NE, the blood concentration of (99m)Tc-HSA, hemodynamic changes and changes of arterial gas profile were measured and compared among three groups. In control group with 100% oxygen ventilation, the extraction rates of 14C-5-HT, 3H-NE and the blood concentration of 99mTc-HSA were not changed. In M group, the extraction rate(%) of 14C-5-HT was decreased from 61.5+/-3.1 to 43.8+/-5.2 in 10 minutes, and such decreased extraction rate(%) was maintained for 2 hours. The extraction rate(%) of (3)H-NE was decreased from 32.3+/-3.6 to 19.5+/-2.5 in 10 minutes. In S group, the extraction rate(%) of 14C-5-HT was decreased from 60.9+/-5.1 to 23.2+/-5.7 in the first 10 minutes, and the extraction rate(%) of H-NE was decreased from 30.1+/-4.3 to l3.1+/-1.9 in 10 min, and decreased slowly thereafter. The blood concentration of 99mTc-HSA was decreased significantly in M group and more in S group compared with control group during two-hour observation. These results suggest that measuring extraction rates of biogenic amines couid be applied for early recognition of ARDS, however, the change of blood 99mTc-HSA concentration could not be applied for early recognition of ARDS, because it has poor correlation to the progression of respiratory failure.