chuka_lis (chuka_lis) wrote,

К вопросу использования кортикостероидов

Хорошо бы и врачи читали такие статьи, и администраторы, диктующие протоколы лечения, тоже.
Acute lung injury and acute respiratory distress syndrome are partly caused by host immune responses. Corticosteroids suppress lung inflammation but also inhibit immune responses and pathogen clearance.
In SARS-CoV infection, as with influenza, systemic inflammation is associated with adverse outcomes.
Theoretically, corticosteroid treatment could have a role to suppress lung inflammation.
No clinical data exist to indicate that net benefit is derived from corticosteroids in the treatment of respiratory infection due to RSV, influenza, SARS-CoV, or MERS-CoV. The available observational data suggest increased mortality and secondary infection rates in influenza, impaired clearance of SARS-CoV and MERS-CoV, and complications of corticosteroid therapy in survivors. If it is present, the effect of steroids on mortality in those with septic shock is small, and is unlikely to be generalisable to shock in the context of severe respiratory failure due to 2019-nCoV.
У трети пациентов, укоторых САРС лечили кортикостероидами, развился кортикостероид-индуцированный диабет. У трети случился остеонекроз, и у 75%-развился остеопороз. Кроме того, они болели и выделяли вирус  дольше (тк корстикостероиды подавляют работу иммунитета), и у части случался после введния стероидов психоз.
Когда лечили гриппозную пневмонию стероидами,  это повышало смертность пациентов.
Течение пневмонии Ковид-19 примерно такое же, как и САРС,  ТОРС развивается тоже по похожему сценарию,   в этой статье можно почитать подробности  безуспешного лечения 50летнго китайца, коорому ничего не помогло, зато задокументиована картина развития заболевания и патологии
"The pathological features of COVID-19 greatly resemble those seen in SARS and Middle Eastern respiratory syndrome (MERS) coronavirus infection...We found that the counts of peripheral CD4 and CD8 T cells were substantially reduced, while their status was hyperactivated...results imply that overactivation of T cells, manifested by increase of Th17 and high cytotoxicity of CD8 T cells, accounts for, in part, the severe immune injury in this patient.
При исследовании на выборке "критических", картина пневмоний тоже похожая.
"Тhe most common symptoms were fever (98%), cough (77%), and dyspnoea (63·5%). Among 52 critically ill  patients,  six  (11%)  did  not  experienced  fever  until  2–8   days   after   the   onset   of   symptoms   related   to   SARS-CoV-2 infection. The median duration from onset of symptoms to radiological confirmation of pneumonia was 5 (IQR3–7) days. The median duration from onset of symptoms to ICU admission was 9·5 (7·0–12·5) days. ..The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of all patients was 17 (IQR 14–19). Most patients had organ function damage, including 35 (67%) with ARDS, 15 (29%) with acute kidney injury, 12 (23%) with cardiac injury, 15 (29%) with liver dysfunction, and one (2%) with pneumothorax "
правда, считают, что смертность критических при Ковид-19 выше (почти 62%), чем при САРС и МЕРС (40-49%)
"33   (63·5%)   patients   were   treated   with   high-flow   nasal  cannula,  37  (71%)  with  mechanical  ventilation,  six (11·5%) with prone position ventilation, six (11·5%) with  extracorporeal  membrane  oxygenation  (ECMO),  nine   (17%)   with   renal   replacement   therapy,   and   18 (35%) with vasoconstrictive agents.
23 (44%) patients  received  antiviral  agents,  49  (94%)  received  antibacterial  agents,  and  30  (58%)  patients  received  glucocorticoids  Oseltamivir   was   given   to   18 (35%) patients, ganciclovir to 14 (27%), and lopinavir to seven (13·5%).For   the   primary   outcome,   among   52   critically   ill   patients with SARS-CoV-2 infection, 32 (61·5%) patients had died at 28 days, and the median duration from ICU admission  to  death  was  7 days  in  the  non-survivors.   Compared   with   survivors,   non-survivors were more likely to develop ARDS (26 [81%] vs9  [45%])  and  were  more  likely  to  receive  mechanical  ventilation (30 [94%] vs 7 [35%]). 30 (81%) of 37 patients requiring mechanical ventilation had died by 28 days."
Сейчас в Китае проводится заодно и клиническое исследование,  на сколько эффективны глюкокортикоиды:
"Although,  intravenous  glucocorticoids  were  commonly  used in patients with severe SARS or MERS pneumonia, their  efficacy  remains  controversial  and  their  use  to  treat  SARS-CoV-2 infection is also controversial.
An ongoing clinical trial (NCT04244591) might shed some light on the safety and efficacy of these drugs as treatment."
кстати, в этом же исследовании отмечено, что баротравма (пневмоторакс) от искуссвтенной вентиляции слуичлась только у 2% больных, "In  patients with SARS, barotrauma occurred in about 25% of   patients   on   mechanical   ventilation.14   The   lower   occurrence  of  barotrauma  in  our  cohort  is  probably  related  to  the  widely  accepted  strategy  of  protective  ventilation in mainland China".

"In conclusion, the mortality of critically ill patients with SARS-CoV-2 pneumonia is high. The survival term of the non-survivors is likely to be within 1–2 weeks after ICU admission. Older patients (>65 years) with comorbidities and ARDS are at increased risk of death. The severity of SARS-CoV-2  pneumonia  poses  great  strain  to  hospital  critical care resources, especially if they are not adequately staffed or resourced".
Хорошо бы нашли что-то более узко-специфичное, для  снижения воспаления и отека легких...
Tags: коронавирус, лечение, медицина, статья
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