pulmoПульмонологияPULMONOLOGIYA0869-01892541-9617Scientific and Practical Journal “PULMONOLOGIYA” LLC10.18093/0869-0189-2024-34-6-775-787pulmo-4662Research ArticleПЕРЕДОВАЯ СТАТЬЯEDITORIALПерспективы адъювантной терапии внебольничной пневмонии системными глюкокортикостероидами: от эксперимента к клинической практикеProspects for adjuvant therapy with systemic corticosteroids for community-acquired pneumonia: from experiment to clinical practicehttps://orcid.org/0000-0001-7914-6173РудаковЮ. В.RudakovYu. V.

Рудаков Юрий Викторович – к. м. н., доцент 1-й кафедры (терапии усовершенствования врачей) имени академика Н.С. Молчанова.

194044, Санкт-Петербург, ул. Академика Лебедева, 6; тел.: (921) 415-45-97

Yuri V. Rudakov - Сandidate of Medicine, Associate Professor, 1st Department and Clinic (Advanced Physician Therapy) named after Academician N. S.Molchanov.

Ul. Akademika Lebedeva 6, Saint-Petersburg, 6194044; tel.: (921) 415-45-97

rudakov_yura@mail.ruhttps://orcid.org/0000-0003-1851-0941СалуховВ. В.SalukhovV. V.

Салухов Владимир Владимирович – д. м. н., профессор, начальник 1-й кафедры и клиники (терапии усовершенствования врачей) имени академика Н.С. Молчанова.

194044, Санкт-Петербург, ул. Академика Лебедева, 6; тел.: (921) 415-45-97

Vladimir V. Salukhov - Doctor of Medicine, Professor, Head of the 1st Department and Clinic (Advanced Physician Therapy) named after Academician N.S. Molchanov.

Ul. Akademika Lebedeva 6, Saint-Petersburg, 6194044; tel.: (921) 415-45-97

vlasaluk@yandex.ruhttps://orcid.org/0000-0002-6521-7986ХаритоновМ. А.KharitonovM. A.

Харитонов Михаил Анатольевич – д. м. н., профессор, профессор 1-й кафедры (терапии усовершенствования врачей) имени академика Н.С. Молчанова.

194044, Санкт-Петербург, ул. Академика Лебедева, 6; тел.: (921) 415-45-97

Mikhail A. Kharitonov - Doctor of Medicine, Professor, Professor, 1st Department and Clinic (Advanced Physician Therapy) named after Academician N.S. Molchanov.

Ul. Akademika Lebedeva 6, Saint-Petersburg, 6194044; tel.: (921) 415-45-97

micjul11@yandex.ruhttps://orcid.org/0000-0002-3880-9548ВолошинН. И.VoloshinN. I.

Волошин Никита Игоревич – адъюнкт 1-й кафедры (терапии усовершенствования врачей) имени академика Н.С. Молчанова.

194044, Санкт-Петербург, ул. Академика Лебедева, 6; тел.: (921) 415-45-97

Nikita I. Voloshin - Adjunct, 1st Department and Clinic (Advanced Physician Therapy) named after Academician N.S. Molchanov.

Ul. Akademika Lebedeva 6, Saint-Petersburg, 6194044; tel.: (921) 415-45-97

nikitavoloshin1990@gmail.comhttps://orcid.org/0000-0002-5999-2150АвдеевС. Н.AvdeevS. N.

Авдеев Сергей Николаевич – д. м. н., профессор, академик Российской академии наук, заведующий кафедрой пульмонологии Института клинической медицины имени Н.В. Склифосовского Первый МГМУ имени И.М. Сеченова; главный внештатный специалист-пульмонолог Министерства здравоохранения Российской Федерации; директор Национального медицинского исследовательского центра по профилю «Пульмонология».

119991, Москва, ул. Трубецкая, 8, стр. 2, тел.: (495) 708-35-76

Sergey N. Avdeev - Doctor of Medicine, Professor, Academician of Russian Academy of Sciences, Head of the Department of Pulmonology, N.V.Sklifosovsky Institute of Clinical Medicine, Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First MSMU of the Ministry of Health of the Russian Federation (Sechenov University); Chief Freelance Pulmonologist of the Ministry of Health of the Russian Federation; Director of the National Medical Research Center for Pulmonology.

Ul. Trubetskaya 8, build. 2, Moscow, 119991; tel.: (495) 708-35-76

serg_avdeev@list.ruФедеральное государственное бюджетное военное образовательное учреждение высшего образования «Военно-медицинская академия имени С.М. Кирова» Министерства обороны Российской ФедерацииРоссияFederal State Budgetary Military Educational Institution of Higher Education “Military Medical Academy named after S.M. Kirov” of the Ministry of Defense of the Russian FederationRussian FederationФедеральное государственное автономное образовательное учреждение высшего образования Первый Московский государственный медицинский университет имени И.М. Сеченова Министерства здравоохранения Российской Федерации (Сеченовский Университет)РоссияFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)Russian Federation202410122024346775787Copyright © Рудаков Ю.В., Салухов В.В., Харитонов М.А., Волошин Н.И., Авдеев С.Н., 20242024Рудаков Ю.В., Салухов В.В., Харитонов М.А., Волошин Н.И., Авдеев С.Н.Rudakov Y.V., Salukhov V.V., Kharitonov M.A., Voloshin N.I., Avdeev S.N.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.pulmonology.ru/pulm/article/view/4662

В ряде случаев у пациентов с тяжелой внебольничной пневмонией (ТВП), несмотря на своевременную и адекватную антибактериальную терапию, возникают смертельные осложнения в виде острого респираторного дистресс-синдрома (ОРДС) и / или септического шока (СШ), обусловленные, как предполагается, чрезмерным неконтролируемым системным воспалительным ответом и неадекватной реакцией надпочечников на инфекцию из-за кортикостероидной (КС) недостаточности, связанной с критическим состоянием. Поэтому при дополнительном применении системных глюкокортикостероидов (сГКС) может существенно улучшиться выживаемость пациентов, переносящих ТВП.

Целью работы явилась демонстрация наиболее актуальных доклинических и клинических исследований и метаанализов, по данным которых оценивается эффективность и безопасность применения системных ГКС при ВП.

Результаты

Результаты. Продемонстрировано, что наиболее оптимальной в отношении риска / пользы схемой применения сГКС является ранняя (в первые 3 суток) низкодозовая (доза, эквивалентная 6 мг в сутки дексаметазона) терапия коротким курсом (5–7 дней) с одномоментной отменой препаратов. Применяется такая схема с наилучшим эффектом у пациентов с ТВП, нуждающихся в искусственной вентиляции легких (инвазивной или неинвазивной) при создании положительного давления в конце выдоха ≥ 5 см вод. ст. или высокопоточной кислородотерапии (вдыхаемая фракция кислорода (FiO2) ≥ 50 %; соотношение парциального давления кислорода в артериальной крови (РаO2) и FiO2 < 300) и / или вазопрессорной поддержке.

Заключение

Заключение. Согласно федеральным клиническим рекомендациям, в настоящее время не следует рутинно применять КС у взрослых пациентов с ВП, за исключением лиц с рефрактерным СШ, однако по результатам описательного обзора продемонстрированы доказательства эффективности использования дополнительной терапии КС у взрослых пациентов при ТВП, особенно осложненной СШ, ОРДС, наличии сопутствующей патологии в виде бронхиальной астмы и / или хронической обструктивной болезни легких при условии отсутствия легочных нагноений, тяжелой гриппозной и микотической инфекции, что, несомненно, является веским аргументом в пользу пересмотра существующих отечественных клинических рекомендаций в части, касающейся применения сГКС. Таким образом, необходимы дальнейшие исследования, чтобы установить подгруппы пациентов, которые могут получить дополнительную пользу или, наоборот, потенциальный вред от терапии КС. Кроме того, требуется определить оптимальную схему применения КС с уточнением конкретных препаратов, их дозы, путей введения, кратности и продолжительности терапии, а также методики отмены.

Some patients with severe community-acquired pneumonia develop fatal complications in the form of acute respiratory distress syndrome and/or septic shock despite the timely adequate antibacterial therapy and presumably due to an excessive uncontrolled systemic inflammatory response and inadequate adrenal response to infection due to the critical illness-related corticosteroid insufficiency (CRICI). Therefore, the additional use of systemic corticosteroids can significantly improve the survival of patients with severe community-acquired pneumonia.

Aim

Aim. To present the most current preclinical and clinical studies and meta-analyses assessing the effectiveness and safety of the use of systemic corticosteroids for communityacquired pneumonia.

The results of these studies demonstrate that the most optimal regimen for the use of systemic corticosteroids in terms of risk and benefit is early (the first 3 days), low-dose (the dose equivalent of 6 mg/day dexamethasone) short-course (5 – 7 days) therapy with immediate withdrawal of the drugs. This regimen produces the best effect in patients with severe community-acquired pneumonia who require ventilation (invasive or non-invasive) with PEEP ≥ 5 cm H2O or high-flow oxygen therapy with FiO2 ≥ 50% and a PaO2/FiO2 ratio less than 300 and/or vasopressor support.

Conclusion

Conclusion. Currently, the federal clinical guidelines do not recommend the routine use of corticosteroids in adult patients with community-acquired pneumonia, with the exception of patients with refractory septic shock. However, this narrative review presents evidence supporting the use of adjunctive corticosteroid therapy in adult patients with severe community-acquired pneumonia, particularly when complicated by septic shock, acute respiratory distress syndrome, comorbid asthma and/or chronic obstructive pulmonary disease, provided there is no pulmonary suppuration, severe influenza or mycotic infection. Undoubtedly, this is a compelling argument in favor of revising existing domestic clinical guidelines regarding the use of systemic corticosteroids. Thus, further research is needed to identify subgroups of patients who may benefit from or potentially be harmed by corticosteroids. In addition, it is necessary to determine the optimal regimen for the use of corticosteroids in terms of specific drugs, their dose, routes of administration, frequency and duration of therapy, as well as the withdrawal.

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The authors declare that there are no conflicts of interest present.