Acute Respiratory Distress Syndrome Medication
- Author: Eloise M Harman, MD; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM more...
No drug has proved beneficial in the prevention or management of acute respiratory distress syndrome (ARDS). Early administration of corticosteroids to septic patients does not prevent the development of ARDS. Numerous pharmacologic therapies, including the use of inhaled or instilled synthetic surfactant, intravenous (IV) antibody to endotoxin, ketoconazole, and ibuprofen, have been tried and are not effective. Statins, which also appeared to have promise in small studies, also did not show benefit in a recently published randomized trial in 60 patients with acute lung injury (ALI).
Small sepsis trials suggest a potential role for antibody to tumor necrosis factor (TNF) and recombinant interleukin (IL)–1 receptor antagonist. Inhaled nitric oxide (NO), a potent pulmonary vasodilator, seemed promising in early trials, but in larger controlled trials, it did not change mortality rates in adults with ARDS. A systematic review, meta-analysis, and trial sequential analysis of 14 randomized controlled trials, including 1303 patients, found that inhaled nitric oxide did not reduce mortality and results in only a transient improvement in oxygenation. Inhaled prostacycline also has not been shown to improve survival.
Because of apparent benefit in small trials, it was thought that there might be a role for high-dose corticosteroid therapy in patients with late (fibroproliferative phase) ARDS. However, an ARDS Study Network trial of methylprednisolone for patients with ARDS persisting for at least 7 days demonstrated no benefit in terms of 60-day mortality. Patients treated later in the course of ARDS, 14 days after onset, had worsened mortality with corticosteroid therapy.
Although no survival advantage was shown in patients treated with methylprednisolone, short-term clinical benefits included improved oxygenation and increased ventilator-free and shock-free days. Patients treated with corticosteroids were more likely to experience neuromuscular weakness, but the rate of infectious complications was not increased.
Development of the late phase of ARDS may represent continued uncontrolled inflammation, and corticosteroids may be considered a form of rescue therapy that may improve oxygenation and hemodynamics but does not change mortality (except that corticosteroids increase mortality in patients who have had ARDS for >14 d).
High-dose methylprednisolone has been used in trials of patients with ARDS who have persistent pulmonary infiltrates, fever, and high oxygen requirement despite resolution of pulmonary or extrapulmonary infection. Pulmonary infection is assessed with bronchoscopy and bilateral bronchoalveolar lavage (BAL) and quantitative culture.
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