Medication Summary

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).^[59]

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.^[30]Inhaled prostacyclin 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.^[60]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.^[61]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.

Class Summary

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).

Methylprednisolone (Solu-Medrol)

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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.

Questions

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Media Gallery

Anteroposterior portable chest radiograph in patient who had been in respiratory failure for 1 week with diagnosis of acute respiratory distress syndrome. Image shows endotracheal tube, left subclavian central venous catheter in superior vena cava, and bilateral patchy opacities in mostly middle and lower lung zones.
Photomicrograph from patient with acute respiratory distress syndrome (ARDS). Image shows ARDS in exudative stage. Note hyaline membranes and loss of alveolar epithelium in this early stage of ARDS.
Portable chest radiograph in a patient with acute respiratory distress syndrome. The condition evolved over approximately 1 week.
Portable chest radiograph in a patient with acute respiratory distress syndrome. The condition evolved over approximately 1 week.
Portable chest radiograph in a patient with acute respiratory distress syndrome. The condition evolved over approximately 1 week.
Photomicrograph from a patient with acute respiratory distress syndrome (ARDS). This image shows ARDS in the early proliferative stage. Note the type 2 pneumocytic proliferation, with widening of the septa and interstitial fibroblast proliferation.
Photomicrograph from a patient with acute respiratory distress syndrome (ARDS). This image shows ARDS in the late proliferative stage. Note the extensive fibroblast proliferation, with incorporation of the hyaline membranes.
Chest radiograph in a patient with acute respiratory distress syndrome (ARDS). The patient was treated with perflubron, which is used for partial liquid ventilation.
Portable chest radiograph. This image shows bilateral opacities that are suggestive of ARDS.
Computed tomography scan in a patient with suspected acute respiratory distress syndrome (ARDS). This image was obtained at the cardiac level with mediastinal window settings and shows bilateral pleural effusions instead of diffuse bilateral lung consolidation. In addition, the presence of some compression atelectasis in the lower lobes is observed.
High-resolution computed tomography scan in a patient with acute respiratory distress syndrome. This image demonstrates a small right pleural effusion, consolidation with air-bronchograms, and some ground-glass-appearing opacities. The findings indicate an alveolar process, in this case, alveolar damage.
ARDS, subacute 4x: low power view of lung in the organizing phase of ARDS. There is compression of alveoli by proliferating interstitial fibrous tissue but occasional hyaline membranes are still visible. Photomicrograph courtesy of Rodolfo Laucirica, M.D
ARDS, subacute 20x: higher power view of an alveolus (center) lined by hyaline membranes with proliferating interstitial fibroblasts to the left and right of center. Photomicrograph courtesy of Rodolfo Laucirica, M.D