Corticosteroids in ARDS

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Corticosteroids in ARDS
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Acute lung injury(ALI)

• Definition
• A syndrome of acute and persistent lung
  inflammation with increased vascular permeability
• Clinical features
• 1. Bilateral radiographic infiltrates
• 2. PaO2/FiO2 201-300mmHg
• 3. No clinical evidence for an elevated left
  atrial pressure (pulmonary capillary wedge
  pressure ? 18 mmHg)

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Acute Respiratory Distress Syndrome

• Definition
• Same as ALI except worse hypoxia
• Acute in onset
• Clinical features
• 1. Bilateral radiographic infiltrates
• 2. PaO2/FiO2 less than 200
• 3. No clinical evidence for an elevated left
  atrial pressure (pulmonary capillary wedge
  pressure ? 18 mmHg)

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Epidemiology

• ALI
• Age-adjusted incidence 86 per 100,000
• In-hospital mortality 39
• ARDS
• Age-adjusted incidence 64 per 100,000
• In-hospital mortality 41
• Overall mortality 25-58

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Causes predisposing conditions
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Pathophysiology - Baseline

• 3 mechanisms keep
• normal lung from
• alveolar edema
• 1. Intravascular protein
• 2. Interstitial lymphatics
• 3. Tight junctions between
• alveolar epithelial cells

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Pathophysiology - Injury

• Pro-inflammatory cytokines(ex.TNF, IL-1, IL-6,
  IL-8)
• Neutrophils recruited, activated, release toxic
  mediators
• Damage capillary endothelium and alveolar
  epithelium
• Normal barriers lost

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Pathophysiology - Consequence

• Impair gas exchange
• increase physiologic dead space
• Decrease lung compliance
• due to stiffness of poorly or nonaerated lung
• Pulmonary hypertension
• occur in up to 25 ARDS patients
• acute cor pulmonale is rare

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Pathologic stages

• Exudative stage diffuse alveolar damage
• Proliferative stage
• resolution of pulmonary edema and
  proliferation of type II alveolar cells, squamous
  metaplasia, myofibroblasts infiltration, early
  collagen deposition
• Fibrotic stage
• obliteration of normal lung architecture,
  diffuse fibrosis, cyst formation

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Treatment

• Supportive care
• sedatives and neuromuscular blockade
• hemodynamic management
• nutritional support
• control of blood glucose
• treatment of nosocomial pneumonia
• ventilator
• prophylaxis against deep venous thrombosis and
  gastrointestinal bleeding
• Novel therapy
• beta agonist
• surfactant
• inhaled vasodilator
• ECMO
• anti-inflammatory
• anti-oxidant

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ARDS

• Ongoing inflammation, parenchymal-cell
  proliferation, disordered deposition of collagen
• May be responsive to corticosteroid?

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Related Studies

• 4 trials of high-dose, short-course for early
  ARDS failed to show survival improvement
• Small case series suggest benefit of
  moderate-dose in persistent ARDS
• A 24-patients trial moderate-dose improve lung
  function and survival for ARDS 7 or more days

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Related studies

• High-dose increase the risk of secondary
  infections?
• Hyperglycemia, poor wound healing, psychosis,
  pancreatitis, prolonged muscle weakness, impaired
  function status

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NHLBI ARDS Clinical Trials Network

• 180 patients from 1997 to 2003
• 7 to 28 days after onset of ARDS
• PaO2FIO2 less than 200
• Protocol of methylprednisolone given
• 1. Single dose of 2mg/kg predicted BW
• 2. 0.5mg/kg Q6H for 14 days
• 3. 0.5mg/kg Q12H for 7 days
• 4. Tapering

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Results

• No difference in 60-day or 180-day hospital
  mortality rate, in days in ICU or hospitalization
  
• Steroid group had more ventilator-free days, more
  improvement in PaO2FiO2, improved compliance,
  higher serum glucose level, lower suspected or
  probable pneumonia

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Discussion

• Routinely use of steroids in ARDS patient is NOT
  supported
• Increased mortality rate if Initiation 2 or more
  weeks after onset of ARDS
• Improve cardiopulmonary physiology, increase
  ventilator-free days, ICU-free days, and
  shock-free days
• Not increase infection, but may increase risk of
  neuromyopathy

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Apply in our patient
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4B1 06-1 ?X?

• 86-year-old man
• 1. RUL adenocarcinoma, status post VATS RUL
  lobectomy and LN dissection
• 2. Pneumonia with septic shock
• 3. hematuria
• 4. BPH s/p TURP

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SICU course

• Increase infiltration of bil. lung
• Fail to wean
• 3/6 sputum culture
• 1. Pseudomonas aeruginosa 3
• 2. Neisseria species 3
• 3. Viridans streptococci 3
• 3/14
• 1. O2 desaturation, unstable hemodynamic status
• 2. FiO2 100, SaO2 lower than 80. On VA ECMO

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ARDS

• 3/4 PaO2/FiO2 94.7/40 236.75
• 3/5 PaO2/FiO2 75.3/40 188.25

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Steroid, timing and dosage

• Body weight 74kg
• 3/14 Solu-Cortef 50mg stat
• 3/15 Solu-Medro 40mg Q8H
• 3/23 Solu-Medro 40mg Q12H
• Protocol of methylprednisolone given
• 1. Single dose of 2mg/kg predicted BW
• 2. 0.5mg/kg Q6H for 14 days
• 3. 0.5mg/kg Q12H for 7 days
• 4. Tapering

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The Final Chapter

• 3/29
• Hypoglycemia
• Asystole, recover after bosmin injection
• 3/30
• Asystole again
• Family decided to hold ECMO support.
• Passed away at 1057am