Acute Lung Injury What is the role of steroids?

      
       

 

          
       

Steroids may have a role in chronic ARDS in patients, without infection, with high O2 requirements days to weeks into the disease process.

Acute lung injury is an inflammatory disease. We know that circulating cytokines decline in survivors over the first week, and persist in non survivors (1). At this time, the disease appears to take on a life of it’s own, and begins to involve lobules previously unaffected, and cause fibroproliferation in already injured lung units. A series of studies utilizing glucocorticoids to prevent progression of inflammation in early ARDS have had very disappointing outcomes. Certainly immunosupression in the presence of infection can be expected to worsen outcomes. Conversely, there appears to be a small body of data supporting the use of steroids in the treatment of chronic persistent ARDS. Meduri and colleagues (2) have looked at the “single hit model” of persistent lung inflammation and postulated that ongoing inflammation due to host defense response was responsible for poor outcomes. Their study of 24 patients (it was originally powered for 100, but was cut short by the supervisory committee) demonstrated statistically significant improvement in outcomes, both in terms of lung injury scores and mortality figures. The results await confirmation by a multicenter trial, being conducted by the NIH-ARDS network.

Below is a protocol for steroids in late ARDS, based on the Meduri paper (2):

  • The patient must have no demonstrable infection, broncho-alveolar lavage may be necessary to confirm this. This includes undrained abscesses, disseminated fungal infection and septic shock.

  • Steroids should not be started less than 7 days, or more than 28 days, from admission.

  • The patient should not have a history of gastric ulceration of active gastrointestinal bleeding.

  • Patients with burns requiring skin grafting, pregnant patients, AIDS, and those in whom life support is expected to be withdrawn, are unsuitable.

  • The patient should have evidence of ALI and require an FiO2 >/= 50%

  • The steroid regimen:

    Loading dose 2mg/kg
    Then 2mg/kg/day from day 1 to 14
    Then 1mg/kg/day from day 15 to 21
    Then 0.5mg/kg/day from day 22 to 28
    Then 0.25mg/kg/day on days 29 and 30
    Finally 0.125mg/kg on days 31 and 32.

  • Patients should be meticulously screened for evidence of lower respiratory tract infection, by performing protected lavage every 3 to 4 days (while the patient is ventilated), and line sepsis (lines should be changed at regular intervals in immunosuppressed patients like this)

References

(1) Meduri GU, Kohler G, Headley S, Tolley E, Stentz F, Postlethwaite A. Inflammatory cytokines in the BAL of patients with ARDS. Persistent elevation over time predicts poor outcome. Chest 1995; 108(5):1303-1314.
(2) Meduri GU, Headley AS, Golden E, Carson SJ, Umberger RA, Kelso T et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA 1998; 280(2):159-165.

Copyright Patrick Neligan 2001-2002

          
                   
       

         
     

       
       

Please note: these tutorials are for personal study purposes only.  They are not currently peer reviewed, and no responsibility will be taken for mistakes or inaccuracies. Reproduction of information is forbidden. All material is copyrighted by the GasWorks Group.