Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial.

Abstract

CONTEXT:

No pharmacological therapeutic protocol has been found effective in modifying the clinical course of acute respiratory distress syndrome (ARDS) and mortality remains greater than 50%.

OBJECTIVE:

To determine the effects of prolonged methylprednisolone therapy on lung function and mortality in patients with unresolving ARDS.

DESIGN:

Randomized, double-blind, placebo-controlled trial.

SETTING:

Medical intensive care units of 4 medical centers.

PARTICIPANTS:

Twenty-four patients with severe ARDS who had failed to improve lung injury score (LIS) by the seventh day of respiratory failure.

INTERVENTIONS:

Sixteen patients received methylprednisolone and 8 received placebo. Methylprednisolone dose was initially 2 mg/kg per day and the duration of treatment was 32 days. Four patients whose LIS failed to improve by at least 1 point after 10 days of treatment were blindly crossed over to the alternative treatment.

MAIN OUTCOME MEASURES:

Primary outcome measures were improvement in lung function and mortality. Secondary outcome measures were improvement in multiple organ dysfunction syndrome (MODS) and development of nosocomial infections.

RESULTS:

Physiological characteristics at the onset of ARDS were similar in both groups. At study entry (day 9 [SD, 3] of ARDS), the 2 groups had similar LIS, ratios of PaO2 to fraction of inspired oxygen (FIO2), and MODS scores. Changes observed by study day 10 for methylprednisolone vs placebo were as follows: reduced LIS (mean [SEM], 1.7 [0.1] vs 3.0 [0.2]; P<.001); improved ratio of PaO2 to FIO2 (mean [SEM], 262 [19] vs 148 [35]; P<.001); decreased MODS score (mean [SEM], 0.7 [0.2] vs 1.8 [0.3]; P<.001); and successful extubation (7 vs 0; P=.05). For the treatment group vs the placebo group, mortality associated with the intensive care unit was 0 (0%) of 16 vs 5 (62%) of 8 (P=.002) and hospital-associated mortality was 2 (12%) of 16 vs 5 (62%) of 8 (P=.03). The rate of infections per day of treatment was similar in both groups, and pneumonia was frequently detected in the absence of fever.

CONCLUSIONS:

In this study, prolonged administration of methylprednisolone in patients with unresolving ARDS was associated with improvement in lung injury and MODS scores and reduced mortality.

• Authors: G U Meduri, A S Headley, E Golden, S J Carson, R A Umberger, T Kelso, E A Tolley
• Journal: JAMA (JAMA) Vol. 280 Issue 2 Pg. 159-65 (Jul 08 1998) ISSN: 0098-7484 [Print] United States
• PMID: 9669790 (Publication Type: Clinical Trial, Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Anti-Inflammatory Agents
• Methylprednisolone

Topics

• Adult
• Anti-Inflammatory Agents (therapeutic use)
• Cross Infection (etiology)
• Double-Blind Method
• Female
• Hospital Mortality
• Humans
• Intensive Care Units
• Male
• Methylprednisolone (therapeutic use)
• Middle Aged
• Multiple Organ Failure (etiology)
• Prospective Studies
• Respiratory Distress Syndrome (complications, drug therapy)
• Respiratory Function Tests
• Severity of Illness Index
• Survival Analysis