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


METHODS
Randomized, double-blind, placebo-controlled trial.


METHODS
Medical intensive care units of 4 medical centers.


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


METHODS
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.


METHODS
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.
Baptist Memorial Hospitals, Veterans Affairs Medical Center, University of Tennessee, Memphis, USA. umeduri@utmem1.utmem.edu
G U
GU
Meduri
A S
AS
Headley
E
E
Golden
S J
SJ
Carson
R A
RA
Umberger
T
T
Kelso
E A
EA
Tolley
D000328:Adult; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D003428:Cross Infection / Q000209:etiology; D004311:Double-Blind Method; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008775:Methylprednisolone / Q000627:therapeutic use*; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology; D011446:Prospective Studies; D012128:Respiratory Distress Syndrome / Q000150:complications / Q000188:drug therapy*; D012129:Respiratory Function Tests; D012720:Severity of Illness Index; D016019:Survival Analysis
D000893:Anti-Inflammatory Agents; D008775:Methylprednisolone