SEATTLE—The use of corticosteroids in for acute respiratory distress syndrome (ARDS) has been controversial, but a recent study has demonstrated that administration of low-dose intravenous (IV) methylprednisolone (Solu-Medrol) at an early phase of the syndrome can reduce mortality and improve overall quality of life, according to data presented at the American College of Chest Physicians annual meeting.
Conducted between 2001 and 2004, this study looked at 743 major thoracic operations for lung or esophageal cancer, including 441 lobectomies, 88 pneumonectomies, 158 esophageal surgeries, and 56 multiple wedge resections.
Postoperative ARDS developed in 31 patients (4.17%). Of these, 8 were treated with conventional therapy and 23 with methylprednisolone sodium succinate (MPSS), which was given daily as an IV push every 6 hours, with a loading dose of 2 mg/kg, followed by a 2 mg/kg daily dose as soon as ARDS diagnosis was confirmed.
“Although short-term treatment with high-dose steroids failed to show any improvement in mortality in patients at risk of ARDS or early ARDS in previous studies, we chose to use the low-dose steroid methylprednisolone to reduce postoperative wound complications and infection. We thought it would be safe and effective,” said lead investigator Hyun-Sung Lee, MD, of the Research Institute and Hospital, National Cancer Center, Goyang-si, Gyeonggi-do, South Korea.
Steroid tapering was not started until dyspnea and chest infiltrated improved. MPSS was continued for 7 days after study entry and then slowly tapered for 4 days. After discontinuation, MPSS was changed to oral prednisolone (Prelone).
“To prevent the rebound phenomenon after steroid tapering, we decided to use the low-dose steroid maintenance. This approach showed a significant reduction in mortality, because the fibroproliferative phase of ARDS begins much sooner than had been previously appreciated. It is most likely that inflammatory and repair mechanisms occur simultaneously rather than subsequently after lung injury,” Dr Lee explained.
Among those receiving conventional therapy, 7 out of 8 (87.5%) died; in contrast, of the 23 patients receiving early steroid therapy, only 3 (13%) died. Follow-up chest high-resolution computed tomography showed that in 18 of those in the early low-dose steroid group, ARDS symptoms were completely resolved.
These findings are consistent with the hypothesis that fibroproliferation is an early response to lung injury, which is inhibited by early low-dose steroid therapy. This study demonstrated that this approach can be done safely, without disturbing wound healing, Dr Lee noted. “This is the first clinical study of early low-dose steroid therapy against ARDS following thoracic surgery. This low dose was well tolerated by the patients and it dramatically improved postoperative mortality,” he said.
He added that this marks a change of thinking in managing these patients, as there had been concern that steroids would exacerbate the infection.
“This is an important finding. It did include a relatively large number of patients,” said Nicola Hanania, MD, of Baylor College of Medicine, Houston, Texas. “It is surprising news, but we need to see this replicated by other researchers.”
Dr Lee and colleagues plan to study this approach in nonsurgical patients with ARDS.