Chest
Clinical Investigations in Critical CareCorticosteroid Rescue Treatment of Progressive Fibroproliferation in Late ARDS: Patterns of Response and Predictors of Outcome
Section snippets
Patient Population
Twenty-five patients, 8 male and 17 female, received IVCT for late ARDS between July 1989 and September 1992. All patients met diagnostic criteria for ARDS as described by Fowler et al.5 Patients were considered candidates for IVCT if they had (1) evidence of progressive respiratory failure with worsening LIS, and (2) no evidence of active infection. ARDS was caused by a direct injury to the lung in 10 patients and indirect injury in 15 patients. Direct injuries leading to ARDS included
Results
Mean APACHE II score on admission was 20.4±1.7 (range, 11 to 31). Patients had severe respiratory failure with a mean LIS of 2.94±0.68 on day 1 of ARDS (highest value in the first 24 h), and all but four patients had an LIS>2.5. Table 2 shows demographics, type of ARDS, APACHE II score, LIS, and MOF score at the time ARDS developed. At the time ARDS developed, 50 percent of nonsurvivors and 11.1 percent survivors had liver failure with a total bilirubin ≥3 mg/dl (p=0.08). One of these four
Discussion
Adult respiratory distress syndrome (ARDS) is a clinical and pathophysiologic entity characterized by the acute and diffuse involvement of the endothelial and epithelial surface of the lung, which leads to respiratory failure. The term “late ARDS” refers to the clinical stage of ARDS in which the lung attempts to repair the initial or persistent injury to the respiratory units. Its histologic correspondent is termed “fibroproliferative phase” which, if unhalted, leads to extensive fibrosis.
Conclusions
The findings of this self-controlled, clinical, interventional study indicate that pulmonary fibroproliferation is potentially responsive to corticosteroid treatment and that responsiveness is associated with improved outcome. Treatment is more effective when administered early into fibroproliferation before dense acellular fibrosis with deranged alveolar architecture occurs. Unfortunately, monitoring of physiologic and clinical variables was not useful in discriminating patients with advanced
ACKNOWLEDGMENTS
We wish to thank Dr. David Armbruster for critique of the manuscript and Reba Umberger for data collection.
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