Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: TOTAL EXPERIENCE

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Ten patients have been treated with a program of sustained ACS for established ARDS including the three described above (Table 1). In all patients, the initiating event(s) had resolved prior to the use of ACS. The ARDS had been present from four to 40 days before the ACS program was initiated (average-11 days). The etiologies of ARDS in our patients were sepsis, aspiration, and trauma (one patient each); cardiopulmonary arrest (two patients); and post-pump cardiopulmonary bypass (five patients). The ACS ther­apy was longer than three weeks in all surviving patients and a dosage of greater than 40 mg a day was employed for an average of 12 days. Patients 3 through 10 were all treated with uninterrupted courses of ACS (Table 1). Their responses to ACS were similar to that demonstrated in patient 3 (Fig 4) except for case 6 who died. After four to seven days of therapy, signifi­cant clinical improvement in ventilatory requirements, oxygenation, and chest roentgenograms were apparent in all patients. Nine Ga citrate scans were performed in eight patients. Significant uptake was observed in all scans (Table 1 and Fig 3).

Table 1—Patient Experience: Established ARDS Treated with Sustained ACS

				ACS		^Ga
				Therapy, Days
		Duration
Case	ARDS	of ARDS,	Total	Dose/(Mg/Day)		Computer	Visual
No.	Classification*	Days	Duration	>240	>40	Ratio	Score	Outcome
1	Isolated	40	150	None	19		2	Survived
2	Complicated	7	28	10	20	1.7	3	Died
						1.95	2
3	Isolated	25	21	4	13			Survived
4	Isolated	7	28	2	5		3	Survived
5	Isolated	3	21	4	10	2.41	3	Survived
6	Complicated	4	14	5	14	3.9	3	Died
7	Complicated	5	28	3	8	1.86	2	Survived
8	Isolated	3	22	4	7	7.79	2	Survived
9	Complicated	8	37	4	12			Survived
10	Complicated	9	30	4	14	1.46	2	Survived

Two infectious complications were seen. A sternal incision infection with sternal separation occurred in patient seven. The patient survived and was dis­charged after open drainage, antibiotic therapy, and the placement of pectoral flaps. Patient 9 suffered empyema following a persistent bronchopleural fis­tula. All patients were treated with an H-2 blocker and no significant gastrointestinal bleeding was iden­tified.
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Table 2—ARDS: Classification and Mortality

	Mortality
		ARDS Treated
Classification	Historic*	with Steriodsf
I. Established ARDS (>72 Hours)
—Initial process controlled
1. ARDS alone	Unknown	0% (0/5)
2. ARDS + additional	Unknown	40% (2/5)
organ dysfunction
Totals	59% (22/37)	20% (2/10)
II. Acute ARDS (<72 Hours)	100% (10/10)	0% (0/0)
— Initial process uncontrolled
Series totals for all patients (I + II)	68% (32/47)	20% (2/10)
* Montgomery et al.
tCurrent series

Two in-hospital deaths occurred for a 20 percent overall mortality rate (Table 2). Only one death oc­curred while the patients were being treated for ARDS (patient 6). This patient had suffered a cardiopulmo­nary arrest during alcohol withdrawal and aspirated. The ARDS developed and persisted until his death; however, improvement was noted in respiratory pa­rameters after ACS was given. The illness was com­plicated by progressive liver failure and ultimately with congestive heart failure and sepsis. A second death occurred in the hospital. The patient described above in case 2 had demonstrated complete resolution of her infiltrates and satisfactory oxygenation on room air when a sudden event led to her death. An arrhythmia or pulmonary embolism was suspected but could not be confirmed. buy female viagra