Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: PATIENT PROFILES AND CLINICAL TECHNIQUES
Ten patients with established ARDS were cared for by the authors over an 18-month period and represent our total experience with ARDS treated with ACS since the index case (Table 1). The first two patients initially had a limited course of ACS, but subsequently completed a sustained course of greater than 21 days. Seven patients had uninterrupted courses of therapeutic ACS for greater than 21 days while one died during therapy.
We define established ARDS as ARDS where the causative process has resolved and where the ARDS has existed for greater than 72 hours’ duration. At the time of diagnosis, all patients had criteria for ARDS based on accepted definitions including the following: severe impairment of oxygenation (requiring Flo, >0.6 for Poa of >55); diffuse infiltrates on chest roentgenography; and hemodynamic stability and pulmonary capillary wedge pressure of less than 16 mm Hg by Swan-Ganz catheter measurements. All patients met these criteria for greater than 72 hours before the treatment with ACS was instituted. Patients selected for therapy were free of identifiable infections; however, hepatic or renal insufficiency did not exclude patients from consideration. viagra jelly online
Gallium-67 citrate scans were performed at 48 hours using standard techniques in patients clinically stable enough for transport to imaging. All patients were injected prior to the initiation of ACS therapy. Intensity of uptake was quantified by two methods: computer generated ratios of background activity to the lung activity, and a visual scoring system of 0 to 3 with 0 equaling no activity and 3 as maximum uptake similar to that of the liver.
A 70-year-old woman (Fig 1) suffered a cardiac arrest at the time of an out-patient cardiac catheterization for evaluation of aortic stenosis. Aortic valve replacement was performed on the ninth hospital day. Cardiac function improved rapidly after surgery to support normal hemodynamics and cardiac output. The postoperative period was complicated by multiple system disease including transient renal insufficiency, two episodes of sepsis, and persistent ARDS. The ARDS was characterized by diffuse interstitial roentgenographs abnormalities, hypoxemia, and ventilator dependence. By the 27th postoperative day (36th hospital day), ARDS was the only major unresolved problem.
FIGURE 1. Clinical course of patient 1. The top bar graphs indicate which days each modality was employed. Inspired oxygen was augmented throughout the hospital stay. Supplemental Oa stand for face mask or nasal prongs oxygen without positive pressure. The line graph in the middle represents the ratio of the arterial partial pressure of oxygen to the percentage of inspired oxygen. The bar graphs at the bottom indicate the total daily dose of adrenocortical steroids.
АСа citrate scan was obtained to assess for the presence of an active inflammatory component, and significant ^Ga uptake was found. Based upon this finding, a therapeutic course of ACS was begun on the 39th hospital day. Within four days, the patient demonstrated significant improvement in both oxygenation and chest roentgenogram. She was also able to support her own ventilation. The ACS dosage was rapidly reduced to a maintenance level. The patient responded with a deterioration in all parameters and required the reinstitution of mechanical ventilation on the 50th hospital day. Again, the major clinical problem was respiratory insufficiency with significant oxygenation difficulties.
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The dosage of ACS was increased on the 60th hospital day. Again, a positive response was seen in oxygenation, chest roentgenogram, and ventilatory assistance requirements, although the responses were slower and less dramatic. On the 96th hospital day, the patient was discharged on nocturnal oxygen and a slowly tapering dose of steroids. Three months after discharge, the patient was not receiving ACS or nocturnal oxygen and was living an active life.