Methylprednisolone Therapy

for Pulmonary Edema

Following Near Drowning
Arnold Sladen, MB, BS (Lond), and Howard L. Zauder, MD, PhD

Methylprednisolone sodium succinate was added to the currently Method

accepted standard therapy for patients who had nearly drowned in All patients who had nearly
fresh water. Resolution of the pulmonary edema with improvement in drowned were admitted to the hos¬
oxygenation and ventilation occurred. Prior to the introduction pital and seen and treated by the
of steroid therapy, mortality had been high, but no deaths occurred authors. The patients were divided
into the following groups:
following the addition of steroids.
Group 1 Group 2
Feb 1968- July 1969-
odell et al1 have document¬ with diffuse pulmonary edema de¬ Period June 1969 July 1970

M ed that the aspiration of

44 ml/kg of body weight
of fresh water into the tracheo-
bronchial tree resulted in ventricu¬
lar fibrillation in 80% of the animals
studied. Transposing these results
to the human, then victims of near
drowning in fresh water have prob¬
ably aspirated less than six times
their normal tidal volume. In this
group of patients, hypoxia and
metabolic acidosis represent the
immediate threat to life.2
Current therapy is designed to
reverse the hypoxia and acidosis
with use of supplemental inspired
oxygen and infusion of sodium bi¬
carbonate. Nonetheless, with this
velops.3 This syndrome has been
described as secondary drowning
by some authors.4,5 Arterial oxygen
No. of
patients
Aspirated
fluid
3
Fresh
water
7
Fresh
water
tension decreases with a widening Ventilation Mechan- Mechan¬
of the alveolar arterial oxygen ten¬ ical ical
sion difference (A-aDo2). In addi¬ Methyl¬
tion, the physiologic dead space to predni¬
tidal volume ratio (Vd/Vt ratio) solone No Yes
increases and compliance decreases. Patients in groups 1 and 2 re¬
Death results from progressive hy- ceived oxygen and sodium bicarbo¬
poxemia and combined respiratory nate on arrival in the emergency
and metabolic acidosis, in spite of room. After admission to the In¬
mechanical ventilation with large tensive Care Unit, both groups re¬
tidal volumes at an inspired oxygen ceived mechanical ventilatory sup¬
fraction of 1.0. port through an endotracheal or
Our previous studies6 of aspira¬ tracheostomy tube. All arterial
tion of acid gastric contents into blood and mixed expired gas sam¬
the tracheobronchial tree directed ples were collected at an Fi o2 =

therapy, the respiratory status fre¬
quently deteriorates. A clinical
picture of progressive dyspnea,
pink frothy sputum, diffuse bilat¬
eral pulmonary rales, and a roent-
the addition of methylprednisolone
sodium succinate (Solu-Medrol)
to the protocol of treatment for all
patients who had nearly drowned
who were admitted to the Bexar
1.0, with the patient in a steady
state, and analyzed by the stan¬
dard methods. Following studies,
the Fi o2 was regulated to maintain
an arterial oxygen tension between

genogram of the chest consistent
From the Respiratory Service of the De-
partment of Anesthesiology and Anesthesia
Laboratories, of the University of Texas
Medical School at San Antonio, San An-
tonio.
Reprint requests to 7703 Floyd Curl Dr,
San Antonio, Tex 78229 (Dr. Sladen).
County Hospital of the University
of Texas Medical School at San An¬
tonio. This present clinical study
was used to evaluate the role of
methylprednisolone in the treat¬
ment of pulmonary edema follow¬
ing near drowning in fresh water.
80 and 100 torr.
Serial roentgenograms of the
chest were obtained at frequent in¬
tervals. Antibiotics were added if
the aspirated water was known to
be contaminated or if infection be¬
came evident. In addition, patients

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Group 1
Patient No. 1 2 3
___Age 4yr
600 ~*~
12 yr 37 yr 19 yr|24
500
400
A-a DO,
ton 300
200-
100
• 1 hour after admission-mechanical
metabolic acidosis reversed
•
72 hours after admission-mechanical ventilation
1. A-aDo2 one hour and 72 hours after admission
(mechanical ventilation with Fi o2
(BP VP H20; Paco2. -
-
in group 2 received methylpred¬
nisolone sodium succinate, 5 mg/
kg/24 hr, intravenously, divided
into six equal doses.
Results
On admission, the three patients
in group 1 had an A-aDo2 ranging
from 300 to 575 torr (Fig 1). The
Vt/Vd ratio ranged from 0.56 to
0.70 (Fig 2). On admission, the
seven patients in group 2 had an
A-aDo2 ranging from 265 to 570
torr (Fig 1). The Vt/Vd ratio
ranged from 0.50 to 0.70 (Fig 2).
Marked similarity is seen in the
ranges of A-aDo2 and Vd/Vt ratio
in patients in group 1 and group 2.
The roentgenograms of the chest on
admission were comparable in both
groups.
All the patients in group 1 died
within 72 hours following admis¬
sion. Death was due to progressive
hypoxemia and respiratory acido¬
sis. All patients in group 2 survived.
They showed progressive improve¬
ment in oxygénation and ventila¬
tion, by reduction in A-aDo2 and
Vd/Vt ratio. Simultaneously, the
clinical and roentgenologic evi¬
dence of pulmonary edema re¬
solved (Fig 3).
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Group 1 Group 2
Patient No. 1 2 3 2 3 I 4 5
Group 2 Age
~~
4 yr 12 yr 37 yr 19 yr. 24 yr 9 yrjl5 yr 14yr 9yr|48yr
1 2 3 4 I 5 6 7 0.8
yr| 9 yr |15 yr|l4 yr| 9 yr |48 yr
0.7
0.6
Vd/Vt
Ratio",0.5
0.4
-
0.33
0.3
• 1 hour postadmission-mechanical ventilation
» 72 hours postadmission-mechanical ventilation
ventilation-respiratory and
Pa coi PË"co2
VD/VT: •
PaCO,
2. Vd/Vt raii'o 1 hour and 72 hours after admission
= 1). Pa o2 = Fi o2 (mechanical ventilation).
Typical Group 2 Patient (Case 4) 400-1
A 15-year-old boy was found uncon¬ 300-
scious at the bottom of a fresh water
swimming pool. On removal from the A-a D02 200
water, he was apneic. Mouth to mouth
resuscitation was initiated until spon¬ torr
100
taneous ventilation returned.
On arrival in the emergency room of
the Bexar County Hospital, he was 0
.61
disoriented, cyanotic, and tachypneic,
with a respiratory frequency of 60 per
minute. He had a cough which was pro¬ .5
VD/Vt
ductive of pink, frothy, watery mate¬
rial. Past history from his family re¬ Ratio A
vealed no previous illnesses.
On examination, diffuse fine and
coarse rales were present over both
—I-1-1-1—
72
Admission 24 48
lung fields. A roentgenogram of the Serum Hgb, 204mg/100 ml
chest (Fig 4) confirmed diffuse bilat¬
eral pulmonary edema. Time in hours
Oxygen at high flow rates via a face 3. Course of A-aDo2 and Vd/Vt
mask and reservoir bag was com¬
menced, and 44 mEq of sodium bicar¬ ratio over 72-hour period following
bonate were infused intravenously. admission (mechanical ventilation
Arterial blood gas studies indicated a with Fio2 1) (patient 4, group 2).
=
need for mechanical ventilatory sup¬
port. The patient was transferred to
the Intensive Care Unit. Nasotracheal ment in Vd/Vt ratio. The marked ele¬
intubation was performed and ventila¬ vation in serum hemoglobin level on
tion with a ventilator (Bird mark 14) admission is a typical finding. The
commenced. Hypoxemia and respira¬ progressive improvement visualized by
tory and metabolic acidosis were roentgenograms of the chest over the
reversed. Methylprednisolone sodium same 72-hour period is presented in
succinate, 40 mg, were administered in¬ Fig 5. These include resolution of the
travenously every four hours for 72 edema.
hours. The patient was discharged from the
The A-aDo2 and Vd/Vt ratio on ad¬ hospital, asymptomatic, on the seventh
mission and during the next 72 hours day after admission. Subsequent ex¬
are shown in Fig 3. The improvement aminations of the patient have re¬
in A-aDo2 is paralleled by the improve- vealed no abnormalities.
 4. Diffuse bilateral fluffy infiltrates at admission,
consistent with diagnosis of pulmonary edema. Heart
within normal limits; pulmonary vasculature normal
(case 4, group 2).
Comment
Earlier concepts that near drown¬
ing in fresh water results in dry
lungs are known to be incorrect. In
fact, pulmonary edema develops.
Treatment with diuretics and oc¬
casionally digitalis has not proven
to be satisfactory.
Alexander,7 in 1968, examined
the lungs of experimental animals
into which solutions of varying pH
and tonicity had been aspirated.
Pulmonary edema was present in
all specimens, including those in
which distilled water was the aspi¬
rated fluid. Electron microscopy
revealed fluid in the alveoli, as well
as separation of the vascular endo-
thelium from the alveolar epitheli¬
um by interstitial fluid. It was
apparent that it was the aspirated
fluid which produced the lesion.
The pH and tonicity increased the
reaction only in terms of degree
and time.
Overwhelming experimental8 and
clinical9 evidence indicates that
corticosteroids are the primary
drugs in the treatment of acid
aspiration into the tracheobronchial
tree. Since the pathologic process
produced by fresh water aspiration
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5.Complete resolution and
edema at 72 hours.
is similar to that produced by acid
aspiration,7 corticosteroids should
be the most efficient drugs in the
treatment of fresh water near
drowning.
This study has demonstrated
that the adminstration of methyl¬
prednisolone, a highly potent anti-
inflammatory drug of low toxicity,
produced marked improvement in
oxygénation and ventilation, and in
the pulmonary edema as visualized
roentgenographically. These results
parallel the beneficial effect of cor¬
ticosteroids used as the current
standard therapy for acid aspira¬
tion pneumonitis (Mendelson's
syndrome).
The action of methylprednisolone
is nonspecific, and its site of action
is local.10 The degree of antiinflam-
matory action is proportional to the
concentration at the site of cellular
damage. Hence, the role of methyl¬
prednisolone is to reduce the acute
inflammatory process, thereby re¬
solving the pulmonary edema.
Although the groups studied were
small, we believe methylpredniso¬
lone should now be included early
and continued for 72 hours in the
current therapy for all victims of
fresh water near drowning.
clearing of pulmonary
This study was supported by a grant
from the Upjohn Co.
Nonproprietary and Trade Names
of Drug
Methylprednisolone sodium succinate—
Solu-Medrol.
References
F: Effects of vol-
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ume aspirated fluid during chlorinated
of
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3. Rosenbaum HT, Thompson WL, Ful-
ler RH: Radiographic pulmonary changes
in near-drowning. Radiology 83:306-313,
1964.
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