Pulmonary Disorders I

Corticosteroids

Proposed rationale for corticosteroid use in ARDS was to prevent fibroproliferation with subsequent

alveolar fibrosis from a proinflammatory response.

Steroids may improve oxygenation, but randomized trials found no definitive mortality benefit.

Although the optimal timing of use remains unknown, consideration may be given in patients

with early (less than 7 days) and late (7 days or more), whereas initiation beyond 14 days after

onset was associated with higher death rates in the LaSRS trial. (N Engl J Med 2006;354:1671-84;

patients initiated on steroids after 14 days of ARDS onset may be misleading. It should be noted this

specific cohort had significant baseline characteristic variation or difference as well as atypically

low death rates in the control group for 60-day (8%) and 180-day (12%) mortality (N Engl J Med

2006;354:1671-84). Furthermore, no significant differences in mortality were found between

steroid and control groups in the greater than 14 days cohort after adjusting for important baseline

Update: Guidelines on Use of Corticosteroids updated their recommendations from 2017, removing

the specification of “early moderate to severe ARDS.” Both the SCCM and the 2024 ATS ARDS

guidelines suggest the use of corticosteroids and provide no specific recommendation to choose

between steroid molecules.

The DEXA-ARDS clinical trial was the first randomized, placebo-controlled clinical trial

2020;8:267-76). The corticosteroid group consisted of dexamethasone 20 mg intravenously daily

over the first 5 days, followed by 10 mg intravenously daily for up to 10 days or upon extubation

(if occurring prior to day 10). Dexamethasone was associated with increased mean ventilator-

free days over placebo at 1 month (12.3 ± 9.9 and 7.5 ± 9.9 days, respectively; p<0.0001). Other

secondary outcomes, including mortality (all-cause, ICU, in-hospital) and MV duration (among all

ICU survivors at day 60), significantly favored the dexamethasone group. Of note, hyperglycemia,

secondary infections, and barotrauma were similar between study groups. The novelty of this trial

compared with previously published corticosteroid studies was the concurrent use of contemporary

lung-protective MV strategies.

the best approach for corticosteroid use in ARDS (BMJ Open Respir Res. 2019;6:e000420; Ann

selected patients with ARDS, whereas neither of the 2019 guidelines provides any recommendations

because of the paucity of quality data (Table 4).

Source

Summary

GRADE Recommendation

Annane 2017

Suggest use in early moderate to severe ARDS

(Pao2/Fio2 < 200 mm Hg AND within 14 d of onset)

Conditional recommendation;

moderate quality of evidence

Griffiths 2019

Limited quality data, resulting in inability to

make a recommendation; rather, states that further

research is warranted

Research recommendation

Papazian 2019

Not reported

Not reported

2024;52(5):e219-e233 2024

Suggest use in adult critically ill patients with

ARDS

Conditional recommendation;

moderate quality of evidence

Qadir 2024

Suggest use in patients with ARDS

Conditional recommendation;

moderate quality of evidence

Abbreviations: ARDS, acute respiratory distress syndrome; Fio2, fraction of inspired oxygen.