From the Guidelines
The recommended duration of corticosteroid therapy for Acute Respiratory Distress Syndrome (ARDS) is typically 7-14 days, with a suggested regimen of methylprednisolone 1 mg/kg/day for early ARDS and 2 mg/kg/day for late ARDS, followed by slow tapering over 13 days. This recommendation is based on the guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients, which suggests that methylprednisolone be considered in patients with early (up to day 7 of onset) and late (after day 6 of onset) persistent ARDS 1. The task force members believed that the quality of the evidence for the effect of corticosteroids on mortality was moderate, given the serious risk of imprecision related to small numbers of events and confidence intervals that approach no effect 1.
Key Considerations
- The dose of methylprednisolone should be 1 mg/kg/day for early ARDS and 2 mg/kg/day for late ARDS, with a slow tapering over 13 days 1.
- Earlier initiation of corticosteroid therapy is associated with better outcomes, with a significant reduction in markers of systemic inflammation, reduction in the duration of mechanical ventilation, and probable reduction in hospital mortality 1.
- Monitoring for adverse effects such as hyperglycemia, secondary infections, and psychiatric disturbances is essential during treatment.
- The optimal duration may vary based on individual patient response, with some patients requiring longer courses if they have a slower clinical improvement.
Rationale
The use of corticosteroids in ARDS has been shown to reduce pulmonary and systemic inflammation, decrease cytokine storm, and potentially prevent progression to pulmonary fibrosis 1. The guidelines suggest that methylprednisolone should be weaned slowly (6–14 days) and not stopped rapidly (2–4 days) or abruptly as deterioration may occur from the development of a reconstituted inflammatory response 1.
From the Research
Duration of Steroid Treatment in ARDS
- The optimal duration of steroid treatment in Acute Respiratory Distress Syndrome (ARDS) is not well established, but several studies provide insight into the treatment duration.
- A study published in 1998 2 used methylprednisolone for 32 days in patients with unresolving ARDS, with improvements in lung function and mortality observed.
- A retrospective study from 2021 3 used methylprednisolone for a median duration of 5 days (IQR: 5-7 days) in patients with ARDS due to COVID-19, and found an association with increased ventilator-free days.
- The duration of steroid treatment in ARDS may vary depending on the specific context and patient population, and further research is needed to determine the optimal treatment duration.
Key Findings
- Methylprednisolone has been shown to improve lung function and reduce mortality in patients with ARDS 2, 4, 5.
- The use of corticosteroids, including methylprednisolone, may be associated with a reduced risk of death in ARDS patients 4, 5.
- However, the optimal dosage, corticosteroid agent, and treatment duration in patients with ARDS remain unclear 5.