From the Guidelines
Steroids are not recommended for the treatment of acute chest syndrome (ACS) due to the potential for significant harm, including rebound pain and increased risk of readmission. The use of corticosteroids in ACS has been debated, but current evidence suggests that the risks outweigh the benefits 1. The pathophysiology behind this involves steroids' immunosuppressive effects potentially worsening underlying infections that often trigger ACS, while also causing fluid retention that can exacerbate pulmonary complications.
Key Considerations
- The American Thoracic Society clinical practice guideline suggests the use of corticosteroids for patients with ARDS, but this is a conditional recommendation with moderate certainty of evidence 1.
- The guideline also highlights the importance of considering individual patient and illness characteristics when making clinical decisions.
- The use of corticosteroids should be accompanied by close surveillance for adverse effects, particularly in patient populations that may be at higher risks of harm.
Management of Acute Chest Syndrome
Instead of steroids, management of ACS should focus on supportive care, including:
- Supplemental oxygen
- Adequate pain control
- Incentive spirometry
- Hydration
- Antibiotics (typically a third-generation cephalosporin plus a macrolide to cover typical and atypical organisms)
- Simple or exchange transfusion to maintain hemoglobin levels and reduce the percentage of sickled cells. Early consultation with hematology is essential for optimal management of these complex patients.
From the Research
Acute Chest Syndrome in Sickle Cell Disease
- Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease, accounting for significant morbidity and mortality 2, 3, 4, 5.
- The management of ACS is based on limited evidence and is currently guided primarily by expert opinion 3.
Treatment Modalities for Acute Chest Syndrome
- The effectiveness of most treatment modalities for ACS management has not been established, including the use of steroids 6.
- Blood transfusion is often used as a therapeutic intervention for ACS to increase blood's oxygen-carrying capacity and reduce complications 3.
- Other treatment modalities for ACS include hydration with IV crystalloid solutions, antibiotics, judicious analgesia, oxygen, and, in severe cases, transfusion 2.
Rationale for Not Using Steroids
- There is limited evidence to support the use of steroids in the treatment of ACS 6, 3.
- The pathophysiology of ACS involves vaso-occlusion in pulmonary vessels resulting in hypoxia, release of inflammatory mediators, acidosis, and infarction of lung tissue, and steroids may not directly address these underlying mechanisms 2.
- The use of steroids in ACS management is not a recommended treatment modality in the available guidelines, and more high-quality studies and trials with a larger patient population are needed to support the recommendations with stronger evidence 6, 3.