What is the role of corticosteroids in Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

Corticosteroids are conditionally recommended for patients with acute respiratory distress syndrome (ARDS), as they may reduce morbidity and mortality, particularly when used in the early phase of the disease. The use of corticosteroids in ARDS is supported by recent guidelines, including the 2024 American Thoracic Society clinical practice guideline, which provides a conditional recommendation for their use 1.

Key Considerations

• The decision to use corticosteroids should be based on individual patient and illness characteristics, taking into account the potential benefits and risks.
• The optimal regimen and duration of corticosteroid treatment are not well established, but methylprednisolone 1-2 mg/kg/day in divided doses for 1-2 weeks with gradual tapering is a suggested approach 1.
• Earlier initiation of corticosteroid treatment, ideally within the first 14 days of ARDS onset, may be associated with better outcomes.
• Potential adverse effects of corticosteroids, such as hyperglycemia, secondary infections, and neuromuscular weakness, should be carefully monitored and managed.

Comprehensive Management Approach

• Corticosteroids should be used as part of a comprehensive approach to managing ARDS, which includes lung-protective ventilation strategies, prone positioning when indicated, and appropriate fluid management.
• Infection surveillance is essential during corticosteroid treatment, as it may blunt the febrile response and increase the risk of hospital-acquired infections.
• Blood glucose monitoring is also crucial, as corticosteroids can cause hyperglycemia, particularly in patients with uncontrolled diabetes.

From the Research

Role of Corticosteroids in Acute Respiratory Distress Syndrome (ARDS)

• The use of corticosteroids in ARDS has been studied in various clinical trials, with some showing improvement in lung function and mortality, while others have found no significant benefit 2, 3, 4.
• A study published in JAMA in 1998 found that prolonged administration of methylprednisolone in patients with unresolving ARDS was associated with improvement in lung injury and multiple organ dysfunction syndrome (MODS) scores, and reduced mortality 2.
• In contrast, a study published in The New England Journal of Medicine in 1987 found that high-dose methylprednisolone did not affect outcome in patients with established ARDS due to sepsis, aspiration, or a mixed cause 3.
• A systematic review and meta-analysis of randomized trials published in 2020 found that corticosteroids reduced all-cause mortality and the duration of mechanical ventilation, and increased the number of ventilator-free days in patients with ARDS 4.
• Another study published in The Medical Journal of Malaysia in 2022 found that the use of higher dose methylprednisolone in COVID-19 with ARDS was not associated with better clinical outcomes, and that a lower dose of methylprednisolone might be sufficient in treating severe COVID-19 with ARDS 5.
• A study published in The Annals of Thoracic Surgery in 2005 found that early low-dose steroid therapy significantly reduced postoperative mortality in patients with postoperative ARDS 6.

Key Findings

• Corticosteroids may improve mortality and shorten ventilation times in patients with ARDS 4.
• The optimal dose and timing of corticosteroid administration in ARDS is unclear, with some studies suggesting that lower doses may be sufficient 5, 6.
• Corticosteroids may increase the risk of hyperglycemia and neuromuscular weakness in patients with ARDS 4.