Steroid Regimen for Severe ARDS
For severe ARDS, methylprednisolone at a dose of 1 mg/kg/day with slow tapering over 6-14 days is the recommended steroid regimen when initiated within 7 days of ARDS onset. 1
Timing-Based Dosing Recommendations
Early ARDS (≤7 days from onset)
- Methylprednisolone 1 mg/kg/day with slow tapering over 6-14 days 1
- Early initiation (within 72 hours) shows better response to lower doses and faster disease resolution 1
- Methylprednisolone is preferred due to greater penetration into lung tissue and longer residence time compared to other steroids 1
Late Persistent ARDS (after day 6 of onset)
- Methylprednisolone 2 mg/kg/day with slow tapering over 13 days 1
- Avoid initiating corticosteroid treatment >14 days after ARDS onset as it may be harmful 2, 3
Evidence Supporting Corticosteroid Use in ARDS
- Corticosteroids probably decrease mortality in ARDS (RR, 0.84; 95% CI, 0.73–0.96) 4
- Treatment may reduce duration of mechanical ventilation by approximately 4-7 days 4, 1
- Hospital length of stay may be reduced by approximately 8 days 4
- Corticosteroids are associated with reduced markers of systemic inflammation 1
- Meta-analyses confirm mortality benefits with RR of 0.78 (95% CI: 0.70-0.87) 5
Administration Protocol
- Administer as continuous IV infusion rather than bolus dosing 1
- Avoid abrupt discontinuation as it may lead to deterioration from reconstituted inflammatory response 1
- For patients not improving with initial therapy, some evidence suggests pulse-dose steroid therapy could be considered for clinical deterioration with persistent fever, worsening radiographic opacities, and hypoxemic respiratory failure 4
Potential Adverse Effects and Monitoring
- Hyperglycemia is common, especially within 36 hours following initial treatment (RR, 1.11; 95% CI, 1.01–1.23) 4, 1
- Regular infection surveillance is essential as glucocorticoid treatment blunts febrile response 1
- Potential for gastrointestinal bleeding (RR, 1.20; 95% CI, 0.43–3.34) 4, 1
- Monitor for neuromuscular weakness, especially with concomitant use of neuromuscular blockers 4
Important Cautions and Contraindications
- Avoid high-dose pulse steroids as initial therapy, as they have not shown benefit in early ARDS 1
- Corticosteroids are not recommended for ARDS associated with influenza, as they may increase mortality 6, 2
- Patients with multiple myeloma or other immunocompromised states require special consideration 6
Adjunctive Measures
- Implement lung-protective ventilation strategies (6 ml/kg predicted body weight) 1
- Use deep vein thrombosis prophylaxis 4
- Provide stress ulcer prophylaxis (H2 receptor inhibitors preferred over sucralfate) 4
- Implement sedation protocols with daily interruption/lightening when possible 4
- Position patient semi-recumbent (head of bed elevated 45 degrees) 4
- Avoid neuromuscular blockers if possible due to risks of prolonged muscle weakness, especially with concomitant steroids 4