What is the recommended dose of hydrocortisone (cortisol) for Acute Respiratory Distress Syndrome (ARDS)?

Hydrocortisone Dosing for ARDS

For ARDS, use methylprednisolone 1 mg/kg/day (not hydrocortisone) for early moderate-to-severe disease (PaO₂/FiO₂ <200 within 14 days of onset), with slow tapering over 6-14 days. 1, 2

Preferred Corticosteroid Agent

• Methylprednisolone is the preferred agent over hydrocortisone for ARDS due to greater penetration into lung tissue and longer residence time compared to other steroids 2
• Hydrocortisone is specifically recommended for septic shock (200 mg/day), not ARDS 1
• The Society of Critical Care Medicine and European Society of Intensive Care Medicine guidelines distinguish between septic shock management (hydrocortisone) and ARDS management (methylprednisolone) 1

Dosing Protocol by Timing

Early ARDS (≤7 days from onset):

• Methylprednisolone 1 mg/kg/day with slow tapering over 6-14 days 2
• Early initiation (within 72 hours) shows better response to lower doses and faster disease resolution when fibroproliferation is still in early cellular stage 1, 2

Late Persistent ARDS (after day 6 of onset):

• Methylprednisolone 2 mg/kg/day with slow tapering over 13 days 2, 3
• Higher doses are required for late-stage disease when fibroproliferation is more established 1

Clinical Benefits

• Reduction in duration of mechanical ventilation by approximately 7 days 1, 2
• Probable reduction in hospital mortality by 7-11% in patients with mild to severe ARDS 1, 2
• Significant reduction in markers of systemic inflammation (inflammatory cytokines and C-reactive protein) 1
• Meta-analysis of 14 RCTs (n=1607) confirmed mortality reduction (RR=0.78,95% CI: 0.70-0.87) 4

Patient Selection Criteria

• Moderate to severe ARDS with PaO₂/FiO₂ <200 1
• Within 14 days of ARDS onset 1
• Active infection must be excluded before initiating therapy 3
• Not recommended for influenza-associated ARDS due to potential harm 5

Critical Pitfalls to Avoid

• Never abruptly discontinue methylprednisolone as this leads to deterioration from reconstituted inflammatory response 2
• Do not confuse early steroid therapy with high-dose pulse steroids, which have not shown benefit 2
• Avoid using random cortisol levels alone to guide therapy decisions, as they correlate poorly with adrenal function in ARDS 6
• High-dose corticosteroids (>400 mg/day hydrocortisone equivalent) are associated with increased mortality in observational studies 7

Monitoring Requirements

• Regular surveillance for hyperglycemia, especially within 36 hours following initial treatment 2
• Infection surveillance is essential as glucocorticoids blunt febrile response 2
• Monitor for gastrointestinal bleeding and nosocomial infections 2

Concurrent Supportive Care

• Continue lung-protective ventilation (6 ml/kg predicted body weight) per ARDS Network protocol 2
• Implement deep vein thrombosis prophylaxis 2
• Provide stress ulcer prophylaxis (H2 receptor inhibitors preferred) 2
• Position patient semi-recumbent (head of bed elevated 45 degrees) 2
• Avoid neuromuscular blockers when possible due to risk of prolonged muscle weakness with concomitant steroids 2

Evidence Quality

The recommendation for methylprednisolone in ARDS is based on moderate quality evidence from multiple RCTs and individual patient data analysis of 322 patients from the four largest trials 1, 2. The consistent finding across trials of reduced mechanical ventilation duration and probable mortality benefit supports this approach, though the conditional recommendation reflects some uncertainty in optimal dosing and timing 1.