What is the American Thoracic Society (ATS) recommendation on corticosteroids in Acute Respiratory Distress Syndrome (ARDS)?

ATS Recommendation on Corticosteroids in ARDS

The American Thoracic Society (2024) suggests using corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence). 1

Target Population for Steroid Therapy

• Corticosteroids should be considered for ARDS patients with PaO2/FiO2 ratio < 300, which defines the severity threshold for treatment 1
• The recommendation applies across all ARDS severity categories (mild, moderate, and severe) meeting this oxygenation criterion 1

Critical Timing Considerations

Steroids must be initiated within the first 14 days of mechanical ventilation to avoid harm. 1

• Starting methylprednisolone after 14 days of ARDS onset may increase mortality risk rather than provide benefit 2
• This represents a critical safety threshold that should not be crossed 1
• For patients who improve rapidly, consider discontinuation at the time of extubation 1

Dosing Regimens

The optimal corticosteroid type and specific regimen remain uncertain, but the ATS provides the following guidance: 1

• For patients with corticosteroid-responsive etiologies (e.g., organizing pneumonia, eosinophilic pneumonia), tailor the regimen to the specific underlying condition 1
• For other ARDS patients, regimens used in prior randomized controlled trials may be employed 1
• Recent meta-analysis supports low-to-moderate dose prolonged glucocorticoid treatment (methylprednisolone 1 mg/kg/day for early moderate-to-severe ARDS; 2 mg/kg/day for late persistent ARDS) 3

Monitoring Requirements and Precautions

Enhanced monitoring is essential for specific high-risk populations: 1

• Immunosuppressed patients require closer surveillance for adverse effects 1
• Patients with metabolic syndrome need more intensive monitoring 1
• Those with increased risk of fungal, parasitic, or mycobacterial infections warrant heightened vigilance 1

Evidence Supporting the Recommendation

The conditional recommendation reflects moderate certainty evidence showing:

• Mortality reduction: Meta-analysis of randomized trials demonstrates corticosteroids reduce mortality in ARDS (RR 0.80,95% CI: 0.71-0.91, p = 0.001) 4
• Improved ventilator-free days: Corticosteroids increase days free from mechanical ventilation 2, 3
• Enhanced oxygenation and compliance: Treatment improves PaO2/FiO2 ratio and respiratory system compliance 2
• Reduced ICU length of stay: Patients experience shorter intensive care unit duration 3

Important Caveats

The recommendation is conditional rather than strong because: 1

• Observational studies show conflicting results, with some demonstrating increased mortality with corticosteroid use (RR 1.16,95% CI: 1.04-1.29) 4
• High-dose corticosteroids are associated with worse outcomes and should be avoided 4
• Historical trials using short-course, high-dose methylprednisolone (30 mg/kg every 6 hours) showed no benefit and potential harm 5
• Neuromuscular weakness occurs more frequently with corticosteroid therapy 2

Integration with Other ARDS Therapies

Corticosteroids should be implemented as part of a comprehensive ARDS management strategy that includes: 1, 6

• Lung-protective ventilation (tidal volume 4-8 mL/kg predicted body weight, plateau pressure <30 cmH2O) as the foundation 1, 6
• Higher PEEP strategies for moderate-to-severe ARDS (PaO2/FiO2 <200) 1, 6
• Prone positioning for severe ARDS (PaO2/FiO2 <100) 1, 6
• Neuromuscular blocking agents in early severe ARDS 1, 6