The swinging pendulum of steroids in ARDS

Now I’m confused. Early high dose (30mg/kg/day) methylprednisolone for ARDS was popular until debunked in the early 1980s. More recently lower doses of methylprednisolone for late stage ARDS was popularized until the publication last year of negative results from an ARDSnet trial. But now, in the April issue of Chest, comes this study looking at even lower dose (1mg/kg/day infusion) methylprednisolone used early in ARDS:

In intention-to-treat analysis, the response of the two groups (63 treated and 28 control) clearly diverged by day 7, with twice the proportion of treated patients achieving a 1-point reduction in LIS (69.8% vs 35.7%; p = 0.002) and breathing without assistance (53.9% vs 25.0%; p = 0.01). Treated patients had significant reduction in C-reactive protein levels, and by day 7 had lower LIS and multiple organ dysfunction syndrome scores. Treatment was associated with a reduction in the duration of mechanical ventilation (p = 0.002), ICU stay (p = 0.007), and ICU mortality (20.6% vs 42.9%; p = 0.03). Treated patients had a lower rate of infections (p = 0.0002), and infection surveillance identified 56% of nosocomial infections in patients without fever.

A wide range of etiologies of ARDS was represented. 41% had pneumonia and 13% had extrapulmonary sepsis. Extrapulmonary and direct pulmonary etiologies of ARDS were equally represented.

A related editorial, Corticosteroids for ARDS: Just do it!, is strongly in favor of the protocol and cites other supporting literature. It stresses counter measures against the adverse effects of corticosteroids such as routine infection surveillance and glycemic control.