Is there evidence to support a phase II trial of inhaled corticosteroids in the treatment of incipient and persistent ARDS?

Acute respiratory distress syndrome (ARDS) is common in intensive care, with high mortality and morbidity. Preclinical studies suggest that corticosteroids reduce lung inflammation in ARDS. Early clinical trials using short courses of high-dose corticosteroids in patients at high risk of ARDS and with early ARDS showed increased mortality despite reduced lung inflammation, although more recent experience with lower doses over more prolonged periods is encouraging. After initial promise, corticosteroids now appear to lack mortality benefit in late ARDS. Systemic deleterious effects may outweigh the local benefit of corticosteroids on lung inflammation. Extensive experience has accumulated in the use of inhaled corticosteroids to treat asthma. Inhalation maximises lung effects while minimising systemic absorption. Inhaled corticosteroids have been used successfully in a variety of animal models of lung injury. There is currently sufficient evidence to support a preliminary clinical trial of inhaled corticosteroids in patients at high risk of ARDS as well as with early and/or late ARDS, using markers of inflammation as a surrogate end-point.