Corticosteroids for ARDS.

The aim of this study was to describe the role of glucocorticoids in immune modulation during critical illness and to review clinical trials and recent meta-analyses of glucocorticoids in early and late acute respiratory distress syndrome (ARDS). Selected reviews of publications, clinical trials, and meta-analyses were considered for the study. Activation of the adrenal axis is an important component of the compensatory anti-inflammatory response to critical illness. A recent meta-analysis of high doses of corticosteroids in patients with or at risk for ARDS demonstrated a trend for greater risk of the development of ARDS and a fatal outcome. Additional meta-analyses of four randomized trials and five cohort studies in patients with established ARDS or pneumonia indicated an overall mortality benefit with corticosteroids but this finding was not confirmed in another meta-analysis limited to randomized trials and excluding the trial focused on pneumonia. Lung function is improved and the duration of mechanical ventilation is reduced with prolonged administration of lower doses. In conclusion, short-duration, high-dose glucocorticoid therapy is not effective in preventing ARDS and may be harmful. Lower doses for persistent ARDS improve lung function and shorten the duration of mechanical ventilation but the impact on long-term mortality is unclear. Additional trials are needed to determine if corticosteroids improve important clinical outcomes before they can be recommended for the routine use of patients with unresolved ARDS.