ARDS · Corticosteroids in ARDS
Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome
| Design | Multicentre randomised, double-blind, placebo-controlled trial |
|---|---|
| Treatment | Methylprednisolone started 7 to 28 days after ARDS onset |
| Control | Placebo |
| Population | 180 patients with persistent ARDS |
| Follow-up | 180 days |
| Primary endpoint | 60-day mortality |
| Result | Hospital mortality at 60 days was 28.6% with placebo (95% CI 20.3 to 38.6) and 29.2% with methylprednisolone (20.8 to 39.4), p=1.0. At 180 days the rates were similar. Cardiopulmonary physiology improved with steroids. Patients enrolled 14 or more days after ARDS onset had increased 60-day mortality on methylprednisolone. |
| Secondary endpoints | 180-day mortality, ventilator-free days, physiological measures, neuromuscular weakness |
These results do not support the routine use of methylprednisolone for persistent ARDS despite the improvement in cardiopulmonary physiology. In addition, starting methylprednisolone therapy more than two weeks after the onset of ARDS may increase the risk of death.
The trial authors, in the published abstract
A textbook dissociation between physiology and outcome, and the origin of the rule that steroids started beyond two weeks may kill. It sits uneasily beside DEXA-ARDS, which gave steroids early and found benefit — timing appears to be the whole story.
Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med 2006 Apr 20;354(16):1671-84.