Corticosteroids for patients with acute respiratory distress syndrome: a systematic review and meta-analysis of randomized trials.

Mammen, Manoj J; Aryal, Komal; Alhazzani, Waleed; Alexander, Paul E

INTRODUCTION Acute respiratory distress syndrome (ARDS) is a rapidly progressing inflammatory lung disease with a high mortality rate without specific pharmacological therapy. OBJECTIVES We conducted a systematic review and meta-analysis on corticosteroid use in ARDS. METHODS A search of four medical literature databases was conducted. We retained randomized trials (RCTs) of corticosteroids in hospitalized adults with ARDS in a search up to February, 2020. Two reviewers identified eligible studies, independently extracted data, and assessed risk of bias. Authors assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS We included seven RCTs (n=851 patients). Corticosteroids reduced all-cause mortality (risk ratio [RR] 0.75, 95% CI: 0.59 to 0.95, p=0.02, moderate certainty) and duration of mechanical ventilation (mean difference [MD] -4.93 days, 95% CI: -7.81 days to -2.06 days, p<0.001, low certainty), and increased ventilator-free days (VFD) (MD 4.28 days, 95% CI: 2.67 days to 5.88 days, p<0.001, moderate certainty), when compared to placebo. Corticosteroids also increased the risk of hyperglycemia (RR 1.12%, 95% CI: 1.01 to 1.24, p=0.03, moderate certainty), and the effect on neuromuscular weakness was unclear (RR 1.30, 95% CI 0.80 to 2.11, p=0.28, low certainty). CONCLUSIONS These results suggest that systemic corticosteroids may potentially improve mortality, ventilator duration, and VFD in patients with ARDS. However, the studies included different corticosteroid classes and initiated the corticosteroid doses at different times, as well as different dosing regimens. Thus caution in the actual clinical application of these results is recommended.