Corticosteroids May Reduce Ventilation Use, Duration in Patients With ARDS

Meta-analyses show that corticosteroids may reduce the risk of acute respiratory distress syndrome (ARDS) in patients with community-acquired pneumonia (CAP), reduce the duration of mechanical ventilation, and increase the number of ventilator-free days and days spent out of the intensive care unit (ICU) in patients with established ARDS, according to a review study published in the International Journal of Clinical Practice.  However, researchers of this review also noted that published meta-analyses of the effect of corticosteroids on mortality largely showed inconsistent findings.

Researchers from Australia and India reviewed 18 meta-analyses (including 38 primary studies) examining the effect of corticosteroid use on outcomes that included ARDS prevention, mortality, ventilator-free days, ICU stay, and safety. The review included 14 meta-analyses of patients with ARDS, 3 of patients with CAP, and 1 analysis of patients in critical care, all published between 2004 and 2020. The pooled cohort of 3760 participants included 1887 assigned to corticosteroids and 1873 assigned to placebo or no corticosteroids.

With respect to corticosteroid use for ARDS prevention, researchers found corticosteroids were associated with significant reductions in ARDS occurrence in patients with CAP, but that corticosteroids appeared to have no significant effect on preventing ARDS in critically ill patients (OR, 1.55; 95% CI, 0.58-4.05).

With respect to mortality, corticosteroids demonstrated inconsistent effects:

• A pooled analysis of 34 primary studies (with 1401 patients assigned to corticosteroids and 1453 patients assigned to control) found a nonsignificant reduction in mortality with corticosteroid use (relative risk [RR], 0.85; 95% CI, 0.71-1.03; P =.09).
• A subgroup analysis of 15 cohort studies found a nonsignificant mortality reduction with corticosteroids vs control (RR, 0.95; 95% CI, 0.71-1.27; P =.73).
• A pooled estimation of 19 randomized controlled trials with 1763 participants demonstrated a significantly lower risk of mortality in patients who received corticosteroids (RR, 0.78; 95% CI, 0.61-0.99; P =.04).

With respect to ICU and ventilator outcomes, corticosteroids showed favorable effects:

• In a pooled analysis of 10 studies (with 555 patients assigned to corticosteroids and 516 patients assigned to control), treatment with corticosteroids was associated with a significantly greater improvement in ventilator-free days compared with control in the meta-analysis (MD, 6.03; 95% CI, 3.59-8.47; P <.00001).
• A quantitative analysis of 4 randomized controlled trials with 146 patients assigned to corticosteroids and 131 patients assigned to control found treatment with corticosteroids was associated with a significantly higher rate of ICU-free days compared with control (MD, 8.04; 95% CI, 2.70-13.38; P =.003).
• In a pooled estimate of 8 studies, patients treated with corticosteroids had a significantly less duration of ventilator use compared with those treated with control (MD, −4.75; 95% CI, −7.63 to −1.88; P =.001).

Researchers described the quality of the data reviewed as ranging from ”critically low” to “high.” Additionally, the researchers said they may have missed some studies with conflicting data because their review included only studies reported in English.

Overall, investigators said their review demonstrated the importance of corticosteroids, both as an adjunctive treatment for CAP and as a therapy that may reduce mechanical ventilation and ICU days, thus promoting faster recovery, a better quality of life, and lower health care costs.

Reference

Rashid M, Khan S, Datta D, et al. Efficacy and safety of corticosteroids in acute respiratory distress syndrome: An overview of meta-analyses. Int J Clin Pract. Published online July 26, 2021. doi:10.1111/ijcp.14645