Intensive Care Medicine

, Volume 34, Issue 1, pp 61–69 | Cite as

Steroid treatment in ARDS: a critical appraisal of the ARDS network trial and the recent literature

  • G. Umberto Meduri
  • Paul E. Marik
  • George P. Chrousos
  • Stephen M. Pastores
  • Wiebke Arlt
  • Albertus Beishuizen
  • Faran Bokhari
  • Gary Zaloga
  • Djillali Annane
Clinical Commentary

Abstract

Objectives

To compare the design and results of randomized trials investigating prolonged glucocorticoid treatment (≥ 7 days) in patients with acute lung injury–acute respiratory distress syndrome (ALI–ARDS), and review factors affecting response to therapy, including the role of secondary prevention.

Design

Trials were retrieved from the Cochrane Central Register of Controlled Trials (CENTRAL). Two investigators collected data on study characteristics, treatment intervention, and outcomes. The methodological quality of trials was determined and data were analyzed with Review Manager 4.2.3.

Measurements and results

Five selected trials (n = 518) consistently reported significant improvement in gas exchange, reduction in markers of inflammation, and decreased duration of mechanical ventilation and intensive care unit stay (all p < 0.05). Two early small clinical trials showed marked reductions in the relative risk (RR) of death with glucocorticoid therapy (RR = 0.14, 95% CI 0.04–0.53; p = 0.004, I2 = 0%). Three subsequent larger trials, when combined, although nominally beneficial, did not reproduce the marked reductions observed in the earlier trials (RR = 0.84; 95% CI 0.68–1.03; p = 0.09, I2 = 9.1%), but achieved a distinct reduction in the RR of death in the larger subgroup of patients (n = 400) treated before day 14 of ARDS [82/214 (38%) vs. 98/186 (52.5%), RR = 0.78; 95% CI 0.64–0.96; p = 0.02, I2 = 0%].

Conclusions

Prolonged glucocorticoid treatment substantially and significantly improves meaningful patient-centered outcome variables, and has a distinct survival benefit when initiated before day 14 of ARDS.

Keywords

Acute respiratory distress syndrome Glucocorticoid treatment Duration of mechanical ventilation Mortality 

Notes

Acknowledgements

We wish to acknowledge Dr. Peter Eichacker for critical review of the manuscript, Dr. David Armbruster for editorial assistance, and Dr. Marek Ancukiewicz (Massachusetts General Hospital, Boston) for providing previously unpublished data and statistical analysis for the ARDS Network.

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Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • G. Umberto Meduri
    • 1
  • Paul E. Marik
    • 2
  • George P. Chrousos
    • 3
  • Stephen M. Pastores
    • 4
  • Wiebke Arlt
    • 5
  • Albertus Beishuizen
    • 6
  • Faran Bokhari
    • 7
  • Gary Zaloga
    • 8
  • Djillali Annane
    • 9
  1. 1.Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of Tennessee Health Science Center and Memphis VA Medical CenterMemphisUSA
  2. 2.Thomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Athens University Medical SchoolAthensGreece
  4. 4.Memorial Sloan-Kettering Cancer CenterNew YorkUSA
  5. 5.University of BirminghamBirminghamUK
  6. 6.VU University Medical CenterAmsterdamNetherlands
  7. 7.Stronger Hospital of Cook CountyChicagoUSA
  8. 8.Baxter HealthcareDeerfieldUSA
  9. 9.Universite de Versailles Saint-Quentin en YvelinesGarchesFrance

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