Prolonged corticosteroid treatment in acute respiratory distress syndrome: impact on mortality and ventilator-free days

Excerpt

We read with interest the letter by Blot and colleagues recently published in Critical Care [1] which concluded that the recommendations of the Corticosteroid Guideline Task Force of SCCM and ESICM [2] for the use of adjunctive corticosteroids in early moderate to severe acute respiratory distress syndrome (ARDS) were based on insufficient evidence. In support of their view, the authors refer to the meta-analysis of Ruan et al. (reference [3] in Blot and colleagues’ letter) also published in Critical Care in 2014. We respectfully disagree with their comments and offer the following observations. First, the meta-analysis by Ruan et al. did not take into account how current understanding of disease pathophysiology impacts the administration of corticosteroid treatment in ARDS. The meta-analysis by Ruan et al. incorporated four randomized trials from the 1980s that investigated short-term (24–48 h) massive daily corticosteroid doses (up to 120 mg/kg methylprednisolone equivalent), an intervention that is obsolete and discredited by the present pathophysiological understanding of ARDS [2]. Thus, the inclusion of these trials in the meta-analysis is mostly responsible for the inconsistency reported in their letter. Moreover, the conclusion by Ruan et al. that the benefits of corticosteroid treatment decreased over time are not supported by the actual findings of the cited trials (Figure 3 in [4], Figure 4 in [5] and Table 5 in [3]). …