Decreased mortality in acute respiratory distress syndrome patients treated with corticosteroids: an updated meta-analysis of randomized clinical trials with trial sequential analysis

Abstract

Background The possible benefits associated with corticosteroid treatment in acute respiratory distress syndrome (ARDS) patients are not fully known. We conducted an updated meta-analysis to assess the effect of corticosteroids in the treatment of patients with ARDS. Methods We systematically searched MEDLINE, Embase, and the Cochrane Library from inception to January 2021 via Ovid to identify randomized controlled trials evaluating the efficacy of glucocorticoids in the treatment of patients with ARDS. The primary outcome was hospital mortality. Secondary outcomes included the number of ventilator-free days at day 28, oxygenation improvement (PaO2/FIO2 ratios), and adverse events. Results Nine studies with 1371 participants were analyzed. The pooled analysis revealed that glucocorticoid use was associated with reduced mortality [relative risk (RR), 0.83; 95% confidence interval (CI) 0.74–0.93; P < 0.01; I2 = 37], and the statistical power was confirmed by trial sequential analysis. Glucocorticoids might also significantly increase the number of ventilator-free days at day 28 (mean deviation 3.66 days, 95% CI 2.64–4.68; P < 0.01) and improve oxygenation (standardized mean difference 4.17; 95% CI 2.32–6.02; P < 0.01). In addition, glucocorticoid use was not associated with increased risks of new infection (RR 0.84; 95% CI 0.70–1.01; P = 0.07) and hyperglycemia (RR 1.11; 95% CI 0.99–1.23; P = 0.06). Conclusions The use of glucocorticoids might result in reduced mortality in patients with ARDS. Glucocorticoids might be recommended as an adjunct to standard care for ARDS; however, the optimal dose and duration of steroid therapy remains unknown and further studies are needed.

Safety and efficacy of corticosteroids in ARDS patients: a systematic review and meta-analysis of RCT data

“…In the present study, we found that corticosteroids could significantly reduce the 28-day mortality of ARDS patients, which is inconsistent with several previous meta-analyses [19,26,41]. Corticosteroid use can improve ICU mortality, in-hospital mortality, and ventilationfree days at 28 days, and these beneficial effects have also been confirmed by other studies [21]. In addition, glucocorticoid use could potentially increase the risk of hyperglycemia (but not gastroduodenal bleeding) among ARDS patients, which is consistent with findings by Fang et al [31].…”

“…Compared to a previous meta-analysis published in 2021 [21], the present study has several advantages as it has six additional RCTs and contains children and participants with COVID-19. Moreover, the sample size of our study was relatively large and the research was of high quality.…”

“…Unfortunately, there is still a lack of conclusive evidence and guidelines for the use of corticosteroids in ARDS patients [16]. This may be due to the conflicting data between recent and previous studies [17][18][19][20][21][22], and a significant heterogeneity being found among the results of the RCTs [18,[23][24][25][26][27]. In addition, the efficacy of corticosteroids has been found to be associated with several clinical variables, and in some cases, corticosteroids are not recommended routinely [1,28].…”

Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation

“…At this point, we are unsure whether identifying subphenotypes in terms of other clinical characteristics or combining biological profiles would have a better predictive value and explore more and new markers to follow up disease may need further research in the future. Fourth, although a recent meta-analysis demonstrated that corticosteroids treatment might reduce overall mortality and duration of mechanical ventilation in ARDS patients [ 34 ], they did not conduct subgroup analyses such as the underlying etiology of ARDS (i.e., direct or indirect injury). Corticosteroids use in ARDS remains highly controversial due to unclear benefits and the optimal dose and duration are unknown, and our study did not evaluate the possible impact of corticosteroids on clinical outcomes in ARDS patients receiving ECMO.…”

Advances in mesenchymal stromal cell therapy for acute lung injury/acute respiratory distress syndrome

“…A retrospective study showed that early high-dose corticosteroid treatment had no effect on hospital mortality; moreover, high doses of steroids usually increase the risk of infection ( Hu et al, 2021 ). A meta-analysis conducted by Lin et al suggested that adjunctive treatment with glucocorticoids may reduce mortality in patients with ARDS, although further research is needed to determine the optimal dose and duration of steroid therapy ( Lin et al, 2021 ). Mechanical ventilation therapies include pulmonary-protective mechanical ventilation, prone position ventilation, and extracorporeal membrane pulmonary oxygenation ( Fan et al, 2018 ; Hadaya and Benharash, 2020 ).…”