Improved oxygenation following methylprednisolone therapy and survival in paediatric acute respiratory distress syndrome

Abstract

BackgroundMethylprednisolone remains a commonly used ancillary therapy for paediatric acute respiratory distress syndrome (PARDS), despite a lack of level 1 evidence to justify its use. When planning prospective trials it is useful to define response to therapy and to identify if there is differential response in certain patients, i.e. existence of ‘responders’ and ‘non responders’ to therapy. This retrospective, observational study carried out in 2 tertiary referral paediatric intensive care units aims to characterize the change in Oxygen Saturation Index, following the administration of low dose methylprednisolone in a cohort of patients with PARDS, to identify what proportion of children treated demonstrated response, whether any particular characteristics predict response to therapy, and to determine if a positive response to corticosteroids is associated with reduced Paediatric Intensive Care Unit mortality.MethodsAll patients who received prolonged, low dose, IV methylprednisolone for the specific indication of PARDS over a 5-year period (2011–2016) who met the PALICC criteria for PARDS at the time of commencement of steroid were included (n = 78).OSI was calculated four times per day from admission until discharge from PICU (or death). Patients with ≥20% improvement in their mean daily OSI within 72 hours of commencement of methylprednisolone were classified as ‘responders’. Primary outcome measure was survival to PICU discharge.ResultsMean OSI of the cohort increased until the day of steroid commencement then improved thereafter. 59% of patients demonstrated a response to steroids. Baseline characteristics were similar between responders and non-responders. Survival to PICU discharge was significantly higher in ‘responders’ (74% vs 41% OR 4.14(1.57–10.87) p = 0.004). On multivariable analysis using likely confounders, response to steroid was an independent predictor of survival to PICU discharge (p = 0.002). Non-responders died earlier after steroid administration than responders (p = 0.003).ConclusionsAn improvement in OSI was observed in 60% of patients following initiation of low dose methylprednisolone therapy in this cohort of patients with PARDS. Baseline characteristics fail to demonstrate a difference between responders and non-responders. A 20% improvement in OSI after commencement of methylprednisolone was independently predictive of survival, Prospective trials are needed to establish if there is a benefit from this therapy.

Pulmonary Specific Ancillary Treatment for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…However, those that received steroids were less likely to require supplemental oxygen at transfer out of the PICU. Finally, another observational study also suggests that children with PARDS who have an improvement in oxygenation following steroid administration have greater odds of survival (74% vs 41%; OR, 4.14; 95% CI, 1.57–10.87; p = 0.004) (56).…”

Lung Microbiota Signature and Corticosteroid Responses in Pneumonia-Associated Acute Respiratory Distress Syndrome in Hematological Patients

“… 12 Improvement of oxygenation within 1 to 2 days of corticosteroids therapy has been proved to be correlated with reduced ICU mortality in pediatric patients with ARDS. 13 On the other hand, side effects like secondary infections may take weeks to occur, 14 which imply that it is possible and crucial to predict the prognosis of corticosteroid-treated patients based on their early response to the drug. Besides, timely withdrawn of the corticosteroids for non-responsive patients may avoid side effects of the drug.…”

Corticosteroids treatment for pediatric acute respiratory syndrome

“…55 1.2 Steroid treatment improves oxygen saturation index in patents. The study performed by Mitting et al 56 on a cohort of 78 PARDS patients who had received methylprednisolone over 5 years (2011-2016) showed a >20% increase in oxygen saturation index in 60% of the patients. Regarding steroid treatment, 59% of the patients showed a response.…”

“…However, more prospective studies are necessary to ascertain the effectiveness of the steroid therapy. 56 1.3 Steroid treatment reduces levels of inflammatory cytokines. De Luca et al 57 revealed a connection between high inflammatory cytokine levels and ARDS in infant bronchoalveolar lavage fluid.…”