Corticosteroids in the prevention and treatment of acute respiratory distress syndrome (ARDS) in adults: meta-analysisBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39537.939039.BE (Published 01 May 2008) Cite this as: BMJ 2008;336:1006
- John Victor Peter, physician1,
- Preeta John, lecturer2,
- Petra L Graham, lecturer3,
- John L Moran, senior consultant4,
- Ige Abraham George, lecturer5,
- Andrew Bersten, professor6
- 1Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India 632 004
- 2Department of Surgical Critical Care and Anaesthesia, Christian Medical College and Hospital, Vellore, India
- 3Department of Statistics, Division of Economic and Financial Studies, Macquarie University, Sydney, NSW, Australia
- 4Department of Intensive Care, Queen Elizabeth Hospital, Woodville, SA, Australia 5011
- 5Department of Medicine, Christian Medical College and Hospital, Vellore, India
- 6Department of Critical Care Medicine, Flinders Medical Centre and School of Medicine, Flinders University, Bedford Park, SA, Australia
- Correspondence to: J L Moran
- Accepted 14 March 2008
Objective To systematically review the efficacy of steroids in the prevention of acute respiratory distress syndrome (ARDS) in critically ill adults, and treatment for established ARDS.
Data sources Search of randomised controlled trials (1966-April 2007) of PubMed, Cochrane central register of controlled trials, Cochrane database of systematic reviews, American College of Physicians Journal Club, health technology assessment database, and database of abstracts of reviews of effects.
Data extraction Two investigators independently assessed trials for inclusion and extracted data into standardised forms; differences were resolved by consensus.
Data synthesis Steroid efficacy was assessed through a Bayesian hierarchical model for comparing the odds of developing ARDS and mortality (both expressed as odds ratio with 95% credible interval) and duration of ventilator free days, assessed as mean difference. Bayesian outcome probabilities were calculated as the probability that the odds ratio would be ≥1 or the probability that the mean difference would be ≥0. Nine randomised trials using variable dose and duration of steroids were identified. Preventive steroids (four studies) were associated with a trend to increase both the odds of patients developing ARDS (odds ratio 1.55, 95% credible interval 0.58 to 4.05; P(odds ratio ≥1)=86.6%), and the risk of mortality in those who subsequently developed ARDS (three studies, odds ratio 1.52, 95% credible interval 0.30 to 5.94; P(odds ratio ≥1)=72.8%). Steroid administration after onset of ARDS (five studies) was associated with a trend towards reduction in mortality (odds ratio 0.62, 95% credible interval 0.23 to 1.26; P(odds ratio ≥1)=6.8%). Steroid therapy increased the number of ventilator free days compared with controls (three studies, mean difference 4.05 days, 95% credible interval 0.22 to 8.71; P(mean difference ≥0)=97.9%). Steroids were not associated with increase in risk of infection.
Conclusions A definitive role of corticosteroids in the treatment of ARDS in adults is not established. A possibility of reduced mortality and increased ventilator free days with steroids started after the onset of ARDS was suggested. Preventive steroids possibly increase the incidence of ARDS in critically ill adults.
Contributors: JVP and JLM conceived, designed, and planned the study. JLM is guarantor. PJ, JVP, and IAG were responsible for the electronic search, data collection, abstraction, hand searching of journals, and data entry. JVP, PJ, and IAG quality assessed the trials. JLM and PLG provided statistical expertise. All authors helped draft the manuscript, carried out a literature search of additional articles, and discussed the results.
Competing interests: None declared.
Ethical approval: Not required.
Provenance and peer review: Not commissioned; externally peer reviewed.