Corticosteroids in the prevention and treatment of acute respiratory distress syndrome (ARDS) in adults: meta-analysis.
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.


METHODS
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.


METHODS
Two investigators independently assessed trials for inclusion and extracted data into standardised forms; differences were resolved by consensus.


RESULTS
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 > or =1 or the probability that the mean difference would be > or =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 > or =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 > or =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 > or =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 > or =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.
Peter
John Victor
JV
Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India 632 004.
John
Preeta
P
Graham
Petra L
PL
Moran
John L
JL
George
Ige Abraham
IA
Bersten
Andrew
A
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000328:Adult; D016638:Critical Illness; D017052:Hospital Mortality; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012128:Respiratory Distress Syndrome / Q000188:drug therapy / Q000401:mortality / Q000517:prevention & control*; D012141:Respiratory Tract Infections / Q000209:etiology; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones