Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis

doi:10.5847/wjem.j.1920-8642.2021.03.008

Abstract

Abstract:

BACKGROUND: There are conflicting results regarding whether corticosteroids have better efficacy than placebo in acute respiratory distress syndrome (ARDS) patients. Therefore, we aim to further evaluate the efficacy and safety of corticosteroids in adult ARDS patients.

METHODS: The databases, including Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, were searched from their inception to May 2, 2020. Randomized controlled trials (RCTs) and observational cohort studies were selected to assess the use of corticosteroids in adult ARDS patients. The quality of the results was judged by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The inverse-variance method with random or fixed effects modeling was used to compute pooled odds ratio (OR), standardized mean difference (SMD), and their 95% confidence interval (CI).

RESULTS: Eight eligible RCTs and six cohort studies were included. The use of corticosteroids was associated with reduced mortality (OR 0.57, 95% CI 0.43-0.76, I²=35.1%, P=0.148) in ARDS patients, and the result was confirmed in the included cohort studies (OR 0.51, 95% CI 0.27-0.95, I²=66.7%, P=0.010). The subgroup analysis stratified by the initiation time and duration of corticosteroid use showed that early ARDS and prolonged corticosteroid use had significant survival benefits in the RCTs. The low-dose corticosteroid use was also associated with significantly more ventilator-free days and a reduced rate of new infections in ARDS patients.

CONCLUSIONS: The low-dose corticosteroid therapy may be safe and reduce mortality, especially in patients with prolonged treatment and early ARDS.

Key words: Low-dose, Corticosteroid, Acute respiratory distress syndrome, Mortality, Systematic review, Meta-analysis

Yu-qing Cui, Xian-fei Ding, Huo-yan Liang, Dong Wang, Xiao-juan Zhang, Li-feng Li, Quan-cheng Kan, Le-xin Wang, Tong-wen Sun. Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis[J]. World Journal of Emergency Medicine, 2021, 12(3): 207-213.

Figures/Tables 3

Table 1

Figure 1.

Figure 2.

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Study	Country	Center	Number of patients		Female/ male	Age, years (mean±SD)		Initial daily dose^a	Time of treatment initiation	Duration of treatment (days)	Primary outcome			Secondary outcomes
			Number of patients			Age, years (mean±SD)					Mortality		MV free days (mean±SD)		New infection rate
			SG	NG		SG	NG				SG	NG	SG	NG	SG	NG
Meduri et al^[11] (2007)	USA	M	63	28	44/47	50.1±15.3	53.2±15.3	Infusion of Me 1 mg/(kg·d)	Early severe ARDS	Up to 28	15/63	12/28	16.5±10.1	8.7±10.2	27/63	16/28
Meduri et al^[12] (1998)	USA	M	16	8	15/9	47.0±39.0	51.0±6.6	Intravenous pushing Me 2 mg/(kg·d)	Unresolving ARDS	Up to 32	2/16	5/8	NA	NA	12/16	6/8
Rezk et al^[13] (2013)	Egypt	M	18	9	4/23	NA	NA	Infusion of Me 1 mg/(kg·d)	Early ARDS	Up to 28	0/18	3/9	NA	NA	NA	NA
Villar et al^[14] (2020)	Spain	M	139	138	86/191	56.0±14.0	58.0±15.0	Intravenously receiving Dex 20 mg/d	Early ARDS	Up to 10	29/139	50/138	12.3±9.9	7.5±9.0	33/139	35/138
Tongyoo et al^[15] (2016)	Thailand	S	98	99	96/101	64.5±17.3	64.3±16.0	Intravenous bolus Hy 200 mg/d	Early ARDS	7	22/98	27/99	12.0±9.7	9.7±10.0	34/98	41/99
Annane et al^[21] (2006)	France	M	85	92	NA	NA	NA	Hy 200 mg/d and Flu 50 μg	Early ARDS	7	54/85	67/92	4.9±8.4	3.1±6.9	12/85	12/92
Steinberg et al^[22](2006)	USA	M	89	91	82/98	49.0±19.0	49.2±16.5	Intravenously receivng Me 2 mg/(kg·d)	Unresolving ARDS	Up to 25	26/89	26/91	11.2±9.4	6.8±8.5	25/89	43/91
Liu et al^[23](2012)	China	S	12	14	7/19	69.8±14.9	55.9±15.3	Intravenous bolus Hy 300 mg/d	Early ARDS	7	3/12	6/14	13.9±11.3	12.8±11.3	3/12	2/14

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