Corticosteroid Administration

Intravenous steroids have generally shown no benefit in the initial treatment of ARDS.41 However, initiation of low to moderate-dose corticosteroids in highly-select patients can improve pulmonary mechanics and reduce ventilator and ICU days without increasing complications including infections and neuropathy/myelopathy.42,43 This select population consists primarily of those with “late-phase” or “prolonged” ARDS, defined as duration of ≥7 days. The ARDSNet Late Steroid Rescue Study Trial demonstrated a potential benefit of steroids in the subgroup of patients with ARDS duration between 7-13 days, but potential harm of steroids when administered to patients who were at ≥14 days of duration. In patients without contraindications, the recommended regimen is methylprednisolone 2 mg/kg IV x1 followed by an infusion of 2 mg/kg/day (can be divided into every 6 hour doses) for 14 days (or for the duration of intubation, whichever is shorter). The infusion can then be tapered over 7-21 days based on clinical judgment. If steroids have not been initiated within two weeks of an ARDS diagnosis, they should be avoided due to an increased mortality with delayed therapy.44 Of note, AEP can masquerade as ARDS and has been described in deployed military members who recently started smoking.45 AEP is highly sensitive to steroid therapy; so it is very important to correctly diagnose AEP from the more common ARDS.