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doi:10.1378/chest.07-1338
(Chest. 2007; 132:1096)
© 2007 American College of Chest Physicians
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Methylprednisolone Infusion in Early Severe ARDS

It Is Pretty, But Is It Art?

Jorge I. F. Salluh, MD, MSc and Marcio Soares, MD, PhD

Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil

Correspondence to: Jorge I. F. Salluh, MD, MSc, Instituto Nacional de Câncer, Centro de Tratamento Intensivo, 10o Andar, Pça. Cruz Vermelha, 23, Rio de Janeiro, Brazil; CEP: 20230–130; e-mail: jorgesalluh{at}yahoo.com.br

To the Editor:

Despite the recent advances in the care of critically ill patients,1 ARDS is still a clinical condition associated with high mortality rates. In this clinical scenario, while most interventions to date have focused on the prevention of morbidity with ventilator-induced lung injury and pneumonia, no therapeutic intervention is indisputably associated with improved outcomes.

Corticosteroids have been used for the treatment of ARDS for the last 20 years; however, their benefits are still unproven.2 Discrepancy of results from clinical trials may be explained by different doses and duration of administration, as well as patient selection and an excess of morbidity imposed by steroid-related side effects. However, the recent study by Meduri and coworkers3 sheds some new light on ARDS pharmacotherapy by demonstrating clinical improvement based on possible immunomodulatory effects of the steroid infusion, thus hastening the resolution of lung injury and organ failures. Common aspects among all studies showing benefits of steroids34 were the use of relatively lower doses, early infusion, and the selection of an extremely severely ill population. Moreover, these "successful" prospective studies had also similar limitations, the foremost one being a relatively small sample size with limited power for the detection of important outcomes (eg, hospital mortality). Therefore, these results must be viewed with caution because the morbidity burden associated with corticosteroids cannot be underestimated and a recent large multicenter clinical trial5 failed to show any significant improvement in the outcomes of patients with ARDS and severe sepsis (as disclosed by the results of the Corticus Study).

In conclusion, we believe that corticosteroids cannot be widely recommended for critically ill patients. Although Dr. Meduri’s results3 are promising, a prospective multicenter trial is absolutely necessary before corticosteroids can be routinely recommended for the treatment of severe ARDS.

Footnotes

The authors have no conflicts of interest to disclose.

References

  1. Vincent, JL (2004) Evidence-based medicine in the ICU: important advances and limitations. Chest 126,592-600[Abstract/Free Full Text]
  2. Calfee, CS, Matthay, MA Nonventilatory treatments for acute lung injury and ARDS. Chest 2007;131,913-920[Abstract/Free Full Text]
  3. Meduri, GU, Golden, E, Freire, AX, et al Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest 2007;131,954-963[Abstract/Free Full Text]
  4. Annane, D, Sebille, V, Bellissant, E Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med 2006;34,22-30[CrossRef][ISI][Medline]
  5. Steinberg, KP, Hudson, LD, Goodman, RB, et al Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med 2006;354,1671-1684[Abstract/Free Full Text]




This Article
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Google Scholar
Right arrow Articles by Salluh, J. I. F.
Right arrow Articles by Soares, M.
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PubMed
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Right arrow Articles by Salluh, J. I. F.
Right arrow Articles by Soares, M.

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