Steroids for early acute respiratory distress syndrome: Critical appraisal of 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

OBJECTIVES: To review the findings and discuss the implications of studies evaluating the use of corticosteroids in early acute respiratory distress syndrome. DESIGN: Critical appraisal of "Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial" by Meduri GU, Golden E, Freire AX, et al (Chest 2007; 131:954-963) and review of the relevant literature. MEASUREMENTS AND MAIN RESULTS: Several studies have now demonstrated a possible benefit to low-dose steroid therapy in early (<7 days) acute respiratory distress syndrome. Meduri et al used a treatment protocol of low-dose prolonged methylprednisolone in their prospective, double-blinded, randomized, placebo-controlled group sequential clinical trial. Almost 50% more patients in the treatment group had improved lung function (decrease in lung injury score by 1 point or extubation) by day 7 (69.8% versus 35.7%; relative risk, 1.96 [95% confidence interval, 1.16-3.30], p = .002). More than double the treated patients were extubated at 7 days (54.0% versus 25.0%; relative risk, 2.16 [95% confidence interval, 1.09-4.26], p = .01). The number needed to treat to improve lung function within 7 days was 2.9 (95% confidence interval, 1.89-8.25). Although the trial was well designed, the group sequential trial design, use of open-label methylprednisolone for nonresponders, and higher percent of control subjects with baseline catecholamine-dependent shock in the intention-to-treat analysis may limit the strength of the data. CONCLUSIONS: The protocol suggested by Meduri and colleagues presents an attractive therapeutic adjunct, but steroids in early acute respiratory distress syndrome cannot be recommended as standard therapy at this time.