Skip to main content

Prolonged corticosteroid treatment in acute respiratory distress syndrome: impact on mortality and ventilator-free days

A Letter to this article was published on 28 December 2017

We read with interest the letter by Blot and colleagues recently published in Critical Care [1] which concluded that the recommendations of the Corticosteroid Guideline Task Force of SCCM and ESICM [2] for the use of adjunctive corticosteroids in early moderate to severe acute respiratory distress syndrome (ARDS) were based on insufficient evidence. In support of their view, the authors refer to the meta-analysis of Ruan et al. (reference [3] in Blot and colleagues’ letter) also published in Critical Care in 2014. We respectfully disagree with their comments and offer the following observations. First, the meta-analysis by Ruan et al. did not take into account how current understanding of disease pathophysiology impacts the administration of corticosteroid treatment in ARDS. The meta-analysis by Ruan et al. incorporated four randomized trials from the 1980s that investigated short-term (24–48 h) massive daily corticosteroid doses (up to 120 mg/kg methylprednisolone equivalent), an intervention that is obsolete and discredited by the present pathophysiological understanding of ARDS [2]. Thus, the inclusion of these trials in the meta-analysis is mostly responsible for the inconsistency reported in their letter. Moreover, the conclusion by Ruan et al. that the benefits of corticosteroid treatment decreased over time are not supported by the actual findings of the cited trials (Figure 3 in [4], Figure 4 in [5] and Table 5 in [3]).

As the Corticosteroid Guideline Task Force state in the guideline, our recommendation for adjunctive use of corticosteroids in early moderate to severe ARDS is a conditional recommendation and not necessarily meant to imply a standard of care treatment. In our analysis [2] the pooled relative risk estimate for hospital mortality (Fig. 1) with corticosteroids was 0.64 (95% confidence interval (CI) 0.46–0.89). Even if one excludes the four studies which Blot and colleagues appear to question [1], the pooled relative risk estimate for hospital mortality is 0.76 (95% CI 0.58–0.99), which is not significantly different from 0.64 (0.46–0.89). Independent of hospital mortality, the use of corticosteroids was associated with approximately a 7-day increase in ventilator-free days (mean difference 7.06 days, 95% CI 3.19–10.93) [2] (supplementary digital content in [5]). Given that our recommendation for adjunctive corticosteroids in ARDS is conditional in nature, ongoing and future prospective trials will certainly impact our future recommendations.

Fig. 1
figure 1

Hospital mortality in ARDS subgroup before day 14. Comparison between randomized trials at high risk of bias versus those at low risk of bias which investigated prolonged glucocorticoid (methylprednisolone or hydrocortisone) treatment in ARDS


  1. Blot M, Salmon-Rousseau A, Chavanet P, Piroth L. Do we know enough to recommend corticosteroids in acute respiratory distress syndrome? Crit Care. 2017;21(1):327.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Annane D, Pastores SM, Rochwerg B, et al. Guidelines to the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (part 1): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med. 2017;45:2078–88.

    Article  PubMed  Google Scholar 

  3. Annane D, Sebille V, Bellissant E. Ger-Inf-05 Study G: Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med. 2006;34(1):22–30.

    Article  PubMed  CAS  Google Scholar 

  4. Meduri GU, Headley AS, Golden E, Carson SJ, Umberger RA, Kelso T, Tolley EA. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1998;280(2):159–65.

    Article  PubMed  CAS  Google Scholar 

  5. Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, Gibson M, Umberger R. Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest. 2007;131(4):954–63.

    Article  PubMed  CAS  Google Scholar 

Download references


No financial support was received. This letter is the result of work supported with the resources and use of facilities at the Memphis VA Medical Center. The contents of this letter do not represent the views of the US Department of Veterans Affairs or the United States Government.

Author information

Authors and Affiliations




GUM wrote the first draft and BR, SMP and DA reviewed, edited, and approved the final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gianfranco Umberto Meduri.

Ethics declarations

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional information

See related letter by Blot et al.,

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Meduri, G.U., Rochwerg, B., Annane, D. et al. Prolonged corticosteroid treatment in acute respiratory distress syndrome: impact on mortality and ventilator-free days. Crit Care 22, 135 (2018).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: