February 7, 2020
Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial.
What was the research question?
Does the use of dexamethasone in moderate to severe ARDS patients improves outcomes in terms of length of stay on the ventilator and mortality rate?
How did they do it?
Multicenter, open-label, randomized trial in 17 ICUs in Spain.
277 patients with moderate to severe ARDS, 24 hours after intubation and ventilator optimization.
Intervention patients received dexamethasone 20 mg IV for 5 days, then 10 mg daily for the next 5 days.
Primary outcome was the 28-day ventilator-free days.
Secondary outcome was 60-day all-cause mortality.
What did they find?
Ventilator-free days was higher in the dexamethasone group than in the control group (mean 12.3 days vs. 7.5 days, p<0·0001).
60-day mortality was better in the dexamethasone group compared to the control group (21% vs. 36%, p=0·0047).
NNT is 7.
No difference in proportion of adverse events: Hyperglycemia (76% vs 70%), new infections in the ICU (24% vs. 25%]), and barotrauma (10% vs 7%).
Dexamethasone patients were less likely to require proning (20% vs. 30%) or ECMO (3.6% vs 6.5%).
The trial was stopped early at 277 out of 314 planned due to slow enrollment.
Some patients were excluded if the clinician felt they would benefit from steroids (this would have made the results even better if they were included).
Some patients randomized to receive no steroid were found to have steroid-responsive disorders and were treated with off-protocol steroid.
77% of whom had pneumonia or sepsis as the cause of ARDS (those are more likely to benefit from steroids that ARDS caused by other conditions)
What does it mean?
The study provides more support for using steroids in the form of dexamethasone in moderate to severe ARDS caused by sepsis or pneumonia as it shortens duration of mechanical ventilation and improves outcome. Other subset of ARDS (i.e. ARDS secondary to trauma) needs further investigations.