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<p>The 2024 global redefinition of acute respiratory distress syndrome (ARDS) broadens diagnostic criteria to include patients on non-invasive respiratory support. While this inclusivity enhances early recognition, it also introduces heterogeneity in disease severity, inflammatory burden, and treatment responsiveness–complicating the use of corticosteroids. Although recent guidelines recommend corticosteroids for moderate-to-severe ARDS, they fall short of specifying optimal timing, dosing, and patient selection. The DEXA-ARDS trial showed that high-dose dexamethasone reduced mortality in moderate-to-severe ARDS regardless of etiology, but its generalizability to less severe or non-intubated patients remains unclear. Conversely, in severe community-acquired pneumonia (CAP), hydrocortisone regimens used in CAPE-COD and APROCCHSS trials demonstrated mortality benefits, suggesting a particular therapeutic niche for corticosteroids in non-viral, infection-associated ARDS. A recent network meta-analysis suggests that low-dose methylprednisolone may reduce ARDS mortality, though phenotype-specific efficacy is not well defined. Despite these encouraging signals, key questions persist: Which corticosteroid? At what dose? For which ARDS phenotype? As evidence accumulates unevenly across ARDS subtypes, guideline-endorsed recommendations may inadvertently mask the nuances required for individualized therapy. Until precision approaches are better defined, clinicians must balance empirical benefit with thoughtful restraint in applying corticosteroids to non-viral ARDS. This concise review summarizes current evidence, key limitations, and pragmatic phenotype-informed strategies for corticosteroid use in non-viral ARDS.</p>

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Corticosteroids in non-viral acute respiratory distress syndrome (ARDS): recommendations outpace evidence – a concise review

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年10月5日

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  • Thanh Luan Nguyen,
  • Phuc Tuong Pham,
  • Van Phieu Duong,
  • Hoang Ngoc Thao Duong

摘要

The 2024 global redefinition of acute respiratory distress syndrome (ARDS) broadens diagnostic criteria to include patients on non-invasive respiratory support. While this inclusivity enhances early recognition, it also introduces heterogeneity in disease severity, inflammatory burden, and treatment responsiveness–complicating the use of corticosteroids. Although recent guidelines recommend corticosteroids for moderate-to-severe ARDS, they fall short of specifying optimal timing, dosing, and patient selection. The DEXA-ARDS trial showed that high-dose dexamethasone reduced mortality in moderate-to-severe ARDS regardless of etiology, but its generalizability to less severe or non-intubated patients remains unclear. Conversely, in severe community-acquired pneumonia (CAP), hydrocortisone regimens used in CAPE-COD and APROCCHSS trials demonstrated mortality benefits, suggesting a particular therapeutic niche for corticosteroids in non-viral, infection-associated ARDS. A recent network meta-analysis suggests that low-dose methylprednisolone may reduce ARDS mortality, though phenotype-specific efficacy is not well defined. Despite these encouraging signals, key questions persist: Which corticosteroid? At what dose? For which ARDS phenotype? As evidence accumulates unevenly across ARDS subtypes, guideline-endorsed recommendations may inadvertently mask the nuances required for individualized therapy. Until precision approaches are better defined, clinicians must balance empirical benefit with thoughtful restraint in applying corticosteroids to non-viral ARDS. This concise review summarizes current evidence, key limitations, and pragmatic phenotype-informed strategies for corticosteroid use in non-viral ARDS.