Corticosteroid exposure in pediatric acute respiratory distress syndrome

Use of systemic corticosteroids in acute respiratory distress syndrome (ARDS) remains controversial, and studies in children are lacking.

We performed an observational, single-center study in a prospectively enrolled cohort of children meeting criteria for ARDS (both Berlin 2012 and AECC 1994 acute lung injury) and pediatric ARDS (PARDS, as defined by PALICC 2015). Comprehensive analysis of corticosteroid utilization was planned, and detailed information collected on corticosteroid use, timing, treatment duration, and cumulative dose while mechanically ventilated. We assessed the association between corticosteroid exposure >24 h and outcomes.

Of the 283 children with PARDS (37 deaths, 13%), 169 (60%) received corticosteroids for >24 h while ventilated: 51% hydrocortisone, 41% methylprednisolone, 5% dexamethasone, 3% combination of corticosteroids. Corticosteroid exposure >24 h was associated with increased mortality, fewer ventilator-free days at 28 days (VFD), and longer duration of ventilation in survivors in unadjusted analyses (all p < 0.05). Multivariate and propensity score adjusted analyses confirmed independent association of corticosteroid exposure with fewer VFD and longer duration of ventilation in survivors, but not with mortality. In planned analyses of high-risk subgroups, no benefit was seen with corticosteroids exposure, with fewer VFD associated with corticosteroid exposure >24 h in patients with ≥3 organ failures and immunocompromised patients.

Corticosteroid exposure >24 h was independently associated with fewer VFD and longer duration of ventilation in survivors, even after adjustment for key potential confounders, including severity of illness, oxygenation index, immunocompromised status, and number of organ failures.