Nancy A. Melville

January 28, 2015

PHOENIX — Oral corticosteroid use before admission to the intensive care unit (ICU) is associated with a reduced risk for acute respiratory distress syndrome in sepsis patients, according to results from a new study. However, mortality rates are higher in these patients.

"It is possible that in an appropriate at-risk population, corticosteroid administration may have a benefit in reducing the incidence or severity of acute respiratory distress syndrome," said Todd Rice, MD, from the Vanderbilt University School of Medicine in Nashville, Tennessee.

"More investigation is needed, however, regarding the relation between corticosteroids and decreased respiratory distress," he told Medscape Medical News here at the Society of Critical Care Medicine 44th Critical Care Congress.

Dr Todd Rice

There has been ongoing interest in the use of corticosteroids in the management of respiratory distress because of their anti-inflammatory properties.

To investigate the effect of corticosteroid use prior to ICU admission on the development of respiratory distress, Dr Rice and his colleagues evaluated data on patients with sepsis from the Validating Acute Lung Injury Biomarkers for Diagnosis (VALID) study cohort.

Of the 1120 patients, 178 (15.9%) had been treated with oral corticosteroids prior to ICU admission.

Table. Differences in Baseline Characteristics

Characteristic Corticosteroid Use, % No Corticosteroid Use, % P Value
Medical ICU admission 90.4 75.8 <.001
Hematologic malignancy or stem cell transplantation 24.7 10.4 <.001
Tobacco use 14.6 35.1 <.001
Alcohol use 5.1 15.9 <.001

 

In the first 96 hours of ICU admission, the incidence of respiratory distress was 33.1% in patients treated with corticosteroids and 40.7% in those who were not (= .06)

On multivariable regression analysis, corticosteroid use prior to admission was associated with a significantly lower incidence of respiratory distress (odds ratio, 0.52; 95% confidence interval, 0.34 - 0.81; P = .004).

Despite a lower rate of acute respiratory distress, the mortality rate was higher in patients treated with corticosteroids than in those who were not (30.4% vs 22.7%; P = .036).

The number of ventilator-free days up to day 28 was the same in the two groups (18 vs 18 days). The length of stay in the ICU was similar in the two groups.

"We expected that we might see a protective effect of chronic steroids on acute respiratory distress development; however, we were a bit surprised that there was not a significant difference in adjusted mortality, length of ICU stay, or, especially, ventilator-free days," said Dr Rice.

He speculated that this might "be related to the fact that although these patients did not develop respiratory distress as frequently, they were more chronically ill at baseline, so this did not translate to a mortality benefit."

Another explanation could be that steroids only delay respiratory distress; the researchers only evaluated the development in the first 96 hours of ICU admission, he explained.

"Critically ill patients die from more than just respiratory distress, so it might be that chronic preadmission steroid use predisposes patients to other mechanisms of death, like shock or the inability to resolve infections," he added.

Exploring Other Outcomes

What is needed now is research looking into why the preadmission use of corticosteroids is associated with reduced respiratory distress, but not lower mortality or other improved outcomes, said Dr Rice.

Although the routine use of corticosteroids in the management of respiratory distress is not currently recommended, this study helps our understanding of the issue, said session comoderator Jorge Hidalgo, MD, from the Karl Heusner Memorial Hospital in Belize City.

"The interesting part of this respiratory distress study is the prophylactic use of the steroids," he said.

However, there are limitations to the work, Dr Hidalgo told Medscape Medical News.

"The population is not standard; there are patients with hematologic malignancies, as well as stem cell transplants, who are more likely to be using other immunomodulators that can influence the inflammatory response," he said.

"Those patients are prone to developing opportunistic infections," he explained, but "we don't know the stages of hematologic malignancies that can influence mortality."

"Nevertheless, this study opens the door for future prospective studies on the prophylactic use of steroids in the respiratory distress population," Dr Hidalgo said.

If future trials use a cohort as homogenous as possible, it will make it easier to "identify the patients who will benefit from such therapy," he explained.

Dr Rice and Dr Hidalgo have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 44th Critical Care Congress: Abstract 61. Presented January 18, 2015.

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