AUTHOR=Schwingshackl Andreas , Meduri Gianfranco Umberto 

TITLE=Rationale for Prolonged Glucocorticoid Use in Pediatric ARDS: What the Adults Can Teach Us

JOURNAL=Frontiers in Pediatrics

VOLUME=Volume 4 - 2016

YEAR=2016

URL=https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2016.00058

DOI=10.3389/fped.2016.00058

ISSN=2296-2360

ABSTRACT=Based on molecular mechanisms and physiologic data, a strong association has been established between dysregulated systemic inflammation and progression of ARDS. In ARDS patients, glucocorticoid receptor-mediated down-regulation of systemic inflammation is essential to restore homeostasis, decrease morbidity, and improves survival and can be significantly enhanced with prolonged low-to-moderate dose glucocorticoid treatment.  A large body of evidence supports a strong association between prolonged glucocorticoid treatment-induced down-regulation of the inflammatory response and improvement in pulmonary and extra-pulmonary physiology. 
The balance of the available data from eight controlled trials (n=622) provides consistent strong level of evidence for improving patient-centered outcomes and hospital survival. The sizable increase in mechanical ventilation-free days (weighted mean difference, 6.48 days; CI 95% 2.57-10.38, p<0.0001) and ICU-free days (weighted mean difference, 7.7 days; 95% CI, 3.13-12.20, p<0.0001) by day 28 is superior to any investigated intervention in ARDS.  For treatment initiated before day 14 of ARDS, the increased in hospital survival (70% vs. 52%, OR 2.41, CI 95% 1.50-3.87, p=0.0003) translates into a number needed to treat to save one life of 5.5.  Importantly, prolonged glucocorticoid treatment is not associated with increased risk for nosocomial infections (22% vs. 27%, OR 0.61, CI 95% 0.35-1.04, p=0.07). 
Treatment decisions involve a tradeoff between benefits and risks, as well as costs.  This low cost highly effective therapy is familiar to every physician, and has a low risk profile when secondary prevention measures are implemented.