CORRESPONDENCE

Corticosteroids in ARDS: A Counterpoint

Glucocorticoids (GC) in all its various forms and formulations are likely one of the most commonly used pharmacologic agents in medicine. Their use can be profoundly therapeutic but are also associated with a myriad of acute and chronic side effects. It is fairly well-accepted in the medical community that GC can be life-saving when used in critically ill patients with severe exacerbations of asthma and chronic obstructive pulmonary disease, HIV-associated pneumocystosis, and systemic vasculitides.

However, the adjunctive role of GC is much more controversial in acute respiratory distress syndrome (ARDS), septic shock, community-acquired pneumonia, and several other serious medical conditions. Despite such controversies, GC should at least be considered for patients with fulminant manifestations of the following conditions as there is equipoise to indicate that GC may improve outcome with acceptable risks: (i) severe ARDS with refractory hypoxemia despite one to two weeks of state-of-the-art management, (ii) recalcitrant, vasopressor-dependent septic shock, (iii) non-influenza, severe community-acquired pneumonia, and (iv) severe alcoholic hepatitis.

The bases for these controversies is likely due to both host factors (e.g., differences in GC resistance and susceptibility to adverse effects) and different phenotypes of any one disease state; e.g., different pathogenesis and pathogens under the rubric of “sepsis.” Elucidation of better biomarkers to determine the underlying pathogenic phenotype will significantly advance our understanding and prediction of which critically ill patients will benefit from GC and who would experience a deleterious effect from its use.

Drowning is defined as a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Worldwide, drowning is the 11th most frequent cause of death in the 0–4 years age group, the third most frequent cause of death in children aged from 5 to 14 years, and the second leading cause of injury related death in childhood. The vast majority of drowning deaths occur in non-Western countries, and as with the majority of accidental deaths, there is a strong male preponderance. The drowning sequence has both pulmonary injury and nonpulmonary sequelae such as hypothermia, electrolyte imbalance, trauma, and hypoxic-ischemic damage. Pulmonary management ranges from the need for some supplemental oxygen to intubation and management of severe acute respiratory distress syndrome. Initial management is often in the field, and care should be taken to evaluate endotracheal tube sizes and ventilation practices as soon as feasible. The strongest predictor of good outcome is duration of immersion. Poor outcomes are observed in 60%–100% of subjects immersed for more than 10 minutes. Predictors of poor outcome include the presence of cardiac (as opposed to respiratory) arrest and the need for prolonged resuscitation defined as more than 20–25 minutes. Medically induced hypothermia has not been shown to change neurological outcome. Drowning disproportionately affects children, and most instances are preventable. Prevention measures through legislative and public health interventions have had modest success.

Drowning is defined as a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Worldwide, drowning is the 11th most frequent cause of death in the 0–4 years age group, the third most frequent cause of death in children aged from 5 to 14 years, and the second leading cause of injury related death in childhood. The vast majority of drowning deaths occur in non-Western countries, and as with the majority of accidental deaths, there is a strong male preponderance. The drowning sequence has both pulmonary injury and nonpulmonary sequelae such as hypothermia, electrolyte imbalance, trauma, and hypoxic-ischemic damage. Pulmonary management ranges from the need for some supplemental oxygen to intubation and management of severe acute respiratory distress syndrome. Initial management is often in the field, and care should be taken to evaluate endotracheal tube sizes and ventilation practices as soon as feasible. The strongest predictor of good outcome is duration of immersion. Poor outcomes are observed in 60%–100% of subjects immersed for more than 10 minutes. Predictors of poor outcome include the presence of cardiac (as opposed to respiratory) arrest and the need for prolonged resuscitation defined as more than 20–25 minutes. Medically induced hypothermia has not been shown to change neurological outcome. Drowning disproportionately affects children, and most instances are preventable. Prevention measures through legislative and public health interventions have had modest success.

Acute respiratory distress syndrome (ARDS) causes overwhelming inflammation, which serves as a potential target for corticosteroids. Despite extensive Western literature, there are no Indian studies evaluating steroids in ARDS.

This was a retrospective study at an Indian intensive care unit (ICU) on ARDS patients. Demographic, clinical, laboratory, and imaging parameters were collected. Patients were divided into cohorts based on steroid use, and some received high-dose (2 mg/kg/day), whereas others received low-dose (1 mg/kg/day) steroids. Primary outcomes were in-hospital mortality and secondary outcomes included need for and duration of invasive mechanical ventilation (IMV), IMV-free days, ICU length of stay (LOS), and total LOS. Two-tailed p < 0.05 was considered statistically significant.

During the 20-month period, 95 patients [median age 37 (30–47) years; 48 (50.5%) males] met our inclusion criteria. Steroid use was noted in 48 (50.5%) patients [11 (22.9%) low-dose and 37 (77.1%) high-dose]. Baseline characteristics of the cohorts, including ARDS severity indices, were comparable. Of these 95 patients, 70 (73.7%) had sepsis, but microbiological diagnosis was positive only in 17 (17.9%) patients. Steroid use did not significantly influence mortality [odds ratio (OR) 0.6 (0.3–1.4)] or need for IMV [OR 1.0 (0.4–2.6)]. There were no differences in outcomes of IMV-free days, ICU LOS, or total LOS. These outcomes were comparable between the high-dose and low-dose steroid users.

Steroid use and comparison of low-dose vs. high-dose steroids did not influence outcomes associated with ARDS in the Indian population.

Clinicians must be aware of the growing list of causes and predisposing factors that may lead to the life-threatening disorder of acute adrenal insufficiency. This review provides a guide to the recognition and treatment of adrenal insufficiency, whether it is primary or secondary to disease, hereditary disorders, medication use, or critical illness.

This review provides a guide to the recognition and treatment of adrenal insufficiency, whether it is primary or secondary to disease, hereditary disorders, medication use, or critical illness.

Adrenal insufficiency — the clinical manifestation of deficient production or action of glucocorticoids — is a life-threatening disorder that may result from either primary adrenal failure or secondary adrenal disease due to impairment of the hypothalamic–pituitary axis.¹,² This article focuses on providing the practicing clinician with new insights into predisposing factors for adrenal insufficiency. When and during what situations should a clinician suspect adrenal insufficiency? What genetic disorders, infections, and medications should be considered? What are the current views on the underlying mechanisms?

The cardinal clinical symptoms of adrenocortical insufficiency, as first described by Thomas Addison in 1855,³ include . . .