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Semin Respir Crit Care Med
DOI: 10.1055/a-2721-6094
Review Article

Corticosteroids for Acute Respiratory Distress Syndrome

Autoren

  • Riccardo Guglielmi

    1   Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy

  • Antonio Campanella

    1   Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy

  • Jesús Villar

    2   Biomedical Research Networking Center in Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
    3   Department of Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
    4   Multidisciplinary Research Group in Intensive Care (GREMCI), Research Unit, Hospital Universitario Dr. Negrín, Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), Las Palmas de Gran Canaria, Spain
    5   Faculty of Health Sciences, Universidad del Atlántico Medio, Tafira Baja, Las Palmas de Gran Canaria, Spain

  • Antoni Torres

    2   Biomedical Research Networking Center in Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
    6   Department of Anesthesiology and Critical Care Medicine, Fundació de Recerca Clínic Barcelona – Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain

  • Carlos Ferrando

    2   Biomedical Research Networking Center in Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
    6   Department of Anesthesiology and Critical Care Medicine, Fundació de Recerca Clínic Barcelona – Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain
    7   Department of Anesthesia and Critical Care, Hospital Clínic, Barcelona, Spain
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Abstract

Acute respiratory distress syndrome (ARDS) remains a heterogeneous and a major challenge disease process despite five decades of study. Emerging translational data delineate three overlapping phases: exudative, proliferative, and fibroproliferative, each driven by distinct immune–mechanical pathways and potentially modifiable by glucocorticosteroids (GC) modulation. Contemporary clinical randomized trials and meta-analyses indicate that early (≤72 hours) administration of systemic GCs at receptor-saturating doses (e.g., dexamethasone from 20 to 10 mg/day, or methylprednisolone 1–2 mg/kg/day) accelerates resolution of pulmonary edema, shortens mechanical ventilation duration, and improves intensive care survival, while prolonged tapering regimens are required once fibroproliferation is established. Conversely, delayed initiation (>14 days), viral pneumonitis with high viral load, recent surgical anastomosis, or uncontrolled fungal coinfection constitute “red flags” in which GCs might increase mortality. Latent-class analyses—a statistical modeling approach in which multivariable data are reduced to indirectly observed (latent) variables—identified two (hyper- and hypoinflammatory) ARDS phenotypes that likely might respond differentially to GC exposure, although we lack validation studies. Therefore, it seems that biomarker-guided precision therapy is poised to replace the historical one-size-fits-all approach. This narrative review integrates epidemiology, pathobiology, pharmacology, and clinical evidence to provide a phase-specific, phenotype-directed framework for GC use in ARDS and outlines future research priorities aimed at harmonizing molecular endotyping with dose, timing, and tapering strategies.

Keywords

acute respiratory distress syndrome - corticosteroids - lung inflammation - systemic inflammation - outcome - organ dysfunction


Publikationsverlauf

Eingereicht: 05. September 2025

Angenommen: 12. Oktober 2025

Artikel online veröffentlicht:
11. November 2025

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