Patients with acute respiratory distress syndrome had similar outcomes regardless of dose of corticosteroids and form of noninvasive respiratory support.

Debate remains about how to treat critically ill patients with COVID-19. Low-dose corticosteroids have become standard of care for patients with COVID-19 and acute respiratory distress syndrome (ARDS); however, prior to the pandemic, a trial suggested benefit for higher-dose corticosteroids for ARDS (Lancet Respir Med 2020; 8: 267-276). Studies have shown varying results when comparing different forms of noninvasive respiratory support.

Investigators from France randomised more than 500 patients admitted to an intensive care unit with COVID-19 and hypoxaemic respiratory failure to high-dose (16.6 mg/day) or low-dose (6 mg/day) dexamethasone. The initial trial design compared high-dose dexamethasone to placebo, but this protocol was modified (based on the results of another trial) after 73 patients were enrolled. Enrolled patients were also randomised to different forms of respiratory support (i.e. nasal cannula oxygen, high-flow oxygen or continuous positive airway pressure).

Sixty-day survival did not differ between groups who received high- or low-dose dexamethasone. Progression to invasive mechanical ventilation was the same for all three forms of respiratory support and was not affected by corticosteroid dose. Adverse events were common but did not differ between groups.

Comment: These results support the current guideline recommendation to treat patients with COVID-19 and ARDS with low-dose dexamethasone (6 mg) daily for 10 days (NEJM JW Infect Dis Jan 2021 report ‘Management of patients with COVID-19’, citations: https://www.bmj.com/content/370/bmj.m3379/; https://www.covid19treatmentguidelines.nih.gov/; and https://www.idsociety.org/COVID19guidelines/). The study was not powered to detect small differences in intubation rates based on form of noninvasive support. It still makes sense to use what it is available, familiar and most comfortable for the patient.
PATRICIA KRITEK, MD, EdM
Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA.

Bouadma L, et al. High-dose dexamethasone and oxygen support strategies in intensive care unit patients with severe COVID-19 acute hypoxemic respiratory failure: the COVID-ICUS randomized clinical trial. JAMA Intern Med 2022 Jul 5; e-pub (https://doi.org/10.1001/jamainternmed.2022.2168).

This summary is taken from the following Journal Watch title: Infectious Diseases.