Acute respiratory distress syndrome (ARDS) is frequently associated with sepsis. ARDS and sepsis exhibit a common pathobiology, namely excessive inflammation. Corticosteroids are powerful anti-inflammatory agents that are routinely used in septic shock and in oxygen-dependent SARS-CoV-2 related acute respiratory failure. Recently, corticosteroids were found to reduce mortality in severe community-acquired pneumonia. Corticosteroids may therefore also have a role to play in the treatment of ARDS. This narrative review was undertaken following a PubMed search for English language reports published before January 2023 using the terms acute respiratory distress syndrome, sepsis and steroids. Additional reports were identified by examining the reference lists of selected articles and based on personnel knowledge of the authors of the field. High-quality research is needed to fully understand the role of corticosteroids in the treatment of ARDS and to determine the optimal timing, dosing and duration of treatment.

https://www.mdpi.com/2077-0383/12/9/3340/pdf?version=1683538563

Corticosteroids in ARDS.

The effect of corticosteroid therapy is still controversial on prevention of mortality in coronavirus disease‐2019 (COVID‐19). The objective of this study is to investigate the effect of corticosteroids on mortality. This systematic review was performed as per preferred reporting items for systematic reviews and meta‐analyses guidelines. A systematic search was performed at different databases namely Medline/PubMed, Cochrane and Google scholar on 10 February 2022. A pooled estimate for effect of corticosteroid therapy on mortality was calculated as outcome of study. Risk bias analysis and Newcastle Ottawa Scale were used to assess the quality of randomized control trial (RCT) and cohort studies, respectively. Cochran's Q test and the I2 statistic were conducted for heterogeneity and accordingly study model was applied. A total 43 studies were included, having sample size of 96,852 patients. Amongst them, 19,426 and 77,426 patients received corticosteroid therapy (intervention group) or standard treatment without corticosteroid (control group), respectively. Mortality observed in the intervention and control group was 14.2% (2749) and 7.1% (5459), respectively. The pooled estimate 2.173 (95% CI: 2.0690–2.2820) showed significantly increased mortality in intervention as compared to control. The pooled estimate of methyprednisolone 1.206 (95% CI: 1.0770–1.3500) showed significantly increased mortality while the pooled estimate of dexamethasone 1.040 (95% CI: 0.9459–1.1440) showed insignificantly increased mortality as compared to control. In conclusion, corticosteroid therapy produced a negative prognosis as depicted by increased mortality among COVID‐19 patients. The possible reasons might be delay in virus clearance and secondary infections due to corticosteroids initiated at high dose in the early stage of infection.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/rmv.2386

Effect of corticosteroid therapy on mortality in COVID‐19 patients—A systematic review and meta‐analysis

Systemic steroids are associated with reduced mortality in hypoxic patients with coronavirus disease 2019 (COVID‐19). However, there is no consensus on the doses of steroid therapy in these patients. Several studies showed that pulse dose steroids (PDS) could reduce the progression of COVID‐19 pneumonia. However, data regarding the role of PDS in COVID‐19 is still unclear. Therefore, we performed this meta‐analysis to evaluate the role of PDS in COVID‐19 patients compared to nonpulse steroids (NPDS). Comprehensive literature search of PubMed, Embase, Cochrane Library, and Web of Science databases from inception through February 10, 2022 was performed for all published studies comparing PDS to NPDS therapy to manage hypoxic patients with COVID‐19. Primary outcome was mortality. Secondary outcomes were the need for endotracheal intubation, hospital length of stay (LOS), and adverse events in the form of superimposed infections. A total of 10 observational studies involving 3065 patients (1289 patients received PDS and 1776 received NPDS) were included. The mortality rate was similar between PDS and NPDS groups (risk ratio [RR]: 1.23, 95% confidence interval [CI]: 0.92–1.65, p = 0.16). There were no differences in the need for endotracheal intubation (RR: 0.71, 95%: CI 0.37–1.137, p = 0.31), LOS (mean difference: 1.93 days; 95% CI: −1.46–5.33; p = 0.26), or adverse events (RR: 0.93, 95% CI: 0.56–1.57, p = 0.80) between the two groups. Compared to NPDS, PDS was associated with similar mortality rates, need for endotracheal intubation, LOS, and adverse events. Given the observational nature of the included studies, randomized controlled trials are warranted to validate our findings.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/jmv.27824

Pulse versus nonpulse steroid regimens in patients with coronavirus disease 2019: A systematic review and meta‐analysis

Purpose
A reappraisal of the validity of the conclusions of systematic reviews (SRs) and meta-analyses related to corticosteroids use for the treatment of COVID-19.


Material and Methods
An overview of SRs (umbrella review). The methodological quality of the SRs was assessed using tha AMSTAR-2 checklist; quality of the evidence was appraised following the GRADE approach.


Results
35 SRs were included in this overview. Data were from 307 overlapping reports, based on 121 individual primary studies (25 randomized clinical trials (RCTs), 96 non-RCTs. In critically ill patients the use of steroids significantly reduced mortality compared to standard of care in 80% of the SRs, more often with moderate/high level of certainty; however, in patients not requiring oxygen supplementation the use of steroids increased the overall mortality in 2/3 of the comparisons. Clinical progression of diseases (need for mechanical ventilation, or for intensive care admission) was more commonly observed among controls compared to steroids recipients (in 9 out of 14 comparisons; certainty of evidence from very-low to moderate). The occurrence of adverse events was similar among steroids recipients and controls. Other outcomes (i.e., viral clearance, length of hospital stay) or issue related to optimal dose and type of steroids were addressed in a minority of SRs, with a high level of uncertainty, so that no definitive conclusions can be drawn.


Conclusions
There is moderate certainty of evidence that corticosteroids reduce mortality and progression of disease in critically ill COVID-19 patients compared to standard of care, without increasing the occurrence of adverse events.

/pdf/corticosteroids-use-for-covid-19-an-overview-of-systematic-2lz681tr.pdf

Corticosteroids use for COVID-19: an overview of systematic reviews.

An 87-Year-Old Man with Acute Catastrophic Pneumonia

Corticosteroid dosing in the range of 0.5-2 mg/kg/day of methylprednisolone equivalents has become a standard part of the management of intensive care unit (ICU) patients with COVID-19 pneumonia based on positive results of randomized trials and a meta-analysis. Alongside such conventional dosing, administration of 1 gm of methylprednisolone daily (pulse dosing) has also been reported in the literature with claims of favorable outcomes. Comparisons between such disparate approaches to corticosteroids for Coronavirus disease 2019 (COVID-19) pneumonia are lacking. In this retrospective study of patients admitted to the ICU with COVID-19 pneumonia, we compared patients treated with 0.5-2 mg/kg/day in methylprednisolone equivalents (high-dose corticosteroids) and patients treated with 1 gm of methylprednisolone (pulse-dose corticosteroids) to those who did not receive any corticosteroids. The endpoints of interest were hospital mortality, ICU-free days at Day 28, and complications potentially attributable to corticosteroids. Pulse-dose corticosteroid therapy was associated with a significant increase in ICU-free days at Day 28 compared to no receipt: adjusted relative risk (aRR): 1.45 (95% confidence interval [CI]: 1.05-2.02; p = 0.03) and compared with high-dose corticosteroid administration (p = 0.003). Nonetheless, receipt of high-dose corticosteroids-but not of pulse-dose corticosteroids-significantly reduced the odds of hospital mortality compared to no receipt: adjusted Odds ratio (aOR) 0.31 (95% CI: 0.12-0.77; p = 0.01). High-dose corticosteroids reduced mortality compared to pulse-dose corticosteroids (p = 0.04). Pulse-dose corticosteroids-but not high-dose corticosteroids-significantly increased the odds of acute kidney injury requiring renal replacement therapy compared to no receipt: aOR 3.53 (95% CI: 1.27-9.82; p = 0.02). The odds of this complication were also significantly higher in the pulse-dose group when compared to the high-dose group (p = 0.05 for the comparison). In this single-center study, pulse-dose corticosteroid therapy for COVID-19 pneumonia in the ICU was associated with an increase in ICU-free days but failed to impact hospital mortality, perhaps because of its association with development of severe renal failure. In line with existing trial data, the effect of high-dose corticosteroids on mortality was favorable.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/jmv.27351

Comparison of pulse-dose and high-dose corticosteroids with no corticosteroid treatment for COVID-19 pneumonia in the intensive care unit.

Background: The use of Non-Invasive Ventilation (NIV) in acute asthma exacerbation remains controversial. Comparative data on patient characteristics that benefit from NIV in asthma exacerbation to those patients that fail NIV remains limited. Our study compares some of these patient characteristics and examines if NIV is safe and effective in carefully selected patients. Methods: Following institutional review board approval, we extracted from the electronic medical record and conducted a retrospective chart-based review of those patients who received NIV in the emergency room for a diagnosis of asthma exacerbation from January 2017 to December 2018. Results and Conclusion: The rate of failure of NIV overall was low, at 9.17%, with younger patients more likely to fail NIV (P = 0.03) and need invasive mechanical ventilation. Surprisingly, baseline asthma severity did not impact NIV failure rate, and neither did body mass index, smoking history, and a host of clinical characteristics. Understandably, the length of stay was significantly longer in the group of patients that failed NIV. There were no adverse events, such as an increased rate of barotrauma events in either group. In conclusion, this study contributes to the growing body of evidence that NIV is a safe and effective adjunct to routine care in the management of patients with asthma exacerbation.

https://www.tandfonline.com/doi/pdf/10.1080/20009666.2021.1955448

The use of non- invasive ventilation in asthma exacerbation - a two year retrospective analysis of outcomes.

Burkholderia cepacia complex consists of highly antibiotic resistant gram negative bacilli that are plant symbionts and also potential agents of human infection.  This bacterial family's claim to fame in clinical medicine is as the scourge of cystic fibrosis patients, in whom it is a notorious respiratory pathogen.  Outside of cystic fibrosis, it rarely comes to mind as an etiology of community acquired pneumonia with or without lung cavitation in immunocompetent hosts.  We describe a case of an otherwise healthy, community-dwelling man who presented with subacute cavitary lung disease, the causative organism of which turned out to be Burkholderia cepacia complex.  Our report is accompanied by a review of the literature, which identified an additional eleven cases in the same category.  We analyze all of the available cases for the emergence of any identifiable patterns or peculiarities.

/pdf/of-onions-and-men-report-of-cavitary-community-acquired-2crq460xp7.pdf

Of onions and men: Report of cavitary community acquired pneumonia due to Burkholderia cepacia complex in an immunocompetent patient and review of the literature.

The term "endemic mycoses" refers to a group of fungi that maintains a baseline rate of infection only in certain geographical regions due to the hospitable enviormental conditions these regions offer. In the United States, Histoplasma capsulatum, Coccidioides spp, and Blastomyces dermatitidis are the three most prevalent endemic human fungal infections. The traditional endemic regions for these pathogens are defined based on data acquired many decades ago, and case detection is subject to diagnostic delays even in classically endemic areas, a problem that is likely to be magnified in areas less familiar with these fungal infections. The present series includes an example of each of these infections diagnosed in a medical center situated in the suburbs of New York City, a location not considered endemic for any of them. Likely routes of acquisition for the three patients are considered, and the history of encounters with these pathogens in New York State is briefly recounted. Altogether, this report is intended to serve as a reminder to clinicians that traditional distribution maps for the endemic mycoses are bound to be outdated in the face of modern trends in globalization, population dynamics, and ecological change.

Ravi Manglani

Papers

Comparison of pulse-dose and high-dose corticosteroids with no corticosteroid treatment for COVID-19 pneumonia in the intensive care unit.

The use of non- invasive ventilation in asthma exacerbation - a two year retrospective analysis of outcomes.

Of onions and men: Report of cavitary community acquired pneumonia due to Burkholderia cepacia complex in an immunocompetent patient and review of the literature.

Close encounters of three kinds: Case-based report of endemic mycoses in the environs of New York city.

Diffuse alveolar hemorrhage as a rare complication of sweet syndrome