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Corticosteroids for ARDS from H1N1 influenza
Databases suggest that 60-70% of patients with severe respiratory failure due to H1N1 received steroids. Brun-Buisson et al looked back at a French registry including 208 patients with H1N1 and ARDS, 83 of whom received steroids. They found a hazard ratio of 2.4 for death associated with steroid administration, rising to 2.8 after applying their propensity scoring model. Receipt of steroids <3 days after intubation increased the association.
Meanwhile, in South Korea, Kim et al retrospectively observed 245 consecutive patients admitted to ICUs with H1N1 in 2009-2010 (162 of whom were intubated). They constructed a case-control analysis (steroids-no steroids, respectively). The steroid group was far sicker, with more ARDS, mechanical ventilation, secondary pneumonias, and also had a high prevalence of receipt of prior corticosteroids. After applying their propensity-matching analysis, the authors conclude that steroids were independently associated with mortality and superinfections (odds ratio 2.2 for death in 90 days).
Neither of these studies were randomized or seemed able to demonstrate control for severity of illness as a confounder (viz., higher steroid use in patients less likely to survive). Read the PRO (D. Annane) / CON (M. Matthay) Blue Journal editorial exchange .