The influence of prehospital systemic corticosteroid use on development of acute respiratory distress syndrome and hospital outcomes

Pre-Hospital Care Of Patients With Severe Burns In Germany: A Review Of 29 Years Of Experience

Despite the high number of burn injuries worldwide, pre-hospital care differs across regions. Data documenting pre-hospital care of severe burn injuries in Germany are scarce. Nevertheless, efficient prehospital care of burn patients is crucial for later outcomes. Therefore, we retrospectively analyzed pre-hospital care in patients admitted to the burn intensive care unit of a specialized burn center in Germany from 1989 to 2018. Approximately one-third of all admitted patients arrived intubated to the burn intensive care unit. Mean total burned surface area was higher in intubated patients than in non-intubated patients. Hypothermia prevention measures were undertaken in most patients. Although cooling was performed in only 36 primarily admitted patients, it did not have an effect on temperature at admission. Instead, in the regression analysis a positive influence on mortality could be found (p=0.03). Inhalation injury was a reason for intubation and corticosteroid therapy. Corticosteroid use declined over the years and had no significant influence on mortality (p=0.38). Inhalation injury could be diagnosed in only 50.68% of patients receiving corticosteroids. Furthermore, especially in recent years, most patients with inhalation injuries did not receive corticosteroids. Although efficient prehospital care is crucial for later outcomes, standard pre-hospital care through first aiders and emergency personnel has not been applied. Therefore, strategies for information exchange, leading to standardized pre-hospital treatment guidelines, should be given high priority with special attention on pre-hospital cooling. In the future, data from registries and surveys can help expand information regarding pre-hospital burn treatment.

What factors predispose patients to acute respiratory distress syndrome?

Sepsis, pneumonia, and shock are the most common conditions predisposing to acute respiratory distress syndrome (ARDS) and certain host genetic variants have been associated with the development of ARDS. Risk modifiers include abuse of alcohol and tobacco, malnutrition, and obesity. The Lung Injury Prediction Score (LIPS) and the simplified Early Acute Lung Injury Score predict ARDS based on clinical and investigational criteria. Hospital-acquired ARDS may result from a medley factors of which high tidal volume ventilation, high oxygen concentration, and plasma transfusion are most commonly implicated. The Checklist for Lung Injury Prevention (CLIP) has been developed to ensure compliance with evidence-based practice that may affect ARDS occurrence. To date, no pharmacologic intervention has been shown to prevent ARDS

Preadmission Oral Corticosteroids Are Associated With Reduced Risk of Acute Respiratory Distress Syndrome in Critically Ill Adults With Sepsis

OBJECTIVES

To determine the association between preadmission oral corticosteroid receipt and the development of acute respiratory distress syndrome in critically ill patients with sepsis.

DESIGN

Retrospective observational study.

SETTING

Medical, surgical, trauma, and cardiovascular ICUs of an academic medical center.

PATIENTS

A total of 1,080 critically ill patients with sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The unadjusted occurrence rate of acute respiratory distress syndrome within 96 hours of ICU admission was 35% among patients who had received oral corticosteroids compared with 42% among those who had not (p = 0.107). In a multivariable analysis controlling for prespecified confounders, preadmission oral corticosteroids were associated with a lower incidence of acute respiratory distress syndrome in the 96 hours after ICU admission (odds ratio, 0.53; 95% CI, 0.33-0.84; p = 0.008), a finding that persisted in multiple sensitivity analyses. The median daily dose of oral corticosteroids among the 165 patients receiving oral corticosteroids, in prednisone equivalents, was 10 mg (interquartile range, 5-30 mg). Higher doses of preadmission oral corticosteroids were associated with a lower incidence of acute respiratory distress syndrome (odds ratio for 30 mg of prednisone compared with 5 mg 0.53; 95% CI, 0.32-0.86). In multivariable analyses, preadmission oral corticosteroids were not associated with in-hospital mortality (odds ratio, 1.41; 95% CI, 0.87-2.28; p = 0.164), ICU length of stay (odds ratio, 0.90; 95% CI, 0.63-1.30; p = 0.585), or ventilator-free days (odds ratio, 1.06; 95% CI, 0.71-1.57; p = 0.783).

CONCLUSIONS

Among ICU patients with sepsis, preadmission oral corticosteroids were independently associated with a lower incidence of early acute respiratory distress syndrome.

Steroids for acute respiratory distress syndrome?

The development and severity of acute respiratory distress syndrome (ARDS) are closely related to dysregulated inflammation, and the duration of ARDS and eventual outcomes are related to persistent inflammation and abnormal fibroproliferation. Corticosteroids are potent modulators of inflammation and inhibitors of fibrosis that have been used since the first description of ARDS in attempts to improve outcomes. There is no evidence that corticosteroids prevent the development of ARDS among patients at risk. High-dose and short-course treatment with steroids does not improve the outcomes of patients with ARDS. Additional studies are needed to recommend treatment with steroids for ARDS.

Reducing the burden of acute respiratory distress syndrome: the case for early intervention and the potential role of the emergency department

The mortality for acute respiratory distress syndrome (ARDS) remains unacceptably high. Success in clinical trials has been limited, resulting in a lack of effective therapies to treat the syndrome. The projected increase in mechanically ventilated patients and global need for critical care services suggests that the clinical and research landscape in ARDS can no longer be confined to the intensive care unit. A demonstrable minority of patients present to the emergency department (ED) with ARDS, and ARDS onset typically occurs shortly after intensive care unit admission. Furthermore, the ED is an entry point for many of the highest-risk patients for ARDS development and progression. These facts, combined with prolonged lengths of stay in the ED, suggest that the ED could represent a window of opportunity for treatment and preventive strategies, as well as clinical trial enrollment. This review aims to discuss some of the potential strategies that may prevent or alter the trajectory of ARDS, with a focus on the potential role the ED could play in reducing the burden of this syndrome.

Prehospital use of inhaled steroids and incidence of acute lung injury among patients at risk

PURPOSE

Inhaled corticosteroids (ICSs) attenuated lung injury in animal studies. We investigated the association between prehospital ICS and incidence of acute lung injury (ALI) among patients at risk.

METHODS

In this ancillary analysis of the large multicenter Lung Injury Prediction Study cohort, we developed a propensity score for prehospital ICS use followed by matching, for all patients and for a subgroup of patients with at least 1 risk factor for direct pulmonary injury. The primary outcome was ALI; secondary outcomes included acute respiratory distress syndrome, need for invasive mechanical ventilation, and hospital mortality.

RESULTS

Of the 5126 patients, 401 (8%) were using ICS. Acute lung injury developed in 343 (7%). The unadjusted incidence of ALI was 4.7% vs 6.9% (P = .12) among those in ICS compared with non-ICS group. In the "direct" lung injury subgroup, the unadjusted incidence of ALI was 4.1% vs 10.6% (P = 0.006). After propensity matching, the estimated effect for ALI in the whole cohort was 0.69 (95% confidence interval, 0.39-1.2; P = .18), and that in the direct subgroup was 0.56 (95% confidence interval, 0.22-1.46; P = .24).

CONCLUSIONS

Preadmission use of ICS in a hospitalized population of patients at risk for ALI was not significantly associated with a lower incidence of ALI once controlled by comprehensive propensity-matched analysis.