ARDS and refractory hypoxaemia

Corticosteroids and pharmacological adjuncts

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

ATS 2024 suggests corticosteroids for ARDS. Use an evidence-based regimen matched to the cause (dexamethasone for COVID-19 and DEXA-ARDS; hydrocortisone for severe CAP). Avoid in influenza. Inhaled vasodilators improve oxygenation but not survival.

At the bedside

Timed steps
  1. 1

    Steroid candidate

    Decide

    Moderate-severe ARDS, early (< 14 days), no contraindication (uncontrolled infection, influenza, fungal infection).

  2. 2

    Non-COVID ARDS

    Regimen

    Dexamethasone 20 mg IV daily days 1-5, then 10 mg days 6-10 (DEXA-ARDS).

  3. 3

    Severe CAP

    Regimen

    Hydrocortisone 200 mg/day for 4-8 days then taper (CAPE COD).

  4. 4

    COVID-19

    Regimen

    Dexamethasone 6 mg daily up to 10 days.

  5. 5

    Side effects

    Monitor

    Glucose, new infection, weakness; stop if alternative diagnosis or harm.

  6. 6

    Inhaled pulmonary vasodilators

    Adjuncts

    Inhaled nitric oxide or epoprostenol as short-term rescue for refractory hypoxaemia or RV failure; no mortality benefit.

DEXA-ARDS regimen

Dexamethasone

IV
Dose
20 mg daily days 1-5, then 10 mg daily days 6-10

Severe community-acquired pneumonia

Hydrocortisone

IV infusion
Dose
200 mg/day × 4 days (8 if not improving), then taper
Preparation
200 mg in 50 mL NS at ~2.1 mL/h
Red flag · call your senior now
Influenza ARDS: steroids associated with higher mortality in observational data; avoid unless another indication.
Pitfall
Starting steroids late (> 14 days) in fibroproliferative ARDS (older ARDSNet LaSRS trial showed harm).
Pearl
Check strongyloides risk (eosinophilia, endemic areas including India) before prolonged steroids; consider empirical ivermectin.

References

  1. 1

    Qadir N, Sahetya S, Munshi L, et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2024;209(1):24-36

  2. 2

    Villar J, Ferrando C, Martínez D, et al. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial (DEXA-ARDS). Lancet Respir Med. 2020;8(3):267-276

  3. 3

    RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med. 2021;384(8):693-704

  4. 4

    Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia (CAPE COD). N Engl J Med. 2023;388(21):1931-1941

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