Association between steroid therapy and increased mortality in patients at risk for ARDS

Background: Corticosteroids are commonly used in critically ill patients with established risk factors for acute respiratory distress syndrome (ARDS), often for indications like sepsis or pneumonia, yet the choice of steroid and its impact on outcomes remain debated.
Methods: We conducted a retrospective analysis of 160 ICU patients with documented clinical risk factors for ARDS at the time of ICU admission to evaluate the effect of corticosteroid therapy on hospital mortality. Clinical characteristics, treatment variables, and outcomes were compared between patients who received corticosteroids and those who did not. A subgroup exploratory analysis further compared outcomes between dexamethasone and hydrocortisone users. Logistic regression models were used to identify mortality predictors.
Results: Of 160 patients, 91 (56.9%) received corticosteroids. Steroid-treated patients had higher Simplified Acute Physiology Score II (SAPS II) scores (54.4 vs. 48.0, p = 0.011), but no significant differences in age, partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO₂/FiO₂), or mechanical ventilation use. Overall mortality was not significantly different between steroid and non-steroid users (42.9% vs. 33.3%, p = 0.221). Among steroid-treated patients, dexamethasone (n = 26) and hydrocortisone (n = 50) were the most frequently used agents. Mortality was significantly higher with hydrocortisone (58%) compared to dexamethasone (26.9%) (p = 0.010). In multivariate analysis, hydrocortisone use was associated with higher hospital mortality (adjusted OR = 4.41; 95% CI: 1.11–17.48; p = 0.035).
Conclusion: Overall corticosteroid use was not associated with improved survival in patients with documented clinical risk factors for ARDS; however, in an exploratory analysis, hydrocortisone use was associated with higher hospital mortality than dexamethasone. Given the retrospective observational design and real-world factors influencing corticosteroid selection, including illness severity, these findings should be interpreted with caution and support the need for prospective studies to clarify these associations.