Corticosteroids in non-viral acute respiratory distress syndrome (ARDS): recommendations outpace evidence - a concise review.

The 2024 global redefinition of acute respiratory distress syndrome (ARDS) broadens diagnostic criteria to include patients on non-invasive respiratory support. While this inclusivity enhances early recognition, it also introduces heterogeneity in disease severity, inflammatory burden, and treatment responsiveness-complicating the use of corticosteroids. Although recent guidelines recommend corticosteroids for moderate-to-severe ARDS, they fall short of specifying optimal timing, dosing, and patient selection. The DEXA-ARDS trial showed that high-dose dexamethasone reduced mortality in moderate-to-severe ARDS regardless of etiology, but its generalizability to less severe or non-intubated patients remains unclear. Conversely, in severe community-acquired pneumonia (CAP), hydrocortisone regimens used in CAPE-COD and APROCCHSS trials demonstrated mortality benefits, suggesting a particular therapeutic niche for corticosteroids in non-viral, infection-associated ARDS. A recent network meta-analysis suggests that low-dose methylprednisolone may reduce ARDS mortality, though phenotype-specific efficacy is not well defined. Despite these encouraging signals, key questions persist: Which corticosteroid? At what dose? For which ARDS phenotype? As evidence accumulates unevenly across ARDS subtypes, guideline-endorsed recommendations may inadvertently mask the nuances required for individualized therapy. Until precision approaches are better defined, clinicians must balance empirical benefit with thoughtful restraint in applying corticosteroids to non-viral ARDS. This concise review summarizes current evidence, key limitations, and pragmatic phenotype-informed strategies for corticosteroid use in non-viral ARDS.