No added benefit with high-dose steroids or different oxygenation strategies for acute hypoxemic respiratory failure due to COVID-19

Reference

Bouadma L, Mekontso-Dessap A, Burdet C, et al, for the COVIDICUS Study Group. High-dose dexamethasone and oxygen support strategies in intensive care unit patients with severe COVID-19 acute hypoxemic respiratory failure: the COVIDICUS randomized clinical trial. JAMA Int Med 2022 Jul 5. Online ahead of print.

Synopsis

In this multicenter study from France, adults admitted to an intensive care unit with acute hypoxemic respiratory failure (AHRF) secondary to COVID-19 were randomized to receive standard dexamethasone phosphate at 6 mg per day for days 1 to 10 (n = 276) or high-dose dexamethasone phosphate at 20 mg per day for days 1 to 5 followed by 10 mg per day for days 6 to 10 (n = 270). All patients were also given matching placebo. Patients who did not require invasive mechanical ventilation (IMV) were then further randomized to receive oxygenation with intermittent continuous positive airway pressure (CPAP), high-flow nasal cannula oxygen (HFNC) at 30 L per minute and increased up to 60 L per minute, or standard oxygen therapy. In all 3 groups, oxygen flow was adjusted for a target oxygen saturation of 92% or greater. Overall, 17% of patients did not adhere to their allocated oxygenation strategy. For the primary outcome of the steroid intervention, there was no significant difference in 60-day mortality (26.8% for the high dose vs 25.9% for the standard dose; hazard ratio 0.96; 95% CI 0.69 - 1.33). This remained true regardless of IMV status. For the primary outcome when comparing the 3 oxygenation strategies, there was no significant difference in criteria to start IMV (worsening respiratory failure, hemodynamic instability, and neurological status deterioration) at 28 days (43.0% with CPAP and 43.8% with HFNC vs 41.4% with standard oxygen). Adverse events were similar in all intervention groups.