Prehospital inhaled corticosteroids may be protective in children with direct lung injury

Background Systemic corticosteroid use in acute respiratory failure has yielded uncertain benefits, partially due to off-target side effects. Inhaled corticosteroids (ICS) confer localized anti-inflammatory benefits and may protect adults with direct lung injury (DLI) from developing respiratory failure. This relationship has not been studied in children. Research Question Do children with direct lung injury who are prescribed pre-hospital inhaled corticosteroids have lower odds of progressing to respiratory failure? Study Design & Methods: This retrospective, single-center cohort identified children presenting to the emergency department with DLI and pre-hospital medication records. The primary outcome was intubation; secondary outcomes included non-invasive respiratory support (NRS). We tested the association of ICS with intubation and NRS, adjusting for confounders. We stratified analyses on history of asthma and performed a sensitivity analysis adjusting for systemic corticosteroid use to account for status asthmaticus. Results Of 35,220 patients, 17,649 (50%) were prescribed ICS. Intubation occurred in 169 patients (73 on ICS) and NRS was used in 3,582 patients (1,336 on ICS). ICS was associated with lower intubation (adjusted OR 0.46, 95% CI 0.31-0.67) and NRS (aOR 0.45, 95% CI 0.40-0.49). The association between ICS and NRS differed according to history of asthma (interaction p = 0.04), with ICS exposure remaining protective only for patients with a history of asthma. Results held true in sensitivity analyses. Interpretation Pre-hospital ICS may protect children with DLI from progressing to respiratory failure, with possible differential efficacy according to history of asthma.