Mortality in COVID-19 patients with acute respiratory distress syndrome and corticosteroids use: a systematic review and meta-analysis

Expert Rev Respir Med. 2020 Nov;14(11):1149-1163. doi: 10.1080/17476348.2020.1804365. Epub 2020 Sep 29.


Objectives: The acute respiratory distress syndrome (ARDS) secondary to viral pneumonitis is one of the main causes of high mortality in patients with COVID-19 (novel coronavirus disease 2019). We systematically reviewed mortality in COVID-19 patients with ARDS and the potential role of systemic corticosteroids in COVID-19 patients.

Methods: Electronic databases and country-specific healthcare databases were searched to identify relevant studies/reports. The quality assessment of individual studies was conducted using the Newcastle-Ottawa Scale. Country-specific proportion of individuals with COVID-19 who developed ARDS and reported death were combined in a random-effect meta-analysis to give a pooled mortality estimate of ARDS.

Results: The overall pooled mortality estimate among 10,815 ARDS cases in COVID-19 patients was 39% (95% CI: 23-56%). The pooled mortality estimate for China was 69% (95% CI: 67-72%). In Europe, the highest mortality estimate among COVID-19 patients with ARDS was reported in Poland (73%; 95% CI: 58-86%) while Germany had the lowest mortality estimate (13%; 95% CI: 2-29%) among COVID-19 patients with ARDS. The median crude mortality rate of COVID-19 patients with reported corticosteroid use was 28.0% (lower quartile: 13.9%; upper quartile: 53.6%).

Conclusions: The high mortality in COVID-19 associated ARDS necessitates a prompt and aggressive treatment strategy which includes corticosteroids. Most of the studies included no information on the dosing regimen of corticosteroid therapy, however, low-dose corticosteroid therapy or pulse corticosteroid therapy appears to have a beneficial role in the management of severely ill COVID-19 patients.

Keywords: Acute respiratory distress syndrome; coronavirus disease 2019; corticosteroids; mortality.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use*
  • Betacoronavirus*
  • COVID-19
  • Coronavirus Infections / complications
  • Coronavirus Infections / mortality*
  • Coronavirus Infections / therapy
  • Humans
  • Pandemics
  • Pneumonia, Viral / complications
  • Pneumonia, Viral / mortality*
  • Pneumonia, Viral / therapy
  • Respiratory Distress Syndrome / mortality*
  • Respiratory Distress Syndrome / therapy
  • Respiratory Distress Syndrome / virology*
  • SARS-CoV-2


  • Adrenal Cortex Hormones

Grant support

This paper was not funded.