The administration of Vitamin C did not change oxygenation in these patients with presumed viral pneumonia. This is consistent with previous studies, although while the CITRIS-ALI study did not show any change in sequential organ failure (SOFA) scores, the unadjusted mortality was much lower in the Vitamin C group.(8,11) It may be that a higher dose of Vitamin C may have more effects than the dose that we used.(12) Combined with corticosteroids, there did start to be a non-statistically significant beneficial separation in the P/F ratio over time. It is important to note that the administration of Vitamin C to critically ill patients has not been associated with any significant adverse effect.(8,13)
This small study also suggests a mortality benefit for corticosteroids in patients with viral pneumonia and ARDS. The recently published RECOVERY Trial in COVID showed a reduced mortality in COVID-19 patients requiring oxygen from 6mg of dexamethasone daily (14,15). The dose of corticosteroids used here was 50mg QID, which is approximately equivalent to 7.5mg of dexamethasone daily. In this cohort, 10/11 patients who received corticosteroids survived, as compared to the 5 patients who died, only one of the five received corticosteroids. Prior studies for corticosteroids in ARDS are controversial, but perhaps low dose steroids do reduce duration of mechanical ventilation.(16,17) Current recommendations advise against corticosteroids for influenza pneumonia, but in critically ill patients on vasopressors, there is a contrary recommendation to suggest steroids for vasopressor refractory shock.(18,19) Vitamin C has been already used in COVID 19 patients requiring mechanical ventilation and studies are underway looking at the combination of Vitamin C and corticosteroids in COVID-19. (20)
There are several limitations to this study. It was not randomised study, and while the illness severity did not vary between groups, it is possible that the results reflect bias from unaccounted variables. Indeed, while all patients received non-invasive ventilation as a minimum, only 9 of the 16 patients were mechanically ventilated. Second, the viral pathogen was not the same for all patients, and it may be that ARDS from influenza (which has a treatment in oseltamivir) is not the same process as ARDS from RSV. Finally, as a single centre study, these questions require testing in a larger, multi-centre study.