ARrest RESpiraTory Failure From PNEUMONIA

Eligibility Criteria

• 1. Hospitalization for acute (defined as ≤ 14 days) onset of symptoms (cough, sputum production, or dyspnea), AND 2. Radiographic evidence of pneumonia by chest radiograph or CT scan, AND 3. One of the following:
• 1. Evidence of systemic inflammation (temperature \< 35◦C or \> 38◦C OR WBC \> or \< upper or lower limits for site OR procalcitonin \> 0.5 mcg/L), OR
• 2. Known current immunosuppression preventing inflammatory response, OR
• 3. High clinical suspicion of pneumonia with microbiologic confirmation of infection. Microbiologic confirmation will include a positive nasal swab for a known respiratory virus; a sputum culture growing a likely pathogenic organism plus moderate or greater WBCs (not required for immunocompromised patients); or a positive blood culture with a likely pathogenic organism - e.g., ¼ vials with S. Epidermidis would NOT qualify)
• * Inability to randomize within 48 hours of presentation to enrolling hospital (randomization beyond 24 hours will be limited to patients with persistent hypoxemia defined by an SpO2 \< 97% while on \> 3L/min O2)
• * Intubation (or impending intubation) prior to enrollment
• * A condition requiring inhaled corticosteroids or beta-agonists (patients receiving inhaled beta-agonists in the ED without an established indication will be eligible if treating clinician is willing to discontinue subsequent treatments)
• * Chronic systemic steroid therapy equivalent to \>10 mg prednisone
• * COVID-19 positive patients receiving \> 6 mg dexamethasone (40 mg prednisone equivalent dose) except for stress dose steroids for septic shock
• * Non-COVID-19 pneumonia patients receiving systemic steroid \> 10 mg prednisone except for stress dose steroids for septic shock
• * Chronic lung or neuromuscular disease requiring daytime oxygen or mechanical ventilation other than for obstructive sleep apnea (OSA) or obesity hypoventilation syndrome
• * Not anticipated to survive \> 48 hours or not expected to require \> 48 hours of hospitalization
• * Contraindication or allergy to inhaled corticosteroids or beta-agonists
• * Patients with heart rate \> 130 bpm, ventricular tachycardia or new supraventricular tachycardia within last 4 hours will be potentially eligible for enrollment after the condition has resolved
• * Patients with K+ \< 3.0 will be potentially eligible for enrollment after the condition has resolved
• * Patient not committed to full support other than intubation or resuscitation (i.e., DNR/DNI status allowed)
• * Pregnancy
• * Incarcerated individual
• * Physician refusal of consent to protocol
• * Patient/surrogate refusal of consent to protocol