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The most recent trials, despite being significantly larger than their predecessors, have displayed similarly heterogeneous results. This narrative review aims to explore the possible underlying reasons for this heterogeneity of treatment effect, providing detail for each of the proposed immune- and nonimmune-mediated mechanisms through which corticosteroids might offer therapeutic benefit for patients with severe pneumonia and providing an in-depth critical appraisal of the most recent large-scale multicentre randomised controlled trials, namely ESCAPe (2022), CAPE COD (2023) and REMAP-CAP (2025). 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