Prednisone in COPD exacerbation requiring ventilatory support: an open-label randomised evaluation

Abstract

Recommendation of the use of systemic steroids in chronic obstructive disease (COPD) exacerbation rely on trials that excluded patients requiring ventilatory support.In an open-label, randomised evaluation of oral prednisone administration, 217 patients with acute COPD exacerbation requiring ventilatory support were randomised (with stratification on the type of ventilation) to usual care (n5106) or to receive a daily dose of prednisone (1 mg?kg -1 ) for up to 10 days (n5111).There was no difference regarding the primary end-point, intensive care unit mortality, which was 17 (15.3%) deaths versus 15 (14%) deaths in the steroid-treated and control groups, respectively (relative risk 1.08, 95% CI 0.6-2.05). Analysis according to ventilation modalities showed similar mortality rates. Noninvasive ventilation failed in 15.7% and 12.7% (relative risk 1.25, 95% CI 0.56-2.8; p50.59), respectively. Both study groups had similar median mechanical ventilation duration and intensive care unit length of stay, which were 6 (interquartile range 6-12) days versus 6 (3.8-12) days and 9 (6-14) days versus 8 (6-14) days, respectively. Hyperglycaemic episodes requiring initiation or alteration of current insulin doses occurred in 55 (49.5%) patients versus 35 (33%) patients in the prednisone and control groups, respectively (relative risk 1.5, 95% CI 1.08-2.08; p50.015).Prednisone did not improve intensive care unit mortality or patient-centred outcomes in the selected subgroup of COPD patients with severe exacerbation but significantly increased the risk of hyperglycaemia. @ERSpublications In COPD exacerbation needing ventilatory support, prednisone has no impact on ICU mortality or related patient outcome

The ambition of theEuropean Respiratory Journal: chapter 3

“…In 2014 more than 200 original articles were published in the ERJ: we were proud to release exciting novel information covering the whole spectrum of respiratory medicine, including epidemiology [18], COPD [19][20][21], asthma [22,23], paediatric pulmonology and cystic fibrosis [24,25], tuberculosis and respiratory infections [26,27], sleep medicine [28], pulmonary vascular medicine [29,30], interstitial lung diseases [31], lung function [32] and lung cancer [33].…”

Systemic steroids in severe forms of COPD exacerbations: a question of balance?

“…Indeed, beyond the nitrogen and the anabolism-catabolism balances discussed above, and that this study does not directly address, what the results of ABROUG et al [6] show is that the risk-benefit balance of systemic steroids in this indication is negative, not only because there is no clear benefit to weight but also because there is some weight on the risk plate of the scale with severe hyperglycaemia occurring more often in the ''prednisone'' group. This side-effect has already been reported as clouding the benefits of systemic steroids in less severe COPD exacerbations [21] and is of particular concern in the general management of the critically ill [22].…”

“…This would be a lesser problem if the said steroids had major other benefits. The study by ABROUG et al [6] suggests that this is not the case in the most severe category of COPD exacerbations, those that require ventilatory assistance.…”

“…In this issue of the European Respiratory Journal, ABROUG et al [6] report data that are first of their kind on the effects of systemic steroids in patients admitted to an intensive care unit (ICU) and requiring ventilatory support for a severe, life-threatening exacerbation of COPD. In an open-label, randomised trial of 217 patients, ABROUG et al [6] observed no difference between patients receiving standard care or standard care plus 1 mg?kg -1 of prednisone, in terms of ICU mortality, the rate of noninvasive ventilation failure, the duration of mechanical ventilation or the ICU length of stay. How are these observations relevant to our quadriceps story?…”

“…In spite of these limitations, the study by ABROUG et al [6] must be taken as what it is, namely a stern, wellfounded warning against the routine (and at times ''instinctive'') prescription of systemic steroids in COPD patients needing acute ventilatory support. Indeed, beyond the nitrogen and the anabolism-catabolism balances discussed above, and that this study does not directly address, what the results of ABROUG et al [6] show is that the risk-benefit balance of systemic steroids in this indication is negative, not only because there is no clear benefit to weight but also because there is some weight on the risk plate of the scale with severe hyperglycaemia occurring more often in the ''prednisone'' group.…”