Anesthesia Management: Steroids for COPD: Less Is Probably More

Authors: Abroug F and Krishnan JA., Am J Respir Crit Care Med 2014 May 1; 189:1014

Patients with chronic obstructive pulmonary disease exacerbations who require intensive care admission do better with low-dose steroids.

A 2010 observational study suggested that relatively low-dose oral corticosteroids were as good as — or better than — high-dose parenteral steroids in hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations, but intensive care unit (ICU) patients were excluded from that study (NEJM JW Gen Med Jun 24 2010). Whether these results can be extrapolated to patients admitted to ICUs is unclear.

Researchers evaluated 17,239 patients (77% older than 60; 31% tobacco users) with COPD exacerbations who were admitted to ICUs at 473 U.S. hospitals. Nearly one third of patients received noninvasive ventilation; 15% were intubated. Almost all patients received antibiotics and bronchodilators. Methylprednisolone doses were categorized as either high (greater than 240 mg) or low (less than 240 mg), based on total methylprednisolone administered on hospital day 1 or 2; 11,083 patients (64%) received high doses.

Patients in the two groups were matched by propensity scoring. After adjusting for unbalanced covariates, the groups had similar in-hospital mortality. Compared with high-dose treatment, low-dose treatment was associated with shorter ICU and hospital lengths of stay, lower hospital costs, and shorter duration of mechanical ventilation. Low-dose patients were less likely to require insulin therapy or develop fungal infections.

Comment

This study strongly suggests that a moderate dose of steroids is more than adequate to treat ICU patients with severe COPD exacerbations. I would feel comfortable treating such patients with less than 240 mg of methylprednisolone (i.e., 80 mg to 160 mg), but a randomized trial is necessary to determine optimal dosing and duration of steroids.