According to research published in the Archives of Internal Medicine, patients with COPD exacerbations requiring mechanical ventilation who receive treatment with IV corticosteroids require a shorter duration of mechanical ventilation, and have a higher chance of successful non-invasive mechanical ventilation.

The authors note that studies evaluating corticosteroids in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations have been limited to patients who were initially cared for outside the ICU.  It is therefore uncertain whether the results are applicable to more severely ill patients; the risks associated with corticosteroids in critically ill patients (e.g. infections, hyperglycaemia) are also unclear.  The purpose of the current study therefore was to evaluate the efficacy and safety of systemic corticosteroid therapy in patients with an acute COPD exacerbation who were receiving ventilatory support.

A total of 354 adults admitted to ICU for ventilator support due to acute COPD exacerbations were screened; 83 were eligible for inclusion and randomised to double-blind treatment with IV methylprednisolone (0.5mg/kg every 6 hours for 72 hours, 0.5mg/kg every 12 hours on days 4 through 6, and 0.5mg/kg/d on days 7 through 10) or placebo. Those with asthma or pneumonia were excluded, as were those who had used systemic corticosteroids within the preceding month, or for the treatment of the COPD exacerbation for >24 hours at the time of randomization (previous corticosteroid use was the most common reason for ineligibility).  The main outcome measures were duration of mechanical ventilation, length of ICU stay, and need for intubation in patients treated with non-invasive mechanical ventilation.

The main results reported are as follows:

• There were no significant differences between the groups in demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables, and corticosteroid rescue treatment

• Treatment with methylprednisolone was associated with a 1-day reduction in the median duration of mechanical ventilation (3 days vs. 4 days; P=0.04) and a non-significant trend toward a shorter length of ICU stay (6 days vs. 7 days; P=0.09).

• The rate of failure of non-invasive mechanical ventilation was lower in patients assigned to corticosteroid treatment (0% vs. 37%; P=0.004).

• In-ICU mortality was similar in the 2 groups (10% vs. 12%; relative risk [RR] 1.16; 95% CI 0.34-4.03; P=0.81).

• Treatment with corticosteroids was associated with an almost 2-fold increase in the risk of hyperglycaemia requiring treatment (46% vs. 25%; RR 1.86; 95% CI 1.00-3.48; P=0.04).

The authors comment that their results may not have a great impact on clinical practice, as most patients in ICU with COPD exacerbations are probably already treated with corticosteroids.  They do however provide evidence of the beneficial effects of systemic corticosteroids on clinical outcomes in a patient population that has never (to their knowledge) previously been enrolled in a clinical trial.

They note some of the study’s limitations, for example the small sample size - it was underpowered for detecting a statistically significant difference in the median length of ICU stay, and also for detecting uncommon risks associated with corticosteroid treatment.