When given to people with acute exacerbations of chronic obstructive pulmonary disease, corticosteroids don’t reduce mortality, but they improve FEV1, reduce hospitalization by ~1 day, and increase 30-day treatment success, according to a 2009 Cochrane review of 10 randomized trials. Patients in ICUs were excluded from the analyzed studies, but you might think these findings would be sufficient to strongly advise corticosteroid use in patients with acute exacerbations of COPD so severe as to require ICU admission. In fact, you could argue that physicians would have to have a compelling reason not to provide this proven treatment to patients with such severe exacerbations.
Or, one could randomize 40 of those patients to placebo, see what happens, and publish it in a big-time journal, on the premise that in critically ill patients, harmful hyperglycemia induced by corticosteroids might exceed the expected respiratory benefits. This was done at 8 ICUs in Spain (Andres Esteban), Mexico, Colombia, and at the University of Texas in San Antonio (Antonio Anzueto).
- The 43 patients who got steroids spent one less day on the ventilator than the 40 who got placebo (3 vs. 4 days, p=0.04).
- Providing placebo instead of corticosteroids appeared to lead to 7 of 19 patients (37%) failing non-invasive ventilation and undergoing intubation and mechanical ventilation (zero of 18 patients receiving steroids failed noninvasive ventilation, p=0.04).
- There was no detected difference in mortality.
- Twice as many steroid-treated patients had hyperglycemia (46% vs. 25%, with a conservative cutoff of blood glucose > 120 mg/dL), but there were no real adverse events attributable to steroids.
These findings were apparent despite only enrolling 83 patients of a planned 198 believed necessary to achieve the desired power. The study took 5 years, mainly because so many patients had received steroids recently (within 30 days or in the emergency department), excluding them.
Hindsight is 20/20, and this study was likely conceived, designed, and approved during the not-so-distant era when hyperglycemia was thought to be more dangerous than it probably is in critically ill nonsurgical patients.
Alia I et al. Efficacy of Corticosteroid Therapy in Patients With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Ventilatory Support. Arch Intern Med 2011;171:1939-1946.