Pulmonary Disorders II

Reduction in the Use of Corticosteroids in Exacerbated COPD (REDUCE) was a randomized,

noninferiority trial. Patients (n=314) were randomized to prednisone 40 mg daily for either 5 days

or 14 days (inhaled bronchodilators and antimicrobials in both groups). ECOPD occurred in 35.9%

of patients in the 5-day group and in 36.8% of patients in the 14-day group (p=0.006) In addition,

although one of the secondary endpoints notes no difference between groups regarding the need for

mechanical ventilation (defined as either intubation or noninvasive ventilation), it is unclear how

not include critically ill patients requiring MV.

A randomized, double-blind trial including 83 adult patients with an ECOPD requiring

hospitalization and ventilatory support (invasive or noninvasive) compared methylprednisolone 0.5

mg/kg intravenously every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4–6, and 0.5 mg/

kg daily on days 7–10 with placebo. Patients receiving corticosteroids had a shorter duration of MV

(p=0.04), trend toward shorter length of ICU stay (p=0.09), fewer noninvasive ventilation failures

(p=0.004), and more hyperglycemia (p=0.04). This study was not powered to detect differences in

length of stay or mortality (Arch Intern Med 2011;171:1939-46).

An open-label, randomized trial included 217 critically ill patients 40 years and older with an

ECOPD requiring MV to receive oral prednisone 1 mg/kg daily for a maximum of 10 days or

usual care. No differences in ICU mortality, noninvasive ventilation failure, duration of MV, or

ICU length of stay were observed. Hyperglycemia significantly increased in the steroid group (Eur

Respir J 2014;43:717-24).

methylprednisolone in more than 17,000 patients with an ECOPD admitted to an ICU. Patients

in the high-dose group had longer ICU and hospital lengths of stay, higher hospital costs, longer

durations of MV, and more hyperglycemia and fungal infections. Mortality did not differ between

An open-label, randomized, parallel-group trial compared fixed-dosed corticosteroid treatment

(prednisone 40 mg/day) with variable-dosed corticosteroid treatment for 5 days for the treatment

of ECOPD in 246 hospitalized patients. Those in the variable-dosed corticosteroid group received

61.4 mg/day of prednisone on average. In-hospital treatment failure was defined as death, need

for MV, administration of additional rescue steroids or aminophylline, or upgrade of antibiotic

use. Those in the variable-dosed group experienced a reduced risk of in-hospital treatment failure

(RR 0.37 [0.18–0.74]). Post hoc analysis did not show a significant difference in treatment failure

for patients receiving less than or greater than 60 mg/day (31.3% vs. 23.4% [p=0.351]); however,

treatment failure was higher in patients receiving 40 mg or less per day, 44.4%, than for those

receiving greater than 40 mg/day, 22.9% (p=0.27). This study suggests a more appropriate fixed

steroid dose for ECOPD is prednisone 60 mg/day rather than 40 mg/day (Chest 2021;160:1660-9).

Antimicrobials (GOLD 2024; Cochrane Database Syst Rev 2018;10:CD010257)

Data are conflicting on which populations benefit from antimicrobials.

A 2018 systematic review comparing antibiotics with placebo for ECOPD found a treatment failure

relative risk of 0.72 (n=1191) among studies in outpatient settings using only antibiotics currently

in practice. No differences in all-cause mortality or treatment failure were identified (Cochrane

Database Syst Rev 2018;10:CD010257).

length of stay.

study used ofloxacin, which is no longer used