Systemic corticosteroid and antibiotic therapy during acute exacerbations of chronic obstructive pulmonary disease requiring ventilatory support

Abstract

Chronic obstructive pulmonary disease (COPD) is characterized by acute exacerbations (AECOPD) which can be life-threatening and contribute to the progressive decline of lung function and deterioration of quality of life.Management of severe AECOPD requiring intensive care unit (ICU) admission is usually based on ventilatory support (mainly by non-invasive ventilation), pharmacologic treatment of bronchial obstruction, and treatment of triggering agents. Systemic corticosteroids and antibiotics are frequently prescribed, based on trials that usually excluded patients requiring ventilatory support. Extrapolation of these trial results to patients requiring ventilator support is not straightforward given the burden of antibiotic resistance in the ICU and the specific adverse effects of corticosteroids in ICU patients including neuromyopathy and sepsis. Few studies have recently evaluated systemic corticosteroids in AECOPD patients requiring ventilatory support: they reached contradictory results regarding intermediate outcomes (ventilation duration, length of stay, and so on) or hard endpoints like ICU mortality. These studies have however consistently highlighted the high risk of developing potentially severe corticosteroids’ side effects. Only one study evaluated systematic antibiotic administration in AECOPD patients requiring ventilatory support. This study suggested that beneficial effects of antibiotics stem from an effect of selective digestive decontamination preventing ventilatory-associated pneumonia. The majority of patients included in that study had invasive mechanical ventilation either at admission or in the 6 h following mechanical ventilation, rendering hazardous any extrapolation to current ventilatory management of such patients who are usually ventilated non-invasively.