The Role of Systemic Corticosteroids in Acute Exacerbation of Chronic Obstructive Pulmonary Disease
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The Role of Systemic Corticosteroids in Acute Exacerbation of Chronic Obstructive Pulmonary Disease Dennis E. Niewoehner Pulmonary Section, Veterans Affairs Medical Center, and University of Minnesota, Minneapolis, Minnesota, USA
Abstract
The administration of systemic corticosteroids for patients with exacerbations of chronic obstructive pulmonary disease (COPD) has become common practice over the past 25 years. This practice remained somewhat controversial because corticosteroids can have serious adverse effects and initial clinical trials provided inconclusive evidence concerning their efficacy. Results from recent clinical trials indicate that systemic corticosteroids are modestly effective in shortening the duration of severe exacerbations of COPD. Systemic corticosteroids administered intravenously or orally to hospitalized patients with exacerbations of COPD reduced the absolute treatment failure rate by about 10%, increased the forced expiratory volume in 1 second (FEV1) by about 100ml, and shortened the hospital stay by 1 to 2 days. Oral corticosteroids probably confer similar benefits when used for treating moderately severe COPD exacerbations in an out-patient setting. The optimal starting dose of corticosteroids is not known, but the duration of treatment should not extend longer than 2 weeks. Hyperglycemia is the most common adverse event, but secondary infections, mental disturbances, and myopathies may also occur.
Episodic worsening of the underlying respiratory disease frequently interrupts the clinical course of disease in patients with advanced chronic obstructive pulmonary disease (COPD). These episodes are commonly described as bronchitic exacerbations. Symptoms include some combination of increased dyspnea, cough, purulent sputum, and chest wheeziness. In one prospective study, it was found that patients with symptomatic COPD experienced a mean of 1.3 exacerbations per year.[1] Individual susceptibility appeared to vary widely as 25% of the participants in that study experienced no COPD exacerbations while 10% had more than three episodes per year. Most exacerbations are thought to have an infectious etiology, and their severity may range from mild, transient increases in cough and sputum at one end of the spectrum to life-threatening respiratory failure at the other extreme. Most patients improve irrespective of therapy, but full recovery is slow in many patients and clinical recovery may remain incomplete in a few.[2] Patients with more severe exacerbations commonly seek medical attention and the most severely ill patients require hospitalization. Hospitalization exacts an enormous human and financial toll. A survey of non-Federal hospitals in the US for 1996 showed that
patients over the age of 44 years with a primary diagnosis of chronic lung disease [International Classification of Disease – Clinical Modification (ICD-CM) codes 491-496 and 500-518] constituted 4.3% of all primary discharge diagnoses.[3] In a prospecti
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