Rationale and use of corticosteroids in chronic obstructive pulmonary disease

End-tidal arterial CO2 partial pressure gradient in patients with severe hypercapnia undergoing noninvasive ventilation

BACKGROUND

Patients with severe hypercapnia represent a particularly serious condition in an emergency department (ED), requiring immediate attention. Noninvasive ventilation (NIV) is an integral part of the treatment for acute respiratory failure. The present study aimed to validate the measurement of end-tidal CO2 (EtCO2) as a noninvasive technique to evaluate the effectiveness of NIV in acute hypercapnic respiratory failure.

METHODS

Twenty consecutive patients admitted to the ED with severe dyspnea were enrolled in the study. NIV by means of bilevel positive airway pressure, was applied to the patients simultaneously with standard medical therapy and continued for 12 hours; the arterial blood gases and side-stream nasal/oral EtCO2 were measured at subsequent times: T0 (admission to the ED), T1h (after 1 hour), T6h (after 6 hours), and T12h (after 12 hours) during NIV treatment.

RESULTS

The arterial CO2 partial pressure (PaCO2)-EtCO2 gradient decreased progressively, reaching at T6h and T12h values lower than baseline (P < 0.001), while arterial pH increased during the observation period (P < 0.001). A positive correlation was found between EtCO2 and PaCO2 values (r = 0.89, P < 0.001) at the end of the observation period.

CONCLUSION

In our hypercapnic patients, the effectiveness of the NIV was evidenced by the progressive reduction of the PaCO2-EtCO2 gradient. The measurement of the CO2 gradient could be a reliable method in monitoring the effectiveness of NIV in acute hypercapnic respiratory failure in the ED.

Management of COPD patients in the intensive care unit

Chronic obstructive pulmonary disease (COPD) is characterized by expiratory airflow limitation that is not fully reversible. Acute exacerbations in patients with moderate to severe COPD can cause severe hypoxia and persistent or severe respiratory acidosis, resulting in respiratory failure and the need for ventilator support. Acute respiratory failure, altered mental status, and hemodynamic instability associated with acute exacerbations of COPD are commonly encountered and require careful management in the intensive care unit (ICU). Noninvasive and invasive ventilator support in conjunction with pharmacotherapy can be lifesaving, although mortality remains high. It is important also to consider pulmonary rehabilitation and palliative care.

Is There a Role for Systemic Corticosteroids in the Management of Stable Chronic Obstructive Pulmonary Disease?

COPD, encompassing both chronic bronchitis and emphysema, usually results from exposure to tobacco smoke. Smoking causes infiltration of the airways with leukocytes, an imbalance between proteases and their naturally occurring inhibitors and local cytokine secretion in the lung, which leads to airway inflammation and alveolar destruction. Corticosteroids have a range of anti-inflammatory actions, particularly inhibition of cytokine secretion, which suggests that they may be effective in COPD. However, data from the highest quality studies available do not show any evidence of significant improvement in symptoms of patients with COPD treated with systemic corticosteroids.A meta-analysis found that about 10% of patients with stable COPD showed an improvement in lung function following treatment with short-term systemic corticosteroids compared with placebo. Exercise capacity in patients with COPD was evaluated in four studies, only one of which found a significant improvement with oral corticosteroids compared with placebo. Long-term systemic corticosteroid treatment in patients with stable COPD has not been found to alter the rate of decline in FEV(1). Although systemic corticosteroids are associated with a range of adverse effects, the data do not allow precise quantification of their contribution to morbidity. However, studies show an increased risk of osteoporosis in COPD. Recent studies have also found an association between oral corticosteroid administration and mortality in patients with stable COPD, but it is not clear if this is a cause and effect relationship. Current data do not support long-term administration of systemic corticosteroids to all patients with stable COPD. Results of studies suggest that short-term oral corticosteroid administration may identify a sub-population of patients with COPD who may benefit through a reduction in the decline in FEV(1) and better control of symptoms by long-term administration of inhaled corticosteroids; these findings need to be tested by further research.

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

OBJECTIVES

To determine the efficacy and safety of inhaled corticosteroids in stable patients with COPD, in terms of objective and subjective outcomes.

SEARCH METHODS

A pre-defined search strategy was used to search the Cochrane Airways Group Specialised Register for relevant literature. Searches are current as of July 2011.

SELECTION CRITERIA

We included randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short-term beta(2)-agonists and bronchial hyper-responsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. We also analysed data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Fifty-five primary studies with 16,154 participants met the inclusion criteria. Long-term use of ICS (more than six months) did not consistently reduce the rate of decline in forced expiratory volume in one second (FEV(1)) in COPD patients (generic inverse variance analysis: mean difference (MD) 5.80 mL/year with ICS over placebo, 95% confidence interval (CI) -0.28 to 11.88, 2333 participants; pooled means analysis: 6.88 mL/year, 95% CI 1.80 to 11.96, 4823 participants), although one major trial demonstrated a statistically significant difference. There was no statistically significant effect on mortality in COPD patients (odds ratio (OR) 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long-term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (generic inverse variance analysis: MD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants; pooled means analysis: MD -0.19 exacerbations per patient per year, 95% CI -0.30 to -0.08, 2253 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (MD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.65, 95% CI 2.03 to 3.46, 5586 participants) and hoarseness. In the long-term studies, the rate of pneumonia was increased in the ICS group compared to placebo, in studies that reported pneumonia as an adverse event (OR 1.56, 95% CI 1.30 to 1.86, 6235 participants). The long-term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over three years.

AUTHORS' CONCLUSIONS

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life and possibly reduced rate of decline in FEV(1)) against the potential side effects (oropharyngeal candidiasis and hoarseness, and risk of pneumonia).

Inhaled corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

The role of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) has been the subject of much controversy. Major international guidelines recommend selective use of ICS. Recently published meta-analyses have reported conflicting findings on the effects of inhaled steroid therapy in COPD.

OBJECTIVES

The objective of the review is to determine the efficacy of regular use of inhaled corticosteroids in patients with stable COPD.

SEARCH STRATEGY

A pre-defined search strategy was used to search the Cochrane Airways Group specialised register for relevant literature. Searches are current as of October 2006.

SELECTION CRITERIA

We selected randomised trials comparing any dose of any type of inhaled steroid with a placebo control in patients with COPD. Acute bronchodilator reversibility to short term beta2-agonists and bronchial hyperresponsiveness were not exclusion criteria. The a priori primary outcome was change in lung function. Data on mortality, exacerbations, quality of life and symptoms, rescue bronchodilator use, exercise capacity, biomarkers and safety were also analysed.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Forty-seven primary studies with 13,139 participants met the inclusion criteria. Medium term use of ICS (> two months and up to six months) resulted in a small improvement in FEV1 in some studies. Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients (weighted mean difference (WMD) 5.80 ml/year with ICS over placebo, 95% CI -0.28 to 11.88, 2333 participants). There was no statistically significant effect on mortality in COPD patients (OR 0.98, 95% CI 0.83 to 1.16, 8390 participants). Long term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible (WMD -0.26 exacerbations per patient per year, 95% CI -0.37 to -0.14, 2586 participants). ICS slowed the rate of decline in quality of life, as measured by the St George's Respiratory Questionnaire (WMD -1.22 units/year, 95% CI -1.83 to -0.60, 2507 participants). Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis (OR 2.49, 95% CI 1.78 to 3.49, 4380 participants) and hoarseness. The few long term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over 3 years.

AUTHORS' CONCLUSIONS

Patients and clinicians should balance the potential benefits of inhaled steroids in COPD (reduced rate of exacerbations, reduced rate of decline in quality of life), against the known increase in local side effects (oropharyngeal candidiasis and hoarseness). The risk of long term adverse effects is unknown.

Acute exacerbation of chronic bronchitis: Need for an evidence-based approach

Acute exacerbations of chronic bronchitis (AECB) can be classified into three levels according to severity: (1) home treatment sufficient; (2) hospitalisation required; (3) hospitalisation in the presence of respiratory failure. This evidence-based classification is useful in ranking the clinical relevance of the episode and its outcome, and makes it possible to define the clinical history, clinical evaluation and diagnostic procedures of an exacerbation. Treatment guidelines vary according to severity, but they are essentially based on appropriate bronchodilator therapy (beta(2) agonists and/or anticholinergics, corticosteroids and antibiotics selected according to the local bacterial resistance pattern). It is important that cases requiring management in an intermediate/special respiratory care unit or intensive care unit (ICU) be identified. This is the stage where oxygen therapy and ventilatory support become particularly important. As first choice, they should be non-invasive, saving intubation and invasive ventilatory support for most severe cases characterised by severe acidemia and hypercapnia. We identify the optimal criteria for hospital discharge and follow-up of patients with AECB. In view of the chronic nature of the underlying disease, a correct follow-up is essential to avoid frequent and repeated relapses.

Oral corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common chronic lung disorder, usually related to cigarette smoking, representing a major and increasing cause of morbidity and mortality. It is defined "as a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases". The use of corticosteroids for their anti-inflammatory effects has been suggested.

OBJECTIVES

To assess the effects of oral corticosteroids on the health status of patients with stable COPD.

SEARCH STRATEGY

Searches of the Cochrane Airways Group Specialised Register and MEDLINE were carried out in December 2003 and 2004. Review articles and bibliographies were searched.

SELECTION CRITERIA

Randomised controlled prospective studies in adults with stable COPD ( post-bronchodilator FEV1 <80% of predicted, FEV1/FVC <70%) and a history of smoking, excluding known asthmatics, in which oral steroid use was compared with placebo and use of co-interventions was matched in both groups.

DATA COLLECTION AND ANALYSIS

Data was extracted independently by two reviewers. All trials were combined using Review Manager (version 4.2.7).

MAIN RESULTS

From 459 titles 24 studies met the inclusion criteria. Treatment lasted three weeks or less in 19 studies, high dose oral steroid was used in 21 studies and subjects had moderate or severe COPD in 15 studies. There was a significant difference in FEV1 after two weeks treatment, WMD 53.30 ml; 95% confidence interval 22.21 to 84.39 favouring oral steroid use compared to placebo when 14 studies with available data (n=396) were combined, with no significant heterogeneity. There was a significant increase in odds for individual patient FEV1 response greater than 20% from baseline with high dose oral steroid treatment compared to placebo, OR 2.71; 95% CI 1.84 to 4.01 (9 studies) . It would be necessary to treat 7 patients (95% CI 5 to 12) with oral corticosteroids to achieve one extra case of increasing FEV1 by more than 20%, with a placebo group risk of 0.13. All differences in health-related quality of life were less than the minimum clinically important difference. There were small statistically significant advantages for functional capacity and respiratory symptom of wheeze with oral steroid treatment but no significant difference in risk of withdrawal from study due to an exacerbation or rate of serious exacerbations over 2 years with low dose oral steroid treatment. There was an increased risk of adverse effects, including increased blood glucose, adrenal suppression and reduced serum osteocalcin.

AUTHORS' CONCLUSIONS

There is no evidence to support the long-term use of oral steroids at doses less than 10-15 mg prednisolone though some evidence that higher doses (>/= 30 mg prednisolone) improve lung function over a short period. Potentially harmful adverse effects e.g.. diabetes, hypertension, osteoporosis would prevent recommending long-term use at these high doses in most patients.

Occurrence and risk factors of oral candidiasis treated with oral antifungals in seniors using inhaled steroids

Oral candidiasis (OC) is a frequent side effect of inhaled corticosteroids (iCSTs). This study estimated occurrence and significance of risk factors of OC treated with antifungals in users of iCSTs under conditions of normal use. This retrospective analysis used data drawn from drug insurance plan records in Quebec, Canada. The sample contained 27,000 seniors using anti-asthma medications during 1990. Three years of data (1989-1991) were searched for use of oral antifungals concurrent with exposure to iCSTs. A case-control study examined factors leading to increased probability of first incidence of OC in new users of iCSTs. Three-year occurrence for OC was 7%. Increased risk for a first occurrence of OC was significantly associated with higher doses of iCST, increased length of iCST exposure, use of antibiotics, use of oral steroids, having three or more prescribers, a history of use of both high and low strengths of iCST, and concurrent use of oral steroids and diabetes medications. The occurrence of OC is relatively high. Knowledge of factors leading to increased risk could facilitate the targetting of patients who need timely intervention, under conditions of normal use.

The response to inhaled and oral steroids in patients with stable chronic obstructive pulmonary disease

BACKGROUND

A significant minority of patients with COPD have favourable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side-effects. Long-term administration of inhaled steroids is a safe means of treatment. However, only a few studies have addressed the role of inhaled steroids in patients with COPD, with conflicting results.

METHODS

Forty-four patients with stable COPD were defined as 'responders to bronchodilators' (increase in FEV1 > or = 20% following administration of beta 2-agonist) (group A), and 124 as 'non-responders to bronchodilators' (group B). All patients were randomized to receive a 6-week course of either a daily dose of 800 micrograms of inhaled budesonide or placebo, separated by 4 weeks when no medication was taken; were randomized again to receive a 6-week course of either 1600 micrograms day-1 of inhaled budesonide, or 800 micrograms day-1 of inhaled budesonide plus placebo; and were randomized once again to receive a 6-week course of either 40 mg day-1 of prednisone or placebo. All stages were performed in a double-blind cross-over design.

RESULTS

Following administration of 800 micrograms day-1 of inhaled budesonide, there was an increase in the mean FEV1 from 1.40 +/- 0.20 to 1.92 +/- 0.22 L (P < 0.001) and a significant decrease in inhaled beta 2 agonist consumption in group A. These changes remained almost stable during the increased dose of inhaled budesonide or during prednisone treatment. The mean FEV1 did not change during the placebo period, or in group B in either treatments.

CONCLUSIONS

Treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about one-quarter of patients with stable COPD, and this rate increased to about three-quarters in patients who responded to beta 2-agonist inhalation. There was no additional benefit in using a higher dose of inhaled budesonide or prednisone.

Chronic obstructive pulmonary disease

Acute exacerbations of underlying COPD are a common cause of respiratory deterioration. Developments have been made in preventive measures, but admission to hospital for acute exacerbations can be expected to remain common. Several expert consensus guidelines have been published to define the appropriate management of COPD patients. These consensus guidelines generally agree, but all acknowledge a lack of large well-controlled clinical studies, especially studies focusing on the management of acute exacerbations. Consequently, many potential controversies exist about the details of managing patients with acute exacerbations. Although studies of many fundamental aspects of management are still needed, the results of controlled clinical trials are sufficient to emphasise the importance of a careful clinical assessment, supplemental oxygen, inhaled bronchodilators to partially improve airway obstruction, corticosteroids to decrease the likelihood of treatment failures and to speed recovery, antibiotics, especially in severe patients, and non-invasive positive-pressure ventilation for treatment of acute ventilatory failure in selected patients.

Chronic necrotizing pulmonary aspergillosis: approach to management

OBJECTIVE

To describe our experience with 6 patients and to review the current literature to update the approach to the diagnosis and treatment of chronic necrotizing pulmonary aspergillosis.

DESIGN

Patient reports and MEDLINE review of English-language literature published after 1980.

RESULTS

Chronic necrotizing pulmonary aspergillosis (CNPA) is a subacute infection most commonly seen in patients with altered local defense from preexisting pulmonary disease or in patients with risk factors that alter systemic immune status. Delays in diagnosis are common. Although initial reports advocated intravenous amphotericin B, itraconazole has emerged as a better initial therapy because of its documented efficacy and minimal toxicity. The dose and duration of therapy should be based on clinical response. In patients who do not respond to medical therapy, pulmonary resection can be considered, but postoperative morbidity is high. Recurrent or relapsing infections occur; chronic maintenance therapy with itraconazole can be considered in patients with residual parenchymal scarring. A wide range of mortality rates has been reported for CNPA. Outcome is most likely influenced by severity of comorbid conditions, extent of underlying pulmonary disease, delays in diagnosis, and initiation of effective therapy.

Effects of long-term low-dose methylprednisolone on rat diaphragm function and structure

In animal studies, high dosages of corticosteroids cause changes in diaphragm structure and function. The present study was designed to investigate the effects of long-term low-dose methylprednisolone (MP) administration on rat diaphragm contractile properties and morphology. Thirty adult rats were treated with saline or MP (0.2 mg/kg/day s.c.) during 6 months. Contractile properties of isolated diaphragm strips, immunohistochemical characteristics analyzed by means of antibodies reactive with myosin heavy chain isoforms, and enzyme activities were determined in the diaphragm muscle. MP significantly reduced diaphragm force generation by -15% over a wide range of stimulation frequencies. The number of type IIb fibers was reduced by MP. There was a mild but significant decrease in type I and IIa fiber cross-sectional area (CSA), whereas type IIx and IIb CSA did not change. These changes resulted in a reduction in the relative contribution of type IIb fibers to total diaphragm muscle area. Biochemically, MP decreased glycogenolytic activity, while fatty acid oxidation and oxidative capacity were increased. In conclusion, long-term low-dose MP administration caused a marked impairment in diaphragm function. This is accompanied by changes in diaphragm muscle morphology and enzyme capacity.

Inhaled budesonide therapy for patients with stable COPD

A significant minority of patients with COPD have favorable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with high-dose inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to inhaled beta 2-agonist will serve to individualize steroid responders. We compared a 6-week course of 800 micrograms/d inhaled budesonide with placebo, separated by 4 weeks when no medication was taken, in a double-blind crossover trial, in 8 patients responding to inhaled beta 2-agonist, and in 22 nonresponders with stable COPD. In six of eight "responders to beta 2-agonist," there was a significant improvement in the FEV1 (defined as > or = 20%) following inhaled budesonide, as compared with placebo. In the 22 "nonresponders to beta 2-agonist," there was no significant improvement in the mean FEV1 (1.41 +/- 0.1 L before, and 1.61 +/- 0.1 L after treatment) with inhaled budesonide or placebo. Over the 6-week course of treatment by either budesonide or placebo, the nonresponders reported similar beta 2-agonist consumption (4.8 +/- 0.2 and 5.0 +/- 0.1 puffs per patient per day, respectively). However, there was a significant difference between the two periods of treatment in the responders as for the mean daily number of beta 2-agonist inhalations (2.4 +/- 0.1 in the budesonide period as compared with 5.3 +/- 0.1 in the placebo period; p < 0.005). We conclude that treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about 25% of patients with stable COPD, and this rate is increased to about 75% in patients who respond to beta 2-agonist inhalation.

Chronic bronchitis

Preview A number of therapies may be beneficial to patients with chronic bronchitis, but quitting smoking is the first and most important step. The authors of this article explain why smoking cessation is so essential for improvement of symptoms and preservation of pulmonary function. They also discuss current pharmacologic approaches to management of chronic bronchitis.

The Pharmacological Treatment of Ambulatory Chronic Obstructive Pulmonary Disease Patients

Because of the widespread prevalence of chronic obstructive pulmonary disease (COPD) and the important role of drug therapy in its management, there is significant opportunity for the pharmacist to interact with COPD patients. Whether educating patients or other health care providers about COPD, a knowledge of the treatment options and their correct application in these patients is essential for pharmacists today. This article reviews the pharmacological management of ambulatory COPD patients, including the roles of β-agonists, anticholinergics, theophylline, steroids, oxygen, and other treatment modalities. Copyright © 1992 by W.B. Saunders Company

Treatment of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is an ever present problem in the United States. Characterized by features of both bronchitis and emphysema, the course is generally slow and progressive. However, acute exacerbations do occur, averaging one to four exacerbations per patient per year. These exacerbations, typically characterized by increasing dyspnea, cough, and sputum production, often require immediate treatment. As single agents, both anticholinergic and β-adrenergic agents have been proven effective in acute COPD exacerbations, yet their combination may provide little added therapeutic effect over either agent alone. In light of questionable effectiveness and the potential for toxicity, the role of methylxanthines in the management of COPD has been critically evaluated over the past several years. Certain patients may show improvement from the use of corticosteroids and/or antibiotics during an acute exacerbation; however, these patients are not always easily identifiable. Lastly, patients presenting with a PaO2 < 60 mm Hg will usually benefit from oxygen therapy. This article discusses some of the current views on the efficacy of these various treatments for acute COPD exacerbations.

Pharmacologic treatment of COPD

Chronic obstructive pulmonary disease (COPD) has a wide variety of pathophysiologic mechanisms that involve the bronchi, bronchioles, and acini. For typical patients, first-line treatment with inhaled beta 2-selective agonists or ipratropium bromide (Atrovent) significantly improves lung function with minimal side effects. Theophylline is no longer routinely used as a first-line agent for the treatment of COPD but may be a useful addition to therapy if proper attention is given to serum drug levels and symptoms of toxicity. Oral prednisone is useful as an adjunctive agent for patients with serious disease who do not respond to other agents; a therapeutic trial showing objective evidence of benefit from this drug is essential. Mucolytics have recently been shown to have a role in improving lung function and also may be useful as adjunctive therapy.