Benefits of Systemic Steroids in Ventilated COPD Exacerbation: Systematic Review and Meta-Analysis

Introduction: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a major cause of acute respiratory failure and mortality in the Intensive Care Unit (ICU). The recommendation regarding systemic corticosteroids in this subgroup of patients with AECOPD is unknown since most studies on systemic steroids in AECOPD have excluded ventilated patients in the ICU. Our study aims to investigate whether systemic steroids benefit the subgroup of AECOPD on ventilation, non-invasive ventilation (NIV) or mechanical ventilation (MV) compared to placebo or no systemic steroids.


Methods: We searched PubMed, Cochrane, and Embase for randomized trials or observational studies comparing systemic steroids to placebo or no systemic steroids in AECOPD on ventilation. Outcomes of interest were ICU mortality, duration of ventilation, NIV failure rate, gastrointestinal bleed, hyperglycemic episodes requiring initiation or alteration of insulin therapy, ventilator-associated pneumonia.


Results: We included 1,596 patients from 6 studies, of which 3 were randomized trials. ICU mortality was not improved in the systemic steroid group compared to placebo or no systemic steroids (Risk ratio (RR) = 1.09; 95% CI 0.62-1.92; p=0.775; I²=0.0%). This effect was seen in both randomized trials and observational study groups. Systemic steroids did not improve the rates of NIV failure compared to placebo or no systemic steroids (Odds ratio (OR) = 1.16; 95% CI 0.82-1.65; p=0.395; I²=57.9%). Systemic steroids did not improve duration of ventilation (mean difference (MD)= -0.74 95% CI -1.78-0.31; p=0.167; I²=83.8%). In the subgroup of RCTs alone systemic steroids did improve duration of ventilation by 1.12 days (MD = -1.12 95% CI -2.23-0.00; p=0.049, I²=59.9%). Hyperglycemic episodes requiring insulin therapy were significantly higher (RR = 1.54; 95% CI 1.15-2.05, p= 0.004; I²=42.4%). There was no statistically significant difference between groups for the complications of gastrointestinal bleed and ventilator-associated pneumonia (VAP).


Conclusions: Critically ill AECOPD patients requiring ventilation may not significantly benefit from systemic corticosteroids, moreover the hyperglycemic complications may counterbalance any minimal benefits.