What is the indication for hydrocortisone (corticosteroid) in acute breathlessness?

Hydrocortisone for Acute Breathlessness

Hydrocortisone is indicated for acute breathlessness in septic shock that is not responsive to fluid resuscitation and moderate-to-high-dose vasopressor therapy, with a recommended dose of less than 400 mg/day for at least 3 days. 1

Indications for Hydrocortisone in Breathlessness

Septic Shock

• Hydrocortisone should be used when:
  • Septic shock is not responsive to adequate fluid resuscitation
  • Moderate to high-dose vasopressor therapy is required (>0.1 μg/kg/min of norepinephrine or equivalent)
  • Recommended dose: IV hydrocortisone <400 mg/day for at least 3 days 1
  • Administration via continuous infusion rather than bolus dosing 2

COPD Exacerbations

• Systemic corticosteroids are indicated for moderate to severe exacerbations
• Recommended regimen: 7-14 day course of systemic corticosteroids
  • Oral route: prednisolone 30 mg/day
  • If oral route not possible: hydrocortisone 100 mg IV 1

Non-Indicated Uses

• Hydrocortisone is not recommended for:
  • Sepsis without shock 1
  • Acute asthma without ventilatory failure (when added to oral prednisolone) 3
  • Early treatment of acute asthma in emergency settings 4, 5
  • Cancer-related dyspnea (evidence is very low quality) 6

Dosing and Administration Protocol

For Septic Shock:

1. Initial dose: IV hydrocortisone <400 mg/day
2. Duration: At least 3 days at full dose
3. Administration method: Continuous infusion (preferred over boluses) 2
4. Tapering: Gradually taper when vasopressors are no longer required 1, 2

For COPD Exacerbations:

1. Dose: 100 mg hydrocortisone IV (if oral route not possible)
2. Duration: 7-14 days of treatment
3. Discontinuation: After the acute episode unless proven effective during clinical stability 1

Monitoring and Precautions

• Monitor for common adverse effects:
  • Hyperglycemia (most common)
  • Hypernatremia 1
• No increased risk of secondary infections with low-dose, short-term use 1
• Monitor patients closely after discontinuing corticosteroids for rebound effects 2
• Consider restarting therapy if patients deteriorate after stopping (e.g., development of shock) 2

Clinical Pearls and Pitfalls

• Pitfall: Using hydrocortisone in sepsis without shock - this provides no benefit and may cause harm 1
• Pitfall: Abrupt discontinuation of hydrocortisone - this may lead to hemodynamic and immunologic rebound effects 2
• Pearl: Low-dose, longer duration therapy (≥3 days) is more effective than high-dose, short-course therapy in septic shock 1
• Pearl: The ACTH stimulation test is not recommended to identify which septic shock patients should receive hydrocortisone 1

In conclusion, while hydrocortisone has specific indications for breathlessness in septic shock and COPD exacerbations, its use should be limited to these scenarios with appropriate dosing and duration to maximize benefit while minimizing adverse effects.