From the Guidelines
A 5-day oral corticosteroid course is reasonable for a patient with possible asthma/COPD who is admitted for pneumonia and unable to wean off oxygen when there are clinical signs of airway obstruction. Prednisone 40mg daily for 5 days is a typical regimen, as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document 1. Before starting steroids, ensure the patient has received appropriate antibiotics for pneumonia for at least 48-72 hours, and that other causes of oxygen dependence (like heart failure or pulmonary embolism) have been considered. Steroids can help reduce airway inflammation and bronchospasm that may be contributing to hypoxemia, especially in patients with underlying obstructive lung disease, by decreasing inflammatory cytokines and reducing airway edema, potentially improving air flow and gas exchange 1. Some studies suggest that patients with an elevated blood eosinophil count may respond better to oral corticosteroids than those with a low blood eosinophil count 1. However, the current evidence supports the use of a 5-day oral corticosteroid course in patients with COPD exacerbations, as it shortens recovery time, improves lung function, and may reduce the risk of early relapse, treatment failure, and length of hospital stay 1. Monitor for improvement in oxygenation, respiratory symptoms, and potential side effects like hyperglycemia. If the patient responds well, this may suggest an underlying obstructive component that warrants further evaluation and possibly maintenance therapy after discharge. Key considerations include:
- Clinical signs of airway obstruction, such as wheezing, prolonged expiration, or decreased air entry
- Receipt of appropriate antibiotics for pneumonia for at least 48-72 hours
- Ruling out other causes of oxygen dependence
- Monitoring for improvement in oxygenation, respiratory symptoms, and potential side effects
- Potential for further evaluation and maintenance therapy after discharge if the patient responds well to steroids.
From the Research
Trial of 5-Day Oral Corticosteroid Course
When considering a patient with possible asthma/Chronic Obstructive Pulmonary Disease (COPD) history admitted for pneumonia who is unable to wean off supplemental oxygen to room air, the decision to trial a 5-day oral corticosteroid (steroid) course can be informed by several studies:
- A study published in 2013 2 found that in patients with acute exacerbations of COPD, a 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment regarding reexacerbation within 6 months of follow-up, significantly reducing glucocorticoid exposure.
- Another study from 2016 3 discussed the management of COPD, suggesting that treatment should be adapted to symptoms and the frequency of exacerbations, but did not specifically address the duration of oral corticosteroid treatment in the context of pneumonia.
- Research on asthma exacerbations, such as a 2016 Cochrane review 4, found no convincing evidence of differences in outcomes between higher doses or longer courses and lower doses or shorter courses of oral steroids, though the evidence was not strong enough to make definitive recommendations.
- An umbrella review from 2009 5 on corticosteroid therapy for adults with acute asthma suggested that a nontapered 5- to 10-day course of corticosteroid therapy seems sufficient for most discharged patients, and combinations of oral and inhaled corticosteroids might minimize the risk of relapse.
- The risk of pneumonia in patients on inhaled corticosteroids was discussed in a 2015 review 6, highlighting an association between chronic use of inhaled corticosteroids and an increased risk of developing pneumonia, though the effect on mortality was unclear.
Key Considerations
- The decision to use a 5-day oral corticosteroid course should consider the patient's specific condition, including the severity of pneumonia and the presence of asthma or COPD.
- The potential benefits of reducing the duration of corticosteroid treatment, such as minimizing exposure to steroids and their potential side effects, should be weighed against the risk of exacerbating the underlying condition.
- Monitoring the patient's response to the treatment and adjusting the duration or dose of corticosteroids as necessary is crucial.
- The evidence from studies on COPD and asthma may inform but not directly dictate the management of a patient with pneumonia, as the context and specific patient needs can differ significantly.