Tapering steroids copd

Great study. While disappointing not to have a mortality benefit, the secondary outcomes are of clinical significance and are likely to increase the use of hydrocortisone in our ICU. At the moment we use bolus dosing, which has been shownpreviously to be non-inferior to continuous infusions, but with more hyperglycaemia and less need for additional lines (Hoang H, Wang S, Islam S, Hanna A, Axelrad A, Brathwaite C. Evaluation of hydrocortisone continuous infusion versus intermittent boluses in resolution of septic shock. P T. 2017; 42 (4): 252-255.). We tend to initiate hydrocortisone once noradrenaline infusion rate goes beyond 10mcg/min and we have variation in practice in terms of tapering or stopping hydrocortisone once vasopressor support is off. The timing of hydrocortisone initiation would be an interesting future study to guide practice.

Narrative: Chronic obstructive pulmonary disease (COPD), a term that encompasses both patients diagnosed with chronic bronchitis and emphysema, is an obstructive lung disease in many cases caused by years of tobacco smoking. It is thought that patients with COPD ‘exacerbation’ (increased shortness of breath or change in their chronic cough and sputum) may benefit from steroids, presumably by reducing the inflammatory response that accompanies the exacerbation.

Benefits: 10 studies contributed data for this Cochrane analysis, representing 1051 patients. There was no statistically significant difference in the mortality of subjects who received systemic steroids compared to placebo. In regards to treatment failure, the review found a NNT of 10 (% reduction). Interestingly, no benefit was found in analysis of studies with steroids for less than 72 hours. The reductions in treatment failure were recorded from studies including both admitted and outpatient/Emergency Department patients.

Harms: Corticosteroids can cause multiple side effects, and some studies evaluated harms, though this was inconsistent across studies. When harms were pooled, there was an absolute risk increase of % for patients receiving steroids (NNH = 7) though this includes some harms that are not patient-oriented (high blood sugars) as well as some that are patient-oriented (diarrhea).

Normally the adrenal glands release cortisol into the blood stream every morning. The brain monitors this amount and regulates the adrenal function. It cannot tell the difference between its own natural cortisone and that of steroid medicines. Therefore, when a person takes high doses of steroids over a long time, the brain may decrease or stop cortisol production. This is called adrenal suppression. Healthcare providers generally decrease a steroid dosage slowly to allow the adrenal gland to recover and produce cortisol at a normal level again. If you have been on steroids long-term do not stop taking them suddenly. Follow your doctor's prescription.

This confusing situation happens often, even when the rescue and maintenance inhalers are of different color. The root problem is lack of standardization among inhalers, with unclear labeling to distinguish between rescue and maintenance inhalers. A contributing cause is lack of proper education for both the caregivers and their patients . All too often proper instructions were not given when the drug was first prescribed. And even when they are provided, patients sometimes don't really understand, or they forget. Either way, having similar inhalers for different purposes is an invitation to error. (This was less likely to be a problem when the drug was studied by the drug companies; see YELLOW BOX above, under 'DPI Type 2'.) The problem is compounded when patients are on multiple inhalers, eg, Proventil for rescue, Advair and Spiriva for maintenance. That's 3 separate devices with two different purposes -- easy for the patient to get confused. (Pills and capsules come in many colors and sizes, but they are all swallowed the same way.) What's needed is a universal delivery device for all inhalers, with perhaps just two colors: red for rescue drugs and green for maintenance drugs. Anyone with clinical interest in the inhaler problems discussed above (Errors 1 & 2) should definitely read Problems With Inhaler Use: A Call for Improved Clinician and Patient Education , by James B. Fink and Bruck K. Rubin (Respiratory Care, Sept 2005, Vol 50, No. 10, pages 1360-75). 3. Not checking some objective measurement of the patient's air flow obstruction. Every patient should have a breathing test to ascertain the degree of impairment caused by the asthma. The most frequently performed test is 'spirometry', which takes just a few minutes and requires the patient to exhale forcefully thru a testing device (shown below).
A patient performing the spirometry test


Graphs from a normal spirometry test; left panel, graph of flow vs. volume; right panel, graph of time vs. volume.

People who cause deliberate harm to others under the guise of “helping” are the worst psychopaths of all. It’s getting harder every day not to conclude that the entire medical industry doesn’t suffer from Munchausen Syndrome By Proxy. The difference is that we just regular people are in fact experiencing health problems, but the medical industry cares less about solving that than their MBAs coming up with a good bottom line, and individuals having lucrative careers pushing pills and trying to keep medicine in the 20th or 19th centuries. This includes the “medical advertising” industry, which in my opinion should have every one of its members taken out and dosed with prednisone and oxycodone till they plotz.

Tapering steroids copd

tapering steroids copd

This confusing situation happens often, even when the rescue and maintenance inhalers are of different color. The root problem is lack of standardization among inhalers, with unclear labeling to distinguish between rescue and maintenance inhalers. A contributing cause is lack of proper education for both the caregivers and their patients . All too often proper instructions were not given when the drug was first prescribed. And even when they are provided, patients sometimes don't really understand, or they forget. Either way, having similar inhalers for different purposes is an invitation to error. (This was less likely to be a problem when the drug was studied by the drug companies; see YELLOW BOX above, under 'DPI Type 2'.) The problem is compounded when patients are on multiple inhalers, eg, Proventil for rescue, Advair and Spiriva for maintenance. That's 3 separate devices with two different purposes -- easy for the patient to get confused. (Pills and capsules come in many colors and sizes, but they are all swallowed the same way.) What's needed is a universal delivery device for all inhalers, with perhaps just two colors: red for rescue drugs and green for maintenance drugs. Anyone with clinical interest in the inhaler problems discussed above (Errors 1 & 2) should definitely read Problems With Inhaler Use: A Call for Improved Clinician and Patient Education , by James B. Fink and Bruck K. Rubin (Respiratory Care, Sept 2005, Vol 50, No. 10, pages 1360-75). 3. Not checking some objective measurement of the patient's air flow obstruction. Every patient should have a breathing test to ascertain the degree of impairment caused by the asthma. The most frequently performed test is 'spirometry', which takes just a few minutes and requires the patient to exhale forcefully thru a testing device (shown below).
A patient performing the spirometry test


Graphs from a normal spirometry test; left panel, graph of flow vs. volume; right panel, graph of time vs. volume.

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