Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease

doi:10.5847/wjem.j.1920-8642.2015.01.006

Abstract

Abstract:

BACKGROUND: This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insufficiency (CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
METHODS: Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit (ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group (n=32) and a control group (n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone (150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers of inflammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value <0.05 was considered statistically significant.
RESULTS: Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4%. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI (23.8% vs. 8.7%, P<0.01). Kaplan-Meier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group (P<0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group (18.2±9.5 vs. 25.8±4.1, P<0.05). Treatment with low-dose glucocorticoid obviously decreased the markers of infection and inflammation (P<0.01), such as C-reactive protein (13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α (26.1±16.2 μg/L vs. 17.5±11.7 μg/L for the control group; 25.0±14.8 μg/L vs. 10.4±7.8 μg/L for the treatment group) and procalcitonin (3.88 μg/L vs. 2.03 μg/L for the control group; 3.77 μg/L vs. 1.26 μg/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group (P<0.01).
CONCLUSION: The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers of infection and inflammation.

Key words: Chronic obstructive pulmonary disease, Acute exacerbation, Glucocorticoid, Critical illness, Corticosteroid insufficiency, Prevalence rate, Prognosis, Inflammation

Wei-ping Sun, Guang-xiong Yuan, Yan-juan Hu, Li-zhen Liao, Lin Fu. Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease[J]. World Journal of Emergency Medicine, 2015, 6(1): 34-39.

Figures/Tables 4

Table 1

Figure 1.

Table 2

Table 3

References 16

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Baseline data	Patients with CIRCI	Patients without CIRCI
Cases (male/female)	63 (50/13)	322 (255/67)
Age (year)	72.3±16.8^#	58.2±18.9
Shock incidence	23.8%^#	8.7%
PaO₂ (mmHg)	65.7±11.8^*	75.6±12.3
PaCO₂ (mmHg)	47.1±13.4	42.5±11.4
Base excess (mmol/L)	2.5 (-7.5, 8.6)	2.0 (-8.2, 7.9)
pH	7.43±0.18	7.40±0.21
APACHE II (scores)	17.0±4.8	14.3±4.0
CPIS (scores)	4.8±1.8	4.0±1.2
CAPS score (score)	29.8±7.8	25.5±6.5
CRP (mg/L)	13.4±5.3	12.1±4.5
IL-6 (μg/L)	13.6±7.2	14.5±9.1
TNF-α (μg/L)	25.3±15.7	23.1±14.0
PCT (μg/L)	3.85 (0.25, 8.3)	3.25 (0.18, 7.1)
White blood cells (×10⁹/L)	14.1±5.4	14.7±6.0
Platelet (×10⁹/L)	168±109	159±114
Lactic acid (mmol/L)	3.2 (1.3, 4.6)^*	2.5 (1.1, 4.0)

Parameters	Control group	Treatment group
Cases (male/female)	31 (25/6)	32 (25/7)
Age (years)	71.8±15.9	72.7±17.2
Prevalence baseline shock	7/31	8/32
28-day non-mechanical ventilation time (days)	18.3±6.2	20.5±5.1
28-day shock incidence	11/31	8/32
28-day non-shock time (days)	18.2±9.5	25.8±4.1^*
28-day duration of ICU stay (days)	12.8±6.1	10.5±5.3

Parameters	Control group		Treatment group
Parameters	Before	After	Before	After
PaO₂ (mmHg)	65.3±11.3	80.4±12.5^*	65.9±12.2	82.5±11.8^*
PaCO₂ (mmHg)	47.4±12.8	40.3±11.5^*	46.6±12.6	37.8±13.7^*
BE (mmol/L)	2.5 (-7.1, 8.5)	1.3 (-5.7, 6.8)	2.5 (-7.8, 8.8)	1.5 (-4.1, 6.5)
pH	7.44±0.20	7.39±0.12	7.43±0.17	7.40±0.15
APACHE II	16.7±4.5	12.3±3.2^*	17.2±4.7	10.1±2.9^*
CPIS score	4.8±1.9	3.1±0.8^*	4.6±1.8	3.0±1.2^*
CAPS score	30.1±6.7	20.3±5.4^*	29.2±7.0	22.0±5.8^*
WBC (×10⁹/L)	14.3±6.2	8.3±4.7^#	14.0±5.5	11.9±3.5
Platelet (×10⁹/L)	165±105	158±96	170±112	161±103
CRP (mg/L)	13.2±5.5	8.3±3.1^#	13.5±5.9	5.1±2.3^#Δ
IL-6 (μg/L)	13.7±7.5	11.4±5.6	13.1±6.9	8.3±3.2^#Δ
TNF-α (μg/L)	26.1±16.2	17.5±9.7^#	25.0±14.8	10.4±7.8^#▲
PCT (μg/L)	3.88 (0.25, 8.5)	2.03 (0.15, 5.1)^#	3.77 (0.21, 8.0)	1.26 (0.10, 3.2)^#▲
Lactic acid (mmol/L)	3.4 (1.2, 4.8)	2.8 (0.8, 3.6)	3.2 (1.0, 4.5)	2.7 (1.0, 4.6)

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