Question 18

College Answer

Syllabus topic/section: 2.1.5 Respiratory Intensive Care – L1.

Aim: To explore the evidence and use of corticosteroids in respiratory infections.

Discussion: Community Acquired Pneumonia (CAP) is one of the leading causes of death in Australia and most developed countries. Candidates who scored well answered specifically about the rationale and evidence for steroids in non-COVID CAP. Depth into the effects of steroid anti-inflammatory, immune modulating properties or link to how this could improve outcomes in respiratory function or other outcomes were rewarded. Candidates who explained their understanding of results of trials or meta-analysis (Blum et al, Torres et al, Meduri et al, CAPE-COD, Cochrane review) and explained reason for use in severe CAP vs non-severe CAP scored more marks. Candidates are advised to take a moment to read the question carefully and respond accurately (e.g. the question was very specific, but answers mostly related to the general use of steroids in critical illness). Specific mention of trial names or mentioning all the trials is not required to pass, however the candidate was rewarded if this information was given. Candidates about to sit their fellowship exam should have a fair understanding of the literature to justify their clinical practice

Marking rubric

Discussion

This has appeared before, as Question 5 from the first paper of 2016, and the candidates with knowledge of deep CICM lore would have been able to identify the level of depth expected. 

Rationale:

• Much of the organ system effects of pneumonia may be related to the inflammatory reaction
• Anti-inflammatory drugs like steroids may reduce the release of cytokines, thereby dampening the SIRS response
• Modulation of the pro-inflammatory response should lead to a more rapid resolution of clinical features
• Similar rationale in specific infections, where the evidence is strong:
  • dexamethasone for pneumococcal meningitis
  • PJP
  • COVID 
• Collateral benefit for any underlying COPD, asthma, organising pneumonia, and hidden adrenal suppression

Potential risks:  this appears to have been a section expecting generic steroid side effects. In the following list some effort was made to relate the risks to the pneumonia in question.

• Immunosuppression could give rise to worsening infection
• Metabolic side effects (eg. hyperglycaemia, hypernatremia, fluid retention) increase the burden and complexity of care and have known mortality disadvantages
• Adrenal suppression could delay discharge from the ICU because of persitsten haemodynamic instability
• CNS side effects (eg. delirium, psychosis) and musculoskeletal side effects (eg. myopathy) could delay weaning from ventilation
• There is an increased risk of GI bleeding
• Some forms of pneumonia are known to get worse with steroids, eg. Influenza where mortality is doubled (Rodrigo et al, 2015 ) and Aspergillus (Parody et al, 2009)

Evidence:

• Torres et al : compared methylprednisolone (n = 61) or placebo (n = 59) for 5 days.
  • Less treatment failure with steroids (13% vs 31%)
  • No difference in mortality
• 785 patients randomised to 50mg prednisolone or placebo
  • "Median time to clinical stability was shorter in the prednisone group" - 3.0 days vs. 4.4
  • Not specifically ICU patients - all CAP admissions were enrolled
• A 2015 meta-analysis including the above data suggested that the use of corticosteroids may reduce
  • mortality by 3%
  • need for mechanical ventilation by 5%
  • hospital stay by 1 day
• CAPE-COD trial (Dequin et al, 2023) gave the treatment group 200mg/day of hydrocortisone tapered over 8-14 days and found:
  • Reduced mortality (6.2% vs 11.9%)
  • Reduced intubation rate (18.0% vs 29.5%)
  • Reduced used of vasopressors (15.3% vs 25%)
  • The effect was most pronounced in the group of patients with the highest CRP (over 150 mg/L)