Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• The Role of Systemic Corticosteroids in COPD Exacerbations

  Acute exacerbations of chronic obstructive pulmonary disease (COPD) are periods of worsening breathlessness, cough, and sputum production that require additional treatment. Airway inflammation, bronchoconstriction, mucus production, and impaired gas exchange can combine to produce a clinically significant decline in respiratory function.

  Systemic corticosteroids are central to managing many moderate and severe exacerbations. Their value lies in reducing airway inflammation, improving airflow, shortening recovery, and lowering the risk of early relapse. However, they are not appropriate for every episode of increased respiratory symptoms, and their benefits must be balanced against adverse effects.

  Why exacerbations require anti-inflammatory treatment

  A COPD flare commonly involves increased inflammation throughout the bronchial tree. Neutrophilic inflammation, airway edema, and excessive mucus can narrow the airways and make routine bronchodilator therapy less effective. Corticosteroids influence several inflammatory pathways, helping restore airway function during the acute phase.

  Clinical benefit is usually reflected by improved dyspnea, better forced expiratory volume, and a reduced likelihood of treatment failure. Steroids may also shorten the duration of an exacerbation and help patients return to their baseline respiratory status sooner.

  The strongest indication is a moderate or severe exacerbation treated in an emergency department, hospital, or urgent outpatient setting. Mild symptom variation that responds to the patient’s usual inhaled medicines does not automatically require oral or intravenous corticosteroids.

  Selecting the dose, route, and duration

  For most adults, a short course of oral prednisone or an equivalent corticosteroid is preferred. A commonly recommended regimen is prednisone 40 mg once daily for five days, although local protocols and individual factors may influence the exact prescription. Longer courses generally add harm without improving outcomes.

  Oral treatment is usually as effective as intravenous therapy when the patient can swallow and absorb medication. Intravenous methylprednisolone may be considered when oral administration is impossible, gastrointestinal absorption is unreliable, or critical illness requires intensive care. Routine use of high-dose intravenous steroids is not supported simply because an exacerbation is severe.

  Patients should generally return to their regular inhaled COPD therapy after the acute course. A short course does not usually require tapering, but prolonged or repeated exposure may suppress the hypothalamic-pituitary-adrenal axis and should be reviewed carefully.

  Weighing benefits against adverse effects

  Even brief systemic corticosteroid treatment can cause hyperglycemia, fluid retention, insomnia, mood changes, dyspepsia, and elevated blood pressure. Repeated courses increase cumulative risks, including osteoporosis, cataracts, muscle weakness, infection, and adrenal suppression. These effects are especially relevant in older adults and people with diabetes or cardiovascular disease.

  Clinical assessment should therefore include the likely severity of the exacerbation, previous response to steroids, comorbidities, and the possibility of an alternative diagnosis. Pneumonia, pulmonary embolism, heart failure, pneumothorax, and acute coronary syndromes can mimic or accompany a COPD flare.

  Blood eosinophil counts may help identify patients more likely to benefit from corticosteroids in some settings, but they should not replace clinical judgment during an acute event. Evidence for biomarker-guided treatment is developing, and thresholds should be interpreted alongside symptoms, examination findings, and disease history.

  Matching treatment to clinical presentation

  Bronchodilators remain the immediate foundation of exacerbation care. Short-acting beta-2 agonists, with or without short-acting anticholinergics, relieve bronchoconstriction, while oxygen should be carefully titrated in patients at risk of hypercapnic respiratory failure. Antibiotics are considered when bacterial infection is suspected, particularly with increased sputum purulence and volume or when ventilatory support is required.

  Systemic steroids do not replace noninvasive ventilation, controlled oxygen therapy, antibiotics when indicated, or treatment of the underlying trigger. A complete management plan also includes assessment of inhaler technique, adherence, vaccination status, smoking exposure, and the need for pulmonary rehabilitation or maintenance therapy after recovery.

  Clinical situation	Usual corticosteroid approach	Key considerations
  Mild worsening managed at home	Often no systemic steroid	Continue prescribed rescue inhalers and seek assessment if symptoms progress
  Moderate exacerbation	Short oral course may be appropriate	Evaluate infection, oxygenation, comorbidities, and treatment response
  Severe exacerbation requiring hospital care	Oral corticosteroid when feasible	Combine with bronchodilators, controlled oxygen, and appropriate monitoring
  Unable to take oral medication	Intravenous equivalent may be used	Switch to oral therapy as soon as clinically practical
  Frequent recent steroid courses	Use only after careful review	Consider cumulative toxicity, alternative diagnoses, and prevention strategies

  Preventing repeated exposure

  Frequent exacerbations often indicate that the long-term COPD treatment plan needs reassessment. Before prescribing another course, clinicians should confirm that the patient is using the correct inhaler, receiving adequate maintenance bronchodilation, and taking inhaled corticosteroids only when clinically indicated. Continued tobacco exposure and untreated comorbidities can also drive recurrent symptoms.

  A written action plan can help patients recognize meaningful deterioration without encouraging unnecessary steroid use. It should explain when to increase rescue medication, when to contact a healthcare professional, and which warning signs require urgent care, such as severe breathlessness, confusion, cyanosis, chest pain, or inability to speak in full sentences.

  Practical recommendations for respiratory care

  • Use a short oral corticosteroid course for clinically significant exacerbations when the expected benefit outweighs individual risks.
  • Prefer oral therapy over intravenous administration when gastrointestinal absorption is intact.
  • Avoid extending treatment beyond the recommended short course without a clear clinical reason.
  • Monitor glucose, mental status, blood pressure, and infection risk in vulnerable patients.
  • Record every systemic steroid course and review prevention strategies after recovery.

  These steps support consistent care across emergency departments, respiratory wards, outpatient clinics, and conference-based clinical education programs. Clear documentation also helps teams identify patients with frequent exacerbations who may need specialist review.

  Make each treatment course count

  Systemic corticosteroids remain an effective component of COPD exacerbation management when used selectively, promptly, and for an appropriate duration. Their role is strongest within a broader strategy that addresses bronchodilation, oxygenation, infection, comorbid disease, and prevention of future flares.

  Respiratory professionals can apply this evidence by reviewing local protocols, discussing steroid stewardship within multidisciplinary teams, and incorporating individualized follow-up into every exacerbation pathway. Share these principles in clinical teaching and congress discussions to support safer, more consistent COPD care.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)