Role of systemic corticosteroids in ventilated patients with chronic obstructive pulmonary disease exacerbation: a systematic review and meta-analysis

Abstract Purpose The recommendation regarding systemic corticosteroids in ventilated patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is unknown since most studies have excluded ventilated patients. Our study aims to investigate whether systemic steroids benefit the subgroup of AECOPD who require ventilation. Methods We systematically searched PubMed, Cochrane, and Embase databases for randomized trials or observational studies comparing systemic steroids to placebo or no systemic steroids, up to April 2025. Outcomes of interest were intensive care unit (ICU) mortality, length of ICU stay, duration of ventilation, non-invasive ventilation (NIV) failure rate, hyperglycemia episodes, and ventilator-associated pneumonia (VAP). Results Six studies including 1596 ventilated AECOPD patients (including subgroups from larger ICU populations), were included in the systematic review. Of these 1424 contributed to the quantitative synthesis of at least one outcome. We performed sensitivity analysis for study type and mode of ventilation. ICU mortality was not significantly decreased in the systemic steroid group compared to placebo or no systemic steroids (Odds ratio (OR) = 1.09; 95% CI 0.62–1.91; p = 0.78; I²=0.0%). There was no statistically significant difference between the groups for duration of ventilation (Mean difference (MD) = -2.24; 95% CI -5.13 to 0.66; p = 0.13; I²=78.7%). In the subgroup of randomized controlled trials (RCTs), systemic steroids were associated with a shorter duration of ventilation (MD = -1.12 days; 95% CI -2.23 to 0.00; p = 0.049; I² = 59.9%). There was no difference between groups for length of ICU stay (MD = -1.60; 95% CI -3.32 to 0.12; p = 0.068; I²=68.5%). There was no statistically significant difference between groups for NIV failure (Odds ratio (OR) = 1.17; 95% CI 0.83–1.67; p = 0.37; I²=58.1%). Hyperglycemia episodes were significantly higher in the steroid group (OR = 2.38; 95% CI 1.56 to 3.62; p < 0.001; I²=0.0%). There was no significant difference in rates of VAP (OR = 1.19; 95% CI 0.80–1.77; p = 0.38; I²=0.0%). Conclusion This meta-analysis suggests that critically ill AECOPD patients on ventilation may not derive a significant benefit from systemic steroids. Prospero protocol No CRD420251034592.