Context

The course of chronic obstructive pulmonary disease (COPD) is punctuated by episodes of exaggerated symptoms, termed ‘exacerbations’, that require additional treatment. Exacerbations are associated with significant morbidity, disease progression, mortality and high costs. The majority of exacerbations are associated with exaggeration of baseline airway inflammation induced by bacterial or viral infection. In addition, eosinophilic exacerbations have been reported. Enhanced inflammation at exacerbation provides rationale for treatment with anti-inflammatory agents, such as corticosteroids.

Systemic corticosteroids shorten recovery time, improve lung function, reduce treatment failure and length of hospital stay. However, they do not reduce mortality in exacerbations. Most guidelines advocate 10–14 days of systemic steroids, at a dose of about 40 mg/day. These recommendations are based …