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Dex Admin with Pneumonia

Question# 739

For patients with bronchoconstriction not believed to be due to asthma/COPD/20 pack year smoking history (ie suspected pneumonia), but who still meet the protocol for dexamethasone, is administration of dexamethasone beneficial or recommended?

Answer:

Thank you for your question and considering additional uses for medications in your formulary to ultimately advocate for your patients!

As you’re aware, dexamethasone, is a synthetic glucocorticoid hormone. It is a man-made version of the hormone cortisol, which is naturally produced by the adrenal glands in the body. Glucocorticoids like dexamethasone are involved in the regulation of a wide range of physiological processes, including metabolism, immune response, and the body's response to stress. They are also used therapeutically as anti-inflammatory and immunosuppressive agents to treat a variety of conditions. Thus, you present a reasonable question.

Community-acquired pneumonia (CAP) is a common and potentially serious illness, that’s associated with considerable morbidity and mortality – especially in the elderly patient or those with major comorbidities. This is not a disease to take lightly, thus treatment is important.

To properly treat this pathology, we must make an accurate diagnosis. Prehospitally, we can have an index of suspicion in the patient presenting with fever, dyspnea, cough, and sputum production, but ultimately, these are non-specific clinical features, and the final diagnosis needs to be confirmed with imaging. This will ultimately guide the treatment with empiric antibiotics.

It’s important to understand that it is rare for a patient with COPD/Asthma/20 pack years of smoking to have bronchoconstriction from an infectious cause like pneumonia and NOT have a component of asthma/COPD in play. Infections are the number one trigger of asthma/COPD. Therefore, any patient with suspicion of pneumonia, bronchoconstriction AND a history of COPD/Asthma/Heavy smoking should be treated with Dexamethasone.

There’s a limited role for glucocorticoids for CAP in the outpatient setting. Thus, for this patient population, prehospital care should focus on supportive care. As with all medications we administer, we need to weigh the risks/benefits, and in this population, the potential risks outweigh the potential benefits.

Depending on the severity, there may be a role a role to administer a glucocorticoid in a patient experiencing a COPD exacerbation as well. It’s important to keep in mind however that the use of the corticosteroid is for the COPD exacerbation, not the CAP.

While this is outside the scope of your question, there may be a role in using glucocorticoids for select critically ill patients (i.e. patients with impending respiratory failure or those requiring mechanical ventilation) as the rationale for use is to reduce the inflammatory response to pneumonia, which may in turn reduce progression to lung injury, ARDS, and mortality; but the studies showing this were hospitalized patients receiving hydrocortisone IV, and these results cannot be extrapolated to prehospital patients and dexamethasone.

In this scenario, we’d encourage you to engage with the BHPs – they’d be happy to help support you navigate this complex patient presentation.

References

UpToDate:
- Drug Monograph
- Treatment of community-acquired pneumonia in adults in the outpatient setting
- Major adverse effects of systemic glucocorticoids
- Treatment of community-acquired pneumonia in adults who require hospitalization
- COPD exacerbations: Management

Published

07 November 2023

ALSPCS Version

5.2

Views

395

Please reference the MOST RECENT ALS PCS for updates and changes to these directives.