Réanimation

, Volume 23, Issue 1, pp 54–64 | Cite as

Corticothérapie systémique et antibiothérapie lors des exacerbations aiguës d’une bronchopneumopathie chronique obstructive nécessitant une assistance ventilatoire

  • I. Ouanes
  • Z. Hammouda
  • S. Ben Abdallah
  • F. Dachraoui
  • L. Ouanes-Besbes
  • F. Abroug
Mise au Point / Update

Résumé

L’histoire naturelle de la bronchopneumopathie chronique obstructive (BPCO) est marquée par les exacerbations aiguës (EABPCO) qui peuvent engager le pronostic vital et contribuent au fléchissement progressif de la fonction respiratoire et à la détérioration de la qualité de vie. La prise en charge des EABPCO sévères admises en réanimation repose sur l’assistance ventilatoire (principalement par ventilation non invasive), le traitement pharmacologique de l’obstruction bronchique et du facteur déclenchant. La corticothérapie systémique et l’antibiothérapie sont fréquemment prescrites dans cette situation, sur la base d’études réalisées principalement en dehors des services de réanimation. L’extrapolation de ces pratiques aux patients de réanimation pose des problèmes spécifiques (pression de sélection microbienne pour les antibiotiques ainsi que neuromyopathie et sepsis pour les corticoïdes). Dans cette mise au point, nous pesons le pour et le contre de ces prescriptions systématiques. Les résultats des rares études évaluant l’administration des corticoïdes spécifiquement chez les patients nécessitant l’assistance ventilatoire sont contradictoires en ce qui concerne les objectifs intermédiaires (durée de ventilation, de séjour...), sans démonstration d’un quelconque avantage sur des critères d’évaluation robustes comme la mortalité. Ces études s’accordent en revanche sur l’existence d’un risque élevé d’effets indésirables potentiellement graves. Quant à l’antibiothérapie, une seule étude en fournit le rationnel. Cette étude suggère que l’efficacité de l’antibiothérapie systématique provient de la prévention de la pneumopathie acquise sous ventilation mécanique. La plupart des patients ont, en effet, été intubés (d’emblée ou rapidement après l’inclusion) rendant hasardeuse l’extrapolation aux pratiques actuelles où la majorité des patients est ventilée de façon non invasive. Une antibiothérapie guidée (par les biomarqueurs comme la protéine C réactive et la procalcitonine) devrait supplanter la pratique de l’antibiothérapie systématique.

Mots clés

BPCO Exacerbation Corticoïde Antibiotique Ventilation Réanimation 

Systemic corticosteroid and antibiotic therapy during acute exacerbations of chronic obstructive pulmonary disease requiring ventilatory support

Abstract

Chronic obstructive pulmonary disease (COPD) is characterized by acute exacerbations (AECOPD) which can be life-threatening and contribute to the progressive decline of lung function and deterioration of quality of life.Management of severe AECOPD requiring intensive care unit (ICU) admission is usually based on ventilatory support (mainly by non-invasive ventilation), pharmacologic treatment of bronchial obstruction, and treatment of triggering agents. Systemic corticosteroids and antibiotics are frequently prescribed, based on trials that usually excluded patients requiring ventilatory support. Extrapolation of these trial results to patients requiring ventilator support is not straightforward given the burden of antibiotic resistance in the ICU and the specific adverse effects of corticosteroids in ICU patients including neuromyopathy and sepsis. Few studies have recently evaluated systemic corticosteroids in AECOPD patients requiring ventilatory support: they reached contradictory results regarding intermediate outcomes (ventilation duration, length of stay, and so on) or hard endpoints like ICU mortality. These studies have however consistently highlighted the high risk of developing potentially severe corticosteroids’ side effects. Only one study evaluated systematic antibiotic administration in AECOPD patients requiring ventilatory support. This study suggested that beneficial effects of antibiotics stem from an effect of selective digestive decontamination preventing ventilatory-associated pneumonia. The majority of patients included in that study had invasive mechanical ventilation either at admission or in the 6 h following mechanical ventilation, rendering hazardous any extrapolation to current ventilatory management of such patients who are usually ventilated non-invasively.

Keywords

COPD Exacerbation Corticosteroid Antibiotic Ventilation Intensive care unit 

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Copyright information

© Société de réanimation de langue française (SRLF) and Springer-Verlag France 2013

Authors and Affiliations

  • I. Ouanes
    • 1
    • 2
  • Z. Hammouda
    • 1
    • 2
  • S. Ben Abdallah
    • 1
    • 2
  • F. Dachraoui
    • 1
    • 2
  • L. Ouanes-Besbes
    • 1
    • 2
  • F. Abroug
    • 1
    • 2
  1. 1.Service de réanimation polyvalenteCHU F.-BourguibaMonastirTunisie
  2. 2.Laboratoire de recherche LR12SP15 « Recherche cardiopulmonaire en médecine intensive et toxicologie »Ministère de l’Enseignement Supérieur et de la Recherche ScientifiqueTunisTunisie

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