© 2006 American Thoracic Society
Adrenal Insufficiency and Ventilator Weaning: Additional Study Is RequiredTo the Editor:While Huang and Lin advance the understanding of adrenal insufficiency (AI) with their recent article (1), certain aspects of their work deserve comment. The authors studied a narrow group of patients, the vast majority of which manifested pneumonia or sepsis as the etiology for respiratory failure. Arguably, the majority of enrolled patients might have been more appropriately assessed for AI or received corticosteroids earlier in their disease course (2, 3). Indeed, the salutary effects of corticosteroid administration on liberation from mechanical ventilation in the patient population studied by Huang and Lin have been suggested by prior publications (3, 4). In addition, the authors failed to report on whether etomidate was used to facilitate intubation in enrolled patients (1). Etomidate inhibits steroidogenesis, and in the critically ill this effect causes significant adrenocortical suppression, obscures the accurate identification and assessment of relative AI, and may deleteriously impact the stress response (5–7). Given the increasing appreciation of the incidence and significance of AI, in studies that examine adrenal function in mechanically ventilated patients, a detailed description of the drugs used for intubation and sedation should be mandatory. Development of failure to wean may represent a unique portion of the spectrum of AI pathophysiology distinct from that more readily identified by hemodynamic instability or altered immunologic response, and corticosteroid administration may improve weaning in particular patients. However, without more rigorous examination, specifics regarding the mechanism and frequency of such observations will remain speculative. Given the limitations of their study, Huang and Lin are premature in broadly recommending "evaluation of AI...for all patients before extubation."
Walter Reed Army Medical Center, Washington, DC FOOTNOTES (The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.) Conflict of Interest Statement: W.L.J. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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