Early emergency department treatment of acute asthma with systemic corticosteroids

In an asthma attack, the airways (passages to the lungs) narrow from muscle spasms and swelling (inflammation). Bronchodilators (reliever inhalers to open up the lungs and airways) can be used for the spasms, and corticosteroids for the swelling. Corticosteroids can be inhaled, or taken by mouth (orally) or through a drip into the veins (intravenously). The review of trials found that systemic (oral or intravenous) corticosteroids reduce the need for people with asthma attacks to stay in hospital, with few adverse effects.

Authors' conclusions: 

Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids. Children appear to respond well to oral steroids.

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Background: 

The airway edema and secretions associated with acute asthma are most effectively treated with anti-inflammatories such as corticosteroids delivered by inhaled, oral, intravenous or intra-muscular routes. There is an unresolved debate about the use of systemic corticosteroids in the early treatment of acute asthma for emergency department patients.

Objectives: 

To determine the benefit of treating patients with acute asthma with systemic corticosteroids within an hour of presenting to the emergency department (ED).

Search strategy: 

Randomised controlled trials were identified from the Cochrane Airways Group Asthma Register. Primary authors and content experts were contacted to identify eligible studies. Bibliographies from included studies and known reviews were searched.

Selection criteria: 

Only randomised controlled trials (RCTs) or quasi-randomised trials were eligible for inclusion. Studies were included if patients presenting to the ED with acute asthma were treated with IV/IM or oral corticosteroids (CS) versus placebo within 1 hour of arrival and either admission rate or pulmonary function results were reported.

Data collection and analysis: 

Trial selection, data extraction and quality assessment were carried out independently by two reviewers, and confirmed with corresponding authors.

Main results: 

Twelve studies involving 863 patients (435 corticosteroids; 428 placebo) were included. Early use of CS for acute asthma in the ED significantly reduced admission rates (N = 11; pooled OR: 0.40, 95% CI: 0.21 to 0.78). This would correspond with a number needed to treat of 8 (95% CI: 5 to 21). This benefit was more pronounced for those not receiving systemic CS prior to ED presentation (N = 7; OR: 0.37, 95% CI: 0.19 to 0.70) and those with more severe asthma (N = 7; OR: 0.35, 95% CI: 0.21 to 0.59). Oral CS therapy in children was particularly effective (N = 3; OR: 0.24, 95% CI: 0.11 to 0.53); no trials in adults used the oral route. Side effects were not significantly different between corticosteroid treatments and placebo.

An update search conducted in September 2002 did not yield any further trials.

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