Early use of inhaled corticosteroids in the emergency department treatment of acute asthma

Edmonds M, Camargo CA, Pollack CV, Rowe BH

Published Online:

October 8, 2008

In an asthma attack, the airways (passages to the lungs) narrow from muscle spasm and swelling (inflammation). Corticosteroid drugs can be used to reduce the swelling. Corticosteroids can be inhaled, or taken by mouth (orally) or through a drip into the veins (intravenously). This review of trials found that inhaled corticosteroids help relieve asthma attacks, but there is not enough evidence of whether there is added benefit when corticosteroids are already being used orally or intravenously. More research is needed. As well, there is not enough evidence to compare the effects of using inhaled corticosteroids alone, instead of taking them orally or intravenously when arriving in hospital with an acute asthma attack.

Abstract (click to read)

Background:

Systemic corticosteroid therapy is central to the management of acute asthma. The use of ICS may also be beneficial in this setting.

Objectives:

To determine the benefit of ICS for the treatment of patients with acute asthma managed in the emergency department (ED).

Search strategy:

Randomised controlled trials (RCTs) were identified from the Cochrane Airways Group register. Bibliographies from included studies, known reviews, and texts also were searched. The search is considered updated to February of 2005.

Selection criteria:

Only RCTs or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma to the ED or its equivalent, and were treated with ICS or placebo, in addition to standard therapy. Two reviewers independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two reviewers.

Data collection and analysis:

Data were extracted independently by two reviewers if the authors were unable to verify the validity of extracted information. Missing data were obtained from the authors or calculated from other data presented in the paper.

Main results:

Ten trials were selected for inclusion. In the included trials, (5 adult, 5 paediatric), a total of 587 patients were studied (294 ICS, 293 non-ICS treated). Patients treated with ICS were less likely to be admitted to hospital (OR: 0.32; 95% CI: 0.18, 0.54). This benefit was evident in the subgroup of patients not receiving concomitant systemic steroids (CS) (OR 0.27; 95% CI: 0.14, 0.52). Patients receiving concomitant CS showed a similar, but non-significant, trend towards reduced admissions compared to placebo treatment (OR 0.45; 95% CI: 0.2, 1.1). Patients receiving ICS also demonstrated small, significant improvements in peak expiratory flows (PEFR WMD: 7%; 95% CI: 4, 11 %) and forced expiratory volumes (FEV1 WMD: 6%; 95% CI: 2, 10 %). The treatment was well tolerated, with few reported adverse side effects. A secondary analysis compared ICS alone vs CS alone; in the seven trials included, there was significant heterogeneity between the study results for admission rates which precluded meaningful pooling of the study results.

Authors' conclusions:

Inhaled steroids reduced admission rates in patients with acute asthma, but it is unclear if there is a benefit of ICS when used in addition to systemic corticosteroids. There is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function or clinical scores when used in acute asthma. Similarly, there is insufficient evidence that ICS alone is as effective as CS. Further research is needed to clarify if there is a benefit of ICS when used in addition to CS.

This record should be cited as:

Edmonds M, Camargo CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD002308. DOI: 10.1002/14651858.CD002308

Assessed as up to date:

September 13, 2005

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Primary Review Group:

Airways Group

Asthma topics:

Treating with Medications > Asthma Attacks > Steroids, inhaled

Health topics:

Lungs & airways > Asthma (acute) > Corticosteroids

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Early use of inhaled corticosteroids in the emergency department treatment of acute asthma

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