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. 2000;2001(2):CD002178.
doi: 10.1002/14651858.CD002178.

Early emergency department treatment of acute asthma with systemic corticosteroids

B H Rowe  1 , C Spooner, F M Ducharme, J A Bretzlaff, G W Bota
Affiliations

Early emergency department treatment of acute asthma with systemic corticosteroids

B H Rowe et al. Cochrane Database Syst Rev. 2000.

Update in

Abstract

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 corticorticoids 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) vs. 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.

Reviewer's 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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Conflict of interest statement

The authors who have been involved in this review have done so without any known conflicts of interest. They are not involved with the primary studies. Dr. Rowe has received unrestricted educational grants for research from Astra, Janssen‐Ortho, Boehringer‐Ingelheim, Forest, Glaxo, Merck, and Sepracor. Dr. Ducharme has received support from Boehringer‐Ingelheim. However, none of the authors are considered paid consultants by any pharmaceutical company that produces CS agents.

Figures

1
1
Forest plot of comparison: 1 Any steroid (po, IM, IV, inhaled) vs placebo, outcome: 1.1 Admitted to hospital (all times).
1.1
1.1. Analysis
Comparison 1 Any steroid (po, IM, IV, inhaled) vs placebo, Outcome 1 Admitted to hospital (all times).
1.2
1.2. Analysis
Comparison 1 Any steroid (po, IM, IV, inhaled) vs placebo, Outcome 2 Admitted to hospital (1‐2 hours).
1.3
1.3. Analysis
Comparison 1 Any steroid (po, IM, IV, inhaled) vs placebo, Outcome 3 Admitted to hospital (3‐4 hours).
1.4
1.4. Analysis
Comparison 1 Any steroid (po, IM, IV, inhaled) vs placebo, Outcome 4 Admitted to hospital (5‐6 hours).
2.1
2.1. Analysis
Comparison 2 Route of administration (Admission), Outcome 1 IV vs placebo.
2.2
2.2. Analysis
Comparison 2 Route of administration (Admission), Outcome 2 Oral vs Placebo.
3.1
3.1. Analysis
Comparison 3 Chronic corticosteroid use prior to ED, Outcome 1 Excluded.
3.2
3.2. Analysis
Comparison 3 Chronic corticosteroid use prior to ED, Outcome 2 Mixed population.
4.1
4.1. Analysis
Comparison 4 Severity at Admission, Outcome 1 High Admit Rate ( Placebo Admission Rate > 40% ).
4.2
4.2. Analysis
Comparison 4 Severity at Admission, Outcome 2 Low Admit Rate (Placebo Admission Rate < 40%).
5.1
5.1. Analysis
Comparison 5 Quality Assessment (Admission), Outcome 1 High quality (Cochrane).
5.2
5.2. Analysis
Comparison 5 Quality Assessment (Admission), Outcome 2 Low quality (Cochrane).
6.1
6.1. Analysis
Comparison 6 Population, Outcome 1 Asthmatic Adults Only.
6.2
6.2. Analysis
Comparison 6 Population, Outcome 2 Asthmatic Children Only.
7.2
7.2. Analysis
Comparison 7 PEFR, Outcome 2 PEFR @ 60 minutes.
7.4
7.4. Analysis
Comparison 7 PEFR, Outcome 4 PEFR @ 120 minutes.
7.5
7.5. Analysis
Comparison 7 PEFR, Outcome 5 Final PEFR.
8.1
8.1. Analysis
Comparison 8 Adverse effects, Outcome 1 Nausea.
8.2
8.2. Analysis
Comparison 8 Adverse effects, Outcome 2 Tremor.
8.3
8.3. Analysis
Comparison 8 Adverse effects, Outcome 3 Headache.
9.1
9.1. Analysis
Comparison 9 Symptoms scores, Outcome 1 Initial Score.
9.2
9.2. Analysis
Comparison 9 Symptoms scores, Outcome 2 Final Score.
See this image and copyright information in PMC

References

References to studies included in this review

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