Early use of inhaled corticosteroids in the emergency department treatment of acute asthma.
BACKGROUND
Systemic corticosteroid therapy is central to the management of acute asthma The use of ICS may also be beneficial in this setting.


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


METHODS
Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews, and texts also were searched.


METHODS
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.


METHODS
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.


RESULTS
Seven trials were selected for inclusion, but data were not available for one of them. In the six usable trials, (4 adult, 2 paediatric), a total of 352 patients were studied (179 ICS, 173 non-ICS treated). Patients treated with ICS were less likely to be admitted to hospital (OR: 0.33; 95% CI: 0.17, 0.64). This benefit was confined to patients not receiving concomitant systemic steroids (CS). Patients receiving concomitant CS showed a similar, but non-significant, trend towards reduced admissions compared to placebo treatment (OR 0.45; 95% CI: 0.18, 1.14). Patients receiving ICS also demonstrated small, significant improvements in peak expiratory flows (PEFR WMD: 8%; 95% CI: 3, 13 %) and forced expiratory volumes (FEV1 WMD: 5%; 95% CI: 0.4, 10 %). The treatment was well tolerated, with few reported adverse side effects. A secondary analysis compared ICS alone vs CS alone; in the four trials included, there was significant heterogeneity between the study results for admission rates which precluded meaningful pooling of the study results.


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.
Division of Emergency Medicine, University of Alberta, 1G1 Walter Mackenzie Centre, 8440-112 Street, Edmonton, Alberta, CANADA, T6G 2B7. Brian.Rowe@ualberta.ca
M L
ML
Edmonds
C A
CA
Camargo
C V
CV
Pollack
B H
BH
Rowe
D000208:Acute Disease; D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000328:Adult; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage*; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D004636:Emergency Service, Hospital; D006801:Humans; D016032:Randomized Controlled Trials as Topic
D000305:Adrenal Cortex Hormones; D018927:Anti-Asthmatic Agents