Chest
Volume 116, Issue 2, August 1999, Pages 285-295
Journal home page for Chest

Clinical Investigations
Asthma
Corticosteroids in the Emergency Department Therapy of Acute Adult Asthma: An Evidence-Based Evaluation

https://doi.org/10.1378/chest.116.2.285Get rights and content

Objective

To review the literature to determine the benefits of corticosteroids (CCSs) (oral, IM, IV, or inhaled) in the treatment of adult patients with acute asthma presenting at an acute-care setting.

Search strategy

A MEDLINE search was conducted using the following terms: (1) Asthma OR Wheez*, AND (2) Glucocorticoids OR Steroids, AND (3) Acute* OR Emerg. Other sources were the CURRENT CONTENTS database, review articles, reference sections of located studies, and a manual search of the top 15 journals for respiratory and emergency medicine.

Selection criteria

Patients were selected for the study by the following criteria: (1) English language; (2) adult patients with asthma whose acute exacerbations were the primary reason for assessment; (3) involvement in randomized, controlled trials conducted in an emergency care setting; (4) patients had participated in a study investigating a primary research question involving treatment with CCSs; and (5) outcomes based on results of pulmonary function tests and on hospital admission rates.

Results

At the 3-h assessment, only high doses of inhaled CCSs significantly improved pulmonary function compared with placebo (effect size [ES], 0.56; 95% confidence interval [CI], 0.15 to 0.97). On the other hand, after receiving IV CCSs, patients required at least 6 to 24 h to show moderate but nonsignificant improvements of pulmonary function (6-h ES, 0.44 [95% CI, −0.01 to 0.89]; 12-h ES, 0.54[95% CI, −0.08 to 1.17]; and 24-h ES, 0.53 [95% CI, −0.39 to 1.45]). The data from the six studies that we used to pool information on admission rate outcome showed a 32% reduction in favor of the use of IV CCSs (relative risk [RR], 0.68 [95% CI, 0.47 to 0.99]; number needed to treat, 12.5 [95% CI, 7.1 to 50]). However, the pooled effect of the three high-quality studies showed no difference between groups (RR, 1.21; 95% CI, 0.67 to 2.18). Oral CCSs provided a similarly beneficial effect on pulmonary function when compared with parenteral administration (ES, −0.14; 95% CI, −0.82 to 0.31. Finally, the results showed a nonsignificant favorable trend toward improved outcome with medium or high doses of CCSs.

Conclusions

This evidence-based evaluation suggests that the administration of parenteral CCSs to the patient on arrival at the emergency department (ED) neither improves airflow obstruction nor reduces the need for hospitalization. Parenteral CCSs probably require> 6 to 24 h to begin to act. Comprehensible conclusions about admission rates in the ED setting are difficult to make. At the 3-h assessment, only high doses of inhaled CCSs (in one study) significantly improved pulmonary function compared with placebo. IV and oral CCSs appear to have equivalent effects, and there is a tendency toward improvement in pulmonary function with medium or high doses.

Section snippets

Search Strategy

To identify all relevant studies, a computerized MEDLINE search was conducted. We searched for studies published in the English language for the years 1966 to October 1998. The following MeSH terms were used in the search: (1) Asthma OR Wheez*, AND (2) Glucocorticoids OR Steroids, AND3 Acute* OR Emerg. The apply limits were: (1) language, English; (2) target population, adults> 18 years old; and (3) publications type, clinical trials. Other sources of relevant articles were the CURRENT CONTENTS

Computerized Search

A total of 87 articles were identified in the initial search. Of these, 21 RCTs were selected for inclusion.2456828293031323334353637383940414243The κ-agreement was 0.81 for this assessment (very good agreement). Reasons for exclusion were the following: non-RCT (40/67, 60%); outpatient studies (12/67, 18%); nonoriginal data (12/67, 18%); and study involved children (3/67, 4%). Following validity assessment, two studies were excluded because they did not fit any of the categories for analysis.

Discussion

The purpose of this review was to perform an evidence-based evaluation of the effectiveness of CCS administration in the treatment of adult patients with acute exacerbations of asthma. This study met most of the methodological criteria that have been suggested as guidelines for scientific reviews,44 and all included trials were randomized and placebo controlled. In addition, this review has identified five trials published between 1994 and 1998, totaling 434 new subjects, that were not included

Conclusion

With reference to the early administration of CCSs in the ED treatment of adult patients with acute asthma, this evidence-based evaluation suggests the following: (1) parenteral administration probably requires > 6 to 24 h to improve pulmonary function in the patient (on the contrary, high doses of inhaled CCSs [one study]8 increase pulmonary function 1 to 3 h after therapy); (2) comprehensible conclusions about admission rates in the ED setting are difficult to make (overall, there is evidence

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