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

M L Edmonds, C A Camargo, C V Pollack, B H Rowe
Cochrane Database of Systematic Reviews 2003, (3): CD002308

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

OBJECTIVES: To determine the benefit of inhaled corticosteroids 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 Review Group register. Bibliographies from included studies, known reviews, and texts also were searched. The search is considered updated to February of 2003.

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 inhaled corticosteroids 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: Eight trials were selected for inclusion, but data were not available for one of them. In the seven usable trials, (4 adult, 3 paediatric), a total of 376 patients were studied (191 with inhaled corticosteroids, 185 without). Patients treated with inhaled corticosteroids were less likely to be admitted to hospital (OR: 0.30; 95% CI: 0.16, 0.57). This benefit was evident in the subgroup of patients not receiving concomitant systemic steroids (OR 0.21; 95% CI: 0.08, 0.53). Patients receiving concomitant systemic steroids showed a similar, but non-significant, trend towards reduced admissions compared to placebo treatment (OR 0.45; 95% CI: 0.18, 1.12). Patients receiving inhaled corticosteroids 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 inhaled corticosteroids alone vs systemic steroids 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.

REVIEWER'S CONCLUSIONS: Inhaled steroids reduced admission rates in patients with acute asthma, but it is unclear if there is a benefit of inhaled corticosteroids when used in addition to systemic corticosteroids. There is insufficient evidence that inhaled corticosteroids result in clinically important changes in pulmonary function or clinical scores when used in acute asthma. Similarly, there is insufficient evidence that inhaled corticosteroids alone are as effective as systemic steroids. Further research is needed to clarify if there is a benefit of inhaled corticosteroids when used in addition to systemic steroids.

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