Asthma: acute exacerbation: early steroids reduce admission.

Clinical bottom line (level 1a)

  1. Patients with acute asthma exacerbations who take steroids early in the emergency department are less likely to be admitted to hospital (NNT = 6 at 6 hours) .
  2. The best route or dose is unclear.
Rowe et al: American Journal of Emergency Medicine 1992; 10 (4): 301-310
Expires November 2002

The study

Systematic review of randomised trials of
  • Patients: acute asthma exacerbations
  • Intervention: parenteral or oral steroids
  • Outcome: hospitalisation rates, relapse rates, pulmonary function or quality of life


    • Articles found in all using MEDLINE and Science Citations Index, 1966 to 1991 (search terms: using 'asthma' and 'adrenal cortex hormones' as MeSH and text words ) and bibliographies were also searched, authors and experts contacted for unpublished studies or other relevant articles.

    Selection criteria: as above
    Appraisal criteria: Selected and appraised by 2 independent blinded reviewers using set criteria (detailed in text)
    Articles excluded if:

    30 studies were included.
    There was no significant heterogeneity found.

    The evidence

    early administration of steroids in the emergency department (5 studies)
    Outcome Time to outcome CER OR
    (95% CI)    		 NNT
    (95% CI)
    hospitalisation 6 hours /
    (40%)    		 0.47
    (0.27 to 0.79)     		6
    (4 to 18)

    • parenteral v. oral steroids (6 studies):
      • pooled effect size: -0.073 (95% CI: -0.39 to 0.25)
      • no significant differences noted in pulmonary function tests at 36 hours
    • dosage of steroids: high v. low (5 studies):
      • pooled effect size: 0.16 (95% CI: -0.17 to 0.49)
      • no significant differences noted between doses used

    Comments

    1. A swift intervention with high dosages of oral corticosteroids during 5 - 10 days should be promoted - but it is as important to promote that it is supported by pro-active treatment of asthma to prevent recurrence of episodes of severe shortness of breath. In the end the improved long term outcome of the patient will depend on the latter.

    Citation

    1. Rowe BH, Keller JL, Oxman AD: effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. American Journal of Emergency Medicine 1992; 10 (4): 301-310
    Contributor: Chris Ball and Clare Wotton, November 2000
    Reviewer: Chris van Weel

    Clinical Question.
    Patient asthma
    Intervention or Exposure steroids early in ED
    Outcome hospital admission