Asthma: acute exacerbation: steroids improved wheeze and FEV1.

Clinical bottom line (level 1b)

  1. Patients with acute severe asthma who received intravenous hydrocortisone compared with placebo were less wheezy (NNT = 1 at 24 hours) , and had a greater FEV1.
  2. There was no change in use of nebulisers.
Fanta et al: American Journal of Medicine 1983; 74: 845-851
Expires November 2002

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: university hospital, USA

20 patients (aged mean 31 years, 75% female) with an acute asthma exacerbation failing to respond to four hours of intensive bronchodilator therapy (isoproterenol or epinephrine every 20 minutes for first hour, then hourly)

Excluded if
  • aged <18 or >45
  • other complicating disease
  • currently on oral corticosteroids


    • Control Group: (n = 9, 9 analysed): saline placebo
    Experimental Group: (n = 11, 11 analysed): hydrocortisone 2 mg/kg iv bolus, followed by 0.5 mg/kg/hour for 24 hours
    All patients had four hours of further bronchodilator therapy plus iv aminophylline, and iv terbutaline. Patients were randomised after this, and continued to receive this medication.
    100% followed for 48 hours
    Outcome notes:
    • wheeze : on chest auscultation

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    wheeze 24 hours 9
    (100%)    		 3
    (27.7%)    		 73%
    (28% to 90%)    		 72.7%
    (46.4% to 99.1%)    		 1
    (1 to 2)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV1 at 24 hours (l/ min) 35
    (22)     		118
    (25)     		83
    (61 to 110)
    nebulisers after 24 hours 12.0
    (0.6)     		11.9
    (0.7)     		0.10
    (-0.52 to 0.72)

    Comments

    1. Steroids were given after eight hours of conventional therapy - a systematic review suggests this reduces effectiveness.
    2. Dose given was significantly greater than current practice (usually 20 to 40 mg prednisolone or its equivalent).

    Citation

    1. Fanta CH, Rossing TH, McFadden ER: glucocorticoids in acute asthma: a critical controlled trial. American Journal of Medicine 1983; 74: 845-851
    Search Terms: acute asthma in Cochrane
    Contributor: Chris Ball and Clare Wotton, Unknown Month 2000
    Reviewer: Mitsuhiro Kamei

    Clinical Question.
    Patient acute severe asthma
    Intervention or Exposure iv hydrocortisone
    Comparison placebo
    Outcome FEV1, wheeze, nebuliser use