Asthma exacerbation: inhaled steroids given in the emergency department reduce admission to hospital

Clinical bottom line (level 1a)

  1. Patients attending an emergency department with acute asthma who received inhaled steroids compared with placebo are less likely to be admitted (NNT = 6 at hours) .
  2. The benefits of adding inhaled steroids to systemic steroids are unclear.
  3. Inhaled steroids alone are not clearly as effective as systemic steroids in reducing hospital admission.
Edmonds et al: Cochrane Library 2000; 4 : -
Expires October 2003

The study

Systematic review of all randomised or quasi-randomised controlled trials of
  • Patients: acute asthma managed in an emergency department (or equivalent)
  • Intervention: inhaled steroids and standard therapy compared with placebo and standard therapy
  • Outcome:

    Articles found in all languages using Cochrane Airways Register (derived from Medline, Embase, CINAHL and hand-searching of 20 respiratory journals), - September 2000 (search terms: detailed in text ) and and searching bibliographies from included studies, known reviews and texts. Respiratory conference abstracts were searched for the last 5 years, pharmaceutical companies, trialists and content experts were contacted to identify relevant articles.

    Selection criteria: by 2 independent reviewers - see above
    Appraisal criteria: by 2 independent reviewers using Jadad criteria
    Articles excluded if:

    7 RCTs found, 6 with available data (4 adult, 2 paediatric) involving 352 patients.
    No significant heterogeneity was found between the papers.

    The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NN T
    (95% CI)
    admission to hospital hours 41/153
    (26.8%)    		 0.33
    (0.17 to 0.64)     		6
    (5 to 13)
    inhaled steroids v. placebo: admission hours 24/103
    (23.3%)    		 0.24
    (0.09 to 0.62)     		6
    (5 to 13)
    inhaled + systemic steroids v. systemic steroids: admission hours 17/50
    (34.0%)    		 0.45
    (0.18 to 1.14)     		7
    (NNT = 4 to infinity;
    NNH = 33 to infinity)
    inhaled v. systemic steroids: admission hours 27/154
    (17.5%)    		 0.89
    (0.18 to 4.52)     		62
    (NNT = 3 to infinity;
    NNH = 7 to infinity)

    • Patients on inhaled steroids had small improvements in PEFR (weighted mean difference 8%: 95% CI: 3% to 13%) and FEV1 (weighted mean difference 5%: 95% 0.4% to 10%).

    Comments

    1. No significant difference in adverse effects was noted between the two groups
    2. The subgroup analysis assessing the addition of inhaled steroids to systemic steroids contained too few patients to exclude an important clinical effect.
    3. The subgroup analysis comparing inhaled and systemic steroids contained too few patients to exclude an important clinical difference.

    Citation

    1. Edmonds ML, Carnargo CA, Pollack CV, et al: early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Library 2000; 4 : -
    Search Terms: asthma in Cochrane Library
    Contributor: Chris Ball, October 2001
    Reviewer:

    Clinical Question.
    Patient
    Intervention or Exposure
    Outcome