Asthma: exacerbation: steroids within 1 hour of attending an emergency department reduce hospital admissions

Clinical bottom line (level 1a)

  1. Patients with acute asthma attending an emergency department who recieve steroids within the first hour compared with placebo are less likely to be admitted (NN T = 6 at 6 hours) .
  2. The benefits of steroids are increased in patients not on steroids (NN T = 4 at 6 hours) , patients with severe asthma (NN T = 4 at 6 hours) and children (NN T = 4 at 6 hours) .
Rowe et al: Cochrane Library 2001; 1 : -
Expires October 2003

The study

Systematic review of all randomised or quasi-randomised trials of
  • Patients: adults or children aged > 2 years with acute asthma presenting to an emergency department
  • Intervention: systemic corticosteroids within an hour of presentation compared with placebo
  • Outcome: admission, pulmonary function

    Articles found in ?all languages using Cochrane Airways Group Asthma Register (derived from Medline, Embase, CINAHL and handsearching of 20 respiratory journals), - September 2000 (search terms: detailed in text ) and reviewing bibliographies of retrieved articles and known reviews. Primary authors and content experts were contacted to identify eligible studies.

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

    12 RCTs found involving 863 patients - 6 in aduts, and 5 in children
    Significant heterogeneity was found, so subgroup analysis was performed.

    The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NN T
    (95% CI)
    admission to hospital 6 hours 209/418
    (%)    		 0.50
    (0.31 to 0.81)     		6
    (4 to 19)
    no previous steroids: admission to hospital 6 hours 167/268
    (62.3%)    		 0.37
    (0.19 to 0.70)     		4
    (3 to 12)
    severe asthma: admission to hospital 6 hours 180/289
    (62.3%)    		 0.35
    (0.21 to 0.59)     		4
    (3 to 8)
    adults: admission to hospital 6 hours 78/220
    (36.5%)    		 0.58
    (0.32 to 1.07)     		9
    (NNT = 5 to infinity;
    NNH = 64 to infinity)
    children: admission to hospital 6 hours 130/199
    (65.3%)    		 0.40
    (0.17 to 0.94)     		4
    (2 to 71)

    Comments

    1. No studies in adults used the oral route.
    2. Adverse effects between the two groups were not clearly different.
    3. 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, Spooner C, Ducharme FM, et al: early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Library 2001; 1 : -
    Search Terms: asthma* in Cochrane Library
    Contributor: Chris Ball, October 2001
    Reviewer:

    Clinical Question.
    Patient
    Intervention or Exposure
    Outcome