A controlled trial of methylprednisolone in the early emergency department treatment of acute asthma in children

Management of Wheezy Preschoolers in the Emergency Department: A Discrete Choice Experiment

OBJECTIVES

This study aimed to elicit pediatric emergency physician's treatment choices for preschool-aged children with wheeze, determine the characteristics of the presenting child that influence treatment choices, and determine whether there is clinical equipoise by eliciting physician willingness to enroll these children in a placebo-controlled trial of corticosteroids.

METHODS

Discrete choice experiments varying the characteristics of the presenting child were designed to elicit Canadian emergency physician's treatment choices, both in the emergency department (ED) and at discharge, for young children presenting with wheeze and their willingness to enroll in a randomized controlled trial (RCT).

RESULTS

Most physicians chose to treat children with albuterol both in the ED and at discharge for all clinical scenarios. The proportion of physicians who chose to treat children with oral corticosteroids both in the ED and at discharge varied widely (from 12% to 81%) across all scenarios. Physician preference whether preschool children with wheeze should be treated with corticosteroids varied depending on the child's age, history of atopy, and previous and continuous wheeze. Between 73% and 86% of physicians were willing to enroll these children in an RCT indicating clinical equipoise.

CONCLUSIONS

Physician treatment choices varied widely indicating clinical equipoise as to the effectiveness of corticosteroids in this population of patients. Management choices with respect to albuterol and corticosteroids were not consistent with published national and international guidelines. In line with this finding, physician's considerable willingness to enroll these children in an RCT may suggest that they are seeking guidance on how to manage these patients.

Asthma in the Preschool Age Child

Wheeze in preschool children (5 years of age and younger) is common. The majority of severe episodes are triggered by viral colds. Unlike atopic asthma in adults and young people, the underlying pathology of this condition is poorly understood, and the label of “preschool wheeze” should therefore not be regarded as a diagnosis but a description of symptoms. It is important to consider other causes of wheeze, but, for the most part, serious conditions such as cystic fibrosis and foreign body aspiration are associated with atypical features on careful history and examination. There remain significant uncertainties about the optimal management of children with this condition. Short-acting bronchodilators are indicated for the acute treatment of wheeze, and current evidence suggests that daily inhaled corticosteroid therapy is an effective preventive therapy, at least in a subgroup of children. Some trials suggest that preemptive therapy with inhaled corticosteroids may be as effective as regular inhaled corticosteroids. Since wheeze is intermittent for the majority of children, preemptive therapy is a logical approach. However, more studies are needed to confirm whether preemptive inhaled corticosteroids are as, or more, effective than regular preventer therapy.

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

BACKGROUND

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

OBJECTIVES

To determine the benefit of ICS for the treatment of patients with acute asthma managed in the emergency department (ED).

SEARCH METHODS

We identified controlled clinical trials from the Cochrane Airways Group specialised register of controlled trials. Bibliographies from included studies, known reviews, and texts also were searched. The latest search was September 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs. Studies were included if patients presented to the ED or its equivalent with acute asthma, and were treated with ICS or placebo, in addition to standard therapy. Two review authors independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two review authors. There were three different types of studies that were included in this review: 1) studies comparing ICS vs. placebo, with no systemic corticosteroids given to either treatment group, 2) studies comparing ICS vs. placebo, with systemic corticosteroids given to both treatment groups, and 3) studies comparing ICS alone versus systemic corticosteroids. For the analysis, the first two types of studies were included as separate subgroups in the primary analysis (ICS vs. placebo), while the third type of study was included in the secondary analysis (ICS vs. systemic corticosteroid).

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors 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. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) with 95% confidence intervals (CIs). Where appropriate, individual and pooled continuous outcomes were reported as mean differences (MD) or standardized mean differences (SMD) with 95% CIs. The primary analysis employed a fixed-effect model and a random-effects model was used for sensitivity analysis. Heterogeneity is reported using I-squared (I(2)) statistics.

MAIN RESULTS

Twenty trials were selected for inclusion in the primary analysis (13 paediatric, seven adult), with a total number of 1403 patients. Patients treated with ICS were less likely to be admitted to hospital (OR 0.44; 95% CI 0.31 to 0.62; 12 studies; 960 patients) and heterogeneity (I(2) = 27%) was modest. This represents a reduction from 32 to 17 hospital admissions per 100 patients treated with ICS in comparison with placebo. Subgroup analysis of hospital admissions based on concomitant systemic corticosteroid use revealed that both subgroups indicated benefit from ICS in reducing hospital admissions (ICS and systemic corticosteroid versus systemic corticosteroid: OR 0.54; 95% CI 0.36 to 0.81; 5 studies; N = 433; ICS versus placebo: OR 0.27; 95% CI 0.14 to 0.52; 7 studies; N = 527). However, there was moderate heterogeneity in the subgroup using ICS in addition to systemic steroids (I(2) = 52%). Patients receiving ICS demonstrated small, significant improvements in peak expiratory flow (PEF: MD 7%; 95% CI 3% to 11%) and forced expiratory volume in one second (FEV(1): MD 6%; 95% CI 2% to 10%) at three to four hours post treatment). Only a small number of studies reported these outcomes such that they could be included in the meta-analysis and most of the studies in this comparison did not administer systemic corticosteroids to either treatment group. There was no evidence of significant adverse effects from ICS treatment with regard to tremor or nausea and vomiting. In the secondary analysis of studies comparing ICS alone versus systemic corticosteroid alone, heterogeneity among the studies complicated pooling of data or drawing reliable conclusions.

AUTHORS' CONCLUSIONS

ICS therapy reduces hospital admissions in patients with acute asthma who are not treated with oral or intravenous corticosteroids. They may also reduce admissions when they are used in addition to systemic corticosteroids; however, the most recent evidence is conflicting. There is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function or clinical scores when used in acute asthma in addition to systemic corticosteroids. Also, there is insufficient evidence that ICS therapy can be used in place of systemic corticosteroid therapy when treating acute asthma. Further research is needed to clarify the most appropriate drug dosage and delivery device, and to define which patients are most likely to benefit from ICS therapy. Use of similar measures and reporting methods of lung function, and a common, validated, clinical score would be helpful in future versions of this meta-analysis.

Acute severe asthma

Acute severe asthma remains a major economic and health burden. The natural history of acute decompensations is one of resolution and only about 0.4% of patients succumb overall. Mortality in medical intensive care units is higher but is less than 3% of hospital admissions. "Near-fatal" episodes may be more frequent, but precise figures are lacking. However, about 30% of medical intensive care unit admissions require intubation and mechanical ventilation with mortality of 8%. Morbidity and mortality increase with socioeconomic deprivation and ethnicity. Seventy to 80% of patients in emergency departments clear within 2 hours with standardized care. The relapse rate varies between 7 and 15%, depending on how aggressively the patient is treated. The airway obstruction in the 20-30% of people resistant to adrenergic agonists in the emergency department slowly reverses over 36-48 hours but requires intense treatment to do so. Current therapeutic options for this group consist of ipratropium and corticosteroids in combination with beta2 selective drugs. Even so, such regimens are not optimal and better approaches are needed. The long-term prognosis after a near-fatal episode is poor and mortality may approach 10%.

Rapid anti-secretory effects of glucocorticoids in human airway epithelium

Glucocorticoids are anti-inflammatory molecules classically described as acting through a genomic pathway. Similar to many steroid hormones, glucocorticoids also induce rapid non-genomic responses. The present paper provides a general overview of the rapid non-genomic effects of glucocorticoids in airway and will be mainly focused on a retrospective of the authors work on rapid effects of glucocorticoids in airway epithelial cell transport. Using fluorescence microscopy, short circuit current measurements in human bronchial epithelial (16HBE14o(-)) cells, we reported rapid non-genomic effects of dexamethasone on cell signalling and ion transport. Dexamethasone (1 nM) rapidly stimulated Na(+)/H(+) exchanger activity and pH(i) regulation in 16HBE14o(-) cells. Dexamethasone also produced a rapid decrease of intracellular [Ca(2+)](i) to a new steady state concentration and inhibited the large and transient [Ca(2+)](i) increase induced by apical adenosine tri-phosphate (ATP). Dexamethasone also reduced by 1/3 the Ca(2+)-dependent Cl(-) secretion induced by apical ATP. The rapid effects of dexamethasone on intracellular pH and Ca(2+) were not affected by inhibitors of transcription, cycloheximide or by the classical glucocorticoid and mineralocorticoid receptors antagonists, RU486 and spironolactone, respectively. The rapid responses to glucocorticoid were reduced by the inhibitors of adenylated cyclase, cAMP-dependent protein kinase (PKA) and mitogen-activated protein kinase (ERK1/2). Our results demonstrate, that dexamethasone at low concentrations, rapidly regulates intracellular pH, Ca(2+) and PKA activity and inhibits Cl(-) secretion in human bronchial epithelial cells via a non-genomic mechanism which neither involve the classical glucocorticoid nor mineralocorticoid receptor.

Salbutamol and/or beclomethasone diproprionate in asthma

OBJECTIVE

Acute severe exacerbation of asthma is potentially life threatening and requires critical assessment and appropriate therapy. Now a days, steroids are often combined with bronchodilators for the treatment of bronchial asthma. Therefore, the present study was undertaken to compare effectiveness of beclomethasone diproprionate-salbutamol combination versus salbutamol alone by MDI (with or without spacer) in acute asthma.

METHODS

A total of 57 paediatric patients (5-12 years) with acute attack of bronchial asthma attending emergency department of Indira Gandhi Medical College and Hospital was randomised to receive salbutamol (100 microg/puff) alone or with BDP (50 microg/puff) by metered dose inhaler with or without spacer. All baseline investigations were repeated one hour after the therapy.

RESULTS

Clinical parameters indicative of severity of asthma improved statistically in all treatment groups. The increase in PEFR was better with MDI-S+B with spacer as compared to other groups, though it failed to reach statistical significance. The fall in serum potassium level is significantly more with MDI-S+B group when spacer was not used. No serious adverse effects were observed in any of the treatment groups.

CONCLUSIONS

Metered dose inhalation of BDP-salbutamol combination with spacer provides better recovery whereas fall in serum potassium with MDI-S+B suggests use of spacer and monitoring of serum potassium during treatment.

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

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.

Early emergency department treatment of acute asthma with systemic corticosteroids

BACKGROUND

The airway edema and secretions associated with acute asthma are most effectively treated with anti-inflammatories such as corticosteroids delivered by inhaled, oral, intravenous or intra-muscular routes. There is an unresolved debate about the use of systemic corticorticoids in the early treatment of acute asthma for emergency department patients.

OBJECTIVES

To determine the benefit of treating patients with acute asthma with systemic corticosteroids within an hour of presenting to the emergency department (ED).

SEARCH STRATEGY

Randomised controlled trials were identified from the Cochrane Airways Group Asthma Register. Primary authors and content experts were contacted to identify eligible studies. Bibliographies from included studies and known reviews were searched.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) or quasi-randomised trials were eligible for inclusion. Studies were included if patients presenting to the ED with acute asthma were treated with IV/IM or oral corticosteroids (CS) vs. placebo within 1 hour of arrival and either admission rate or pulmonary function results were reported.

DATA COLLECTION AND ANALYSIS

Trial selection, data extraction and quality assessment were carried out independently by two reviewers, and confirmed with corresponding authors.

MAIN RESULTS

Twelve studies involving 863 patients (435 corticosteroids; 428 placebo) were included. Early use of CS for acute asthma in the ED significantly reduced admission rates (N = 11; pooled OR: 0.40, 95% CI: 0.21 to 0.78). This would correspond with a number needed to treat of 8 (95% CI: 5 to 21). This benefit was more pronounced for those not receiving systemic CS prior to ED presentation (N = 7; OR: 0.37, 95% CI: 0.19 to 0.70) and those with more severe asthma (N = 7; OR: 0.35, 95% CI: 0.21 to 0. 59). Oral CS therapy in children was particularly effective (N = 3; OR: 0.24, 95% CI: 0.11 to 0.53); no trials in adults used the oral route. Side effects were not significantly different between corticosteroid treatments and placebo.

REVIEWER'S CONCLUSIONS

Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids. Children appear to respond well to oral steroids.

Early parenteral corticosteroid administration in acute asthma

To test the hypothesis that early parenteral corticosteroid administration may be associated with a rapid improvement in airflow obstruction in adult asthmatic patients, a randomized, double-blind placebo-controlled study was carried out. Forty-five adult asthmatic patients, with initial peak expiratory flow rates (PEFRs) of < 200 L/sec received an intravenous bolus of either 125 mg methylprednisolone (MP) or normal saline before any other emergency department treatments. This was immediately followed by 3 aerosol treatments of 2.5 mg of albuterol separated by 20-minute intervals. PEFRs and heart rates were measured over a 1-hour time frame. There was not a significantly higher rate of increase of PEFR in the MP group compared with the saline group. Similarly, the rate of increase in percent PEFR showed a trend to being higher in the saline group (P = .061). There was no significant difference in the proportion of hospitalizations and side effects between the two groups. Adjustment for other variables did not result in a model showing an enhanced PEFR improvement with MP treatment. This study does not support the concept that corticosteroid treatment effects are beneficial within the first hour after administration. Further studies of rapid-acting modalities to enhance bronchodilation are needed in treating acute asthmatics.

Intravenous versus oral corticosteroids in the management of acute asthma in children

STUDY OBJECTIVE

To determine whether oral corticosteroids are significantly better at preventing the need for hospital admission than i.v. corticosteroids in children with moderate to severe asthma exacerbation.

METHODS

We carried out a randomized, double-blind, controlled trial of patients in the emergency department of a tertiary urban children's hospital. Patients who presented to the ED with moderate to severe asthma (defined as forced expiratory volume in 1 second [FEV1] < 60% predicted for height in patients aged 7 to 18 years and as Pulmonary Index Score [PIS] between 6 and 11 for patients aged 18 months through 6 years). Patients were randomized to receive 2 mg/kg oral methylprednisolone or 2 mg/kg i.v. methylprednisolone 30 minutes after the initial treatment with nebulized albuterol. Each patient was otherwise treated with an identical regimen of frequent nebulized albuterol and i.v. theophylline for a total of 4 hours.

RESULTS

Forty-nine patients were enrolled. Four hours after treatment, both groups had similar respiratory rates, oxygen saturation, PISs, and FEV1 values. Eleven of 23 patients in the oral group (48%) and 13 of 26 patients in the i.v group (50%) were admitted to the hospital (P = .88). The 90% confidence interval for the 2% cifference in admission rate to the hospital (favoring oral methylprednisolone) ranged from 21% (favoring i.v. methylpredinisolone) to 25% (favoring oral methylprednisolone). Patients discharged home demonstrated greater improvement from baseline with regard to PIS and FEV1 than patients who were admitted. Two patients in each group failed to complete the standard treatment or returned to the hospital within 48 hours of ED discharge.

CONCLUSION

These data suggest that for children with moderate to severe asthma exacerbation, hospital admission rates are similar in children given oral methylprednisolone and those given i.v. methylprednisolone.