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 corticosteroids 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 methods
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) versus 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.

An update search conducted in September 2002 did not yield any further trials.

Authors' 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.

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Early emergency department treatment of acute asthma with systemic corticosteroids

Background Acute asthma is responsible for many emergency department visits annually. Between 12-16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation and this review examines the evidence for using systemic corticosteroids to improve outcomes after discharge from the ED. Objectives To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. Search strategy The Cochrane Airways Group "Asthma and Wheez* RCT" register was searched using the terms: a) Asthma OR Wheez* b) Glucocorticoid OR Steroid* AND c) Exacerbat* OR Relapse* OR Emerg*. In addition, authors of all included studies were contacted to determine if unpublished studies which met the inclusion criteria were available. Bibliographies from included studies, known reviews and texts were also searched for additional citations. Selection criteria Only randomized controlled trials were eligible for selection. Studies were included in this review if they dealt with the outpatient treatment of asthmatic exacerbations using glucocorticoids at discharge and reported either relapse rate or PFTs. Two independent reviewers first identified potentially relevant studies and then selected articles for inclusion. Methodological quality was assessed independently by two reviewers. Agreement was assessed using kappa (k) statistics. Data collection and analysis Data were extracted independently by two reviewers; authors were contacted to verify the extracted data and clarify missing information. When author contact was unsuccessful, missing data were estimated from graphs where possible. Sensitivity, sub-group and overall analyses were performed using the Cochrane Review Manager. Main results A search that yielded 229 references identified 169 (73%) original publications. Reviewers identified 8 studies for potential inclusion (k =0.76); 18 references were added by searching publication reference lists and contact with authors. Of these 26 articles, a total of 7 were included in the overview. Two studies used intramuscular corticosteroids, five studies used oral corticosteroids. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (odds ratio (OR) 0.35; 95% confidence interval (CI): 0.17, 0.73). This favourable effect was maintained over the first 21 days (OR 0.33; 95% CI: 0.13, 0.82). Patients receiving corticosteroids had less need for beta-agonists (weighted mean difference (WMD) -3.3 activations/day; 95% CI: -5.5, -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI: -0.47, 0.56) and side effects (SMD 0.03; 95% CI : -0.38, 0.44) in the first 7-10 days, while rarely reported, showed no differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. It appears that IM corticosteroids are similarly efficacious to a 7-10 day tapering course of oral agents. From these results, as few as 13 patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. Reviewer's conclusions A short course of corticosteroids following assessment for an acute exacerbation of asthma significantly reduces the number of relapses to additional care and decreases beta-agonist use without an apparent increase in side effects. Intramuscular corticosteroids appear as effective as oral agents.

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Corticosteroids for preventing relapse following acute exacerbations of 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%.

Acute Severe Asthma

Background. Recent studies have shown that the use of parenteral corticosteroids in the emergency department decreases the hospitalization rate for patients with acute asthma. We studied the efficacy of oral corticosteroids in the emergency department treatment of moderately ill children with acute asthma. Methods. Emergency department patients aged 1 through 17 years whose chief complaint was acute asthma were assigned a pulmonary index, based on clinical evaluation. Those with a moderate exacerbation (pulmonary index = 9 through 13) received either 2 mg/kg of oral prednisone or placebo in a randomized, double-blind fashion. Patients in each group were then treated with an identical regimen of frequent aerosolized albuterol, for up to a maximum of 4 hours. Results. Seventy-five patients were assessed. Overall, 11 (31%) of 36 in the prednisone group required hospitalization compared with 19 (49%) of 39 in the placebo group (P = .10). Among the sickest patients (initial pulmonary index > 10), 7 (32%) of 22 prednisone-treated patients required hospitalization compared with 13 (72%) of 18 placebo-treated patients (P Conclusions. These data demonstrate that oral prednisone, within 4 hours of its administration, reduced the need for hospitalization among a subset of children treated in the emergency department for acute asthma.

Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.

The objective of this study was to determine the effect of steroid therapy on pulmonary function, admission rates, and relapse rates in patients presenting with acute exacerbations of asthma. Computerized MEDLINE and SCIENCE CITATION searches were combined with review of reference lists from book chapters and articles to identify published randomized trials on steroid interventions. Over 700 articles were reviewed by two independent reviewers who identified 30 relevant randomized controlled trials for analysis. Study validity was independently assessed by two reviewers and information regarding populations, interventions, and outcomes was abstracted. Binary outcomes were combined and reported as odds ratios (OR), using the Mantel-Haenszel method. Individual and pooled effect sizes (ES) were determined for pulmonary function data. The authors found that the use of steroids early in the treatment of asthmatic exacerbations reduces admissions in adults (common OR 0.47; 95% confidence interval (CI) 0.27, 0.79) and children (OR 0.06-0.42). They found steroids effective in preventing relapse in the outpatient treatment of asthmatic exacerbations (OR 0.15; CI 0.05, 0.44). Oral and intravenous steroids appear to have equivalent effects on pulmonary function in acute exacerbations (ES -0.07; CI -0.39, 0.25). The authors conclude that overall, steroid therapy provides important benefits to patients presenting to emergency departments with acute exacerbations of asthma. Further research into dosage, alternative routes of administration, and alternative outcome measures is needed.

Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis.

Twenty-eight children with persistent bronchospasm after outpatient therapy were treated for eight days with methylprednisolone or placebo in a prerandomized double-blind manner, in addition to treatment with optimal oral bronchodilators. At follow-up visits 1, 7, and 14 days after onset of therapy, a history was taken and physical examination and pulmonary function tests were performed. Initially and on the 14th day, patients underwent cosyntropin tests of adrenal function. Patients kept daily peak flow charts. Both groups improved with time. However, by 24 hours after starting methylprednisolone therapy, the placebo group continued to show reversibility after isoproterenol inhalation whereas the methylprednisolone group did not. By day 7 there were significantly more patients with normal 1-second forced expiratory volume (FEV1) and forced expiratory flow in the middle half of the forced vital capacity (FEF25-75%) in the methylprednisolone group and mean FEF25-75% was significantly higher for this group (P less than .02). By day 14, six days after finishing treatment with the study drugs, more patients in the placebo group had residual wheezing, but pulmonary function tests were now similar for the two groups. Although both groups showed a decline in cosyntropin responsiveness on day 14 compared with day 1, there was no difference between the steroid- and placebo-treated patients. This study proves that short-term corticosteroid therapy will accelerate resolution of moderately severe and severe-acute attacks of asthma without significant suppression of adrenal function.

Double-blind evaluation of methylprednisolone versus placebo for acute asthma episodes.

Summary
Acute severe asthma in children should be managed by immediate attention to the patient's clinical condition. Careful observation, the use of sequential pulmonary function tests and appropriate blood gas studies will facilitate evaluation of severity. Therapy should be directed at the reversal and7sol;or correction of these abnormalities as well as anticipation of early treatment of potential complications. By the aggressive management of this condition, the incidence of complications can be reduced, the length of hospital stay shortened and substantial morbidity and possible mortality minimized.

Gail G. Shapiro

Papers

Double-blind evaluation of methylprednisolone versus placebo for acute asthma episodes.

Treatment of acute asthma in children.