Corticosteroids in the treatment of acute asthmaAsthma is a chronic inflammatory disease, steroida is characterised by reversible airflow obstruction in response to a variety of stimuli. Exacerbations in response to airway irritants are part of the natural history of asthma, but often they also represent a failure in chronic treatment. Presentations to emergency departments and other acute care settings are iv steroids for acute asthma and frequently lead to hospitalisation and other complications. After treatment, however, most patients are discharged to the care of their primary care physician for further management. This review highlights the role of systemic and inhaled corticosteroids as mainstays of treatment in the acute and sub-acute phase of an exacerbation. These agents form the basis iv steroids for acute asthma most current clinical practice guidelines, yet their use is not universal.
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See related handout on how to treat an asthma attack , written by the authors of this article. Asthma exacerbations can be classified as mild, moderate, severe, or life threatening.
Criteria for exacerbation severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation. In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta 2 agonists 20 minutes apart followed by a reassessment of peak expiratory flow and symptoms may be safely employed at home.
Administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta 2 agonist therapy in children and adults. In the ambulatory and emergency department settings, the goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse.
Multiple doses of inhaled anticholinergic medication combined with beta 2 agonists improve lung function and decrease hospitalization in school-age children with severe asthma exacerbations. Intravenous magnesium sulfate has been shown to significantly increase lung function and decrease the necessity of hospitalization in children.
The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization, with the most pronounced effect in patients with severe exacerbations. Airway inflammation can persist for days to weeks after an acute attack; therefore, more intensive treatment should be continued after discharge until symptoms and peak expiratory flow return to baseline.
In , the prevalence of asthma in the United States was nearly 8 percent close to 9 percent in children younger than 18 years , and approximately 4 percent of Americans 5 percent of children experienced an asthma attack. One study of children up to 18 years of age presenting to the emergency department with acute asthma symptoms identified multiple risk factors for a subsequent emergency department visit: In persons older than two years with asthma, neither the injectable nor the intranasal influenza vaccine increases the likelihood of an asthma exacerbation in the period immediately following vaccination.
However, one study of infants found an increase in wheezing and hospital admissions after intranasal influenza vaccination. Influenza vaccination appears to improve asthma-related quality-of-life in children during influenza season. Inhaled short-acting beta 2 agonists are the cornerstones of treatment for acute asthma.
An inhaler with a spacer is equivalent to nebulized short-acting beta 2 agonist therapy in children and adults. Continuous beta 2 agonist administration reduces hospital admissions in patients with severe acute asthma.
Inhaled anticholinergic medication improves lung function and decreases hospitalization in school-age children with severe asthma exacerbations. When multiple doses are used in combination with short-acting beta 2 agonists. Intravenous magnesium sulfate increases lung function and decreases hospitalizations in children with an acute asthma exacerbation. The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization.
Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children. For information about the SORT evidence rating system, go to https: Asthma exacerbations can be classified as mild, moderate, severe, or life threatening Table 1.
Although no single parameter has been identified to assess exacerbation severity, lung function is a useful method of assessment, with a PEF of 40 percent or less of predicted function indicating a severe attack in patients five years or older. An oxygen saturation of less than 92 to 94 percent one hour after beginning standard treatment is a strong predictor of the need for hospitalization.
Oral systemic corticosteroids; some symptoms last for one to two days after treatment begins. Oral systemic corticosteroids; some symptoms last for more than three days after treatment begins. Minimal or no relief from frequent inhaled short-acting beta 2 agonist. National Asthma Education and Prevention Program. Expert panel report 3: Guidelines for the diagnosis and management of asthma; Laboratory data are not required for most patients with acute exacerbations.
Some tests that may be useful include complete blood count, serum theophylline, and basic chemistries. Chest radiography is not routinely recommended because it has not been shown to alter the care of patients with an uncomplicated asthma exacerbation.
Electrocardiography is rarely helpful, unless there is a history or suspicion of cardiac disease. Early treatment is the most effective strategy for managing asthma exacerbations. It is essential to teach patients how to monitor signs and symptoms, and take appropriate action.
Patients who have a written asthma action plan and appropriate medication can often manage mild exacerbations at home Figure 1 6. Key components of an asthma action plan that have reduced emergency department visits and hospitalization include standard written instructions; criteria based on symptoms or PEF compared with personal best to trigger action; two to three action points; and individualized, written instructions on the use of inhaled or oral corticosteroids.
These patients should have an asthma action plan that emphasizes early communication with their physician. Algorithm for home management of acute asthma exacerbations.
Previous severe exacerbation e. Two or more hospitalizations or three or more emergency department visits in the past year. In children five to 12 years of age with frequent acute exacerbations, a short course of oral prednisolone at the onset of worsening symptoms produced a modest benefit in terms of decreased symptoms, health resource use, and absence from school.
The data are insufficient to make a recommendation for children; however, a meta-analysis of data from more than 1, adults confirms that increasing the dosage does not reduce the risk of a subsequent asthma exacerbation requiring oral corticosteroids.
A randomized controlled trial examined the use of parent-initiated montelukast Singulair; 4 mg for children two to five years of age and 5 mg for children six to 14 years of age in children with intermittent asthma, defined as three to six episodes of asthma requiring acute hospital- or office-based care with symptom- and medication-free periods between episodes. When given at the onset of asthma or upper respiratory tract infection symptoms, montelukast therapy resulted in a reduction in unscheduled health care visits and time lost from work and school or childcare.
Inhaled short-acting beta 2 agonists are the cornerstones of treatment for patients with acute asthma. Treatments should be 20 minutes apart followed by a reassessment of PEF and symptoms. Patients whose PEF declines after treatment should contact their physician and seek emergent care. Multiple studies have shown that administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized short-acting beta 2 agonist therapy in children older than one year four puffs per dose and adults six puffs per dose.
In the ambulatory and emergency department settings, the goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse by intensifying therapy and carefully monitoring response Figure 2. Early use of systemic corticosteroids can reduce the risk of relapse. Algorithm for emergency department and inpatient management of acute asthma exacerbations. Guidelines for thediagnosis and management of asthma; The administration of oxygen to maintain saturation of at least 94 percent is recommended in all patients presenting with a moderate to severe asthma exacerbation.
Oxygen should be administered as soon as possible, preferably in the prehospital phase in an office setting or in transport by emergency medical services. However, there are insufficient data to support the use of heliox in the treatment of acute asthma exacerbations. Inhaled short-acting beta 2 agonist treatment is the mainstay of office or emergency department treatment of moderate to severe asthma exacerbations. If the patient can tolerate a measurement of PEF or forced expiratory volume in one second FEV 1 , an initial value should be obtained and repeated to monitor treatment response.
In patients with severe exacerbations, continuous beta 2 agonist administration has been shown to improve pulmonary function measurements and reduce hospital admission with no notable differences in pulse, blood pressure, or tremor. A meta-analysis of randomized controlled trials compared the combination of inhaled anticholinergics and beta 2 agonists with beta 2 agonists alone in children one to 18 years of age with mild, moderate, or severe exacerbations of asthma.
The results showed that adding multiple doses of inhaled anticholinergic medication improves lung function and decreases hospitalizations in school-aged children with severe asthma exacerbations.
The addition of intravenous magnesium sulfate to standard therapy has been studied in adults and children with divergent results. In adults with severe exacerbations of asthma PEF of 25 to 30 percent or less of predicted function , intravenous magnesium sulfate therapy resulted in slightly better lung function but no change in rates of hospitalization.
Nebulized magnesium sulfate has a weak effect on respiratory function and hospital admission rates in adults, and no effect on either outcome in children. The administration of systemic corticosteroids mg hydrocortisone sodium succinate injection [Solu-Cortef] or mg methylprednisolone sodium succinate injection [Solu-Medrol] in adults, or 1 to 2 mg per kg of prednisone or prednisolone in children one to 18 years of age within one hour of emergency department presentation decreases the need for hospitalization.
In a Cochrane review, the most pronounced effect occurred in patients with severe exacerbations. Inhaled corticosteroids do not prevent relapse of symptoms requiring admission or improve quality of life or symptom scores. In adults and in hospitalized children one to 16 years of age, corticosteroid use resulted in earlier discharge and fewer symptomatic relapses. The addition of intravenous aminophylline to conventional therapy in children and adults has no additional benefit in reducing hospital admissions.
It does significantly increase the risk of adverse effects, including vomiting, palpitations, and arrhythmias. The intervention showed promising results in objective measure of lung function and reduced rates of hospitalization, but the data are insufficient to make broad recommendations for the use of noninvasive positive pressure ventilation.
Patients sent home from the emergency department with systemic corticosteroids a five- to day nontapering course of to mg prednisone per day in adults have decreased relapse of asthma symptoms, future hospitalizations, and use of short-acting beta 2 agonists. Allergen avoidance is routinely recommended after emergency department discharge to decrease further acute exacerbations of asthma.
Despite multiple trials of allergen control, there are no data showing that pet allergen or dust mite allergen avoidance techniques successfully reduce allergens in the home to levels that improve asthma symptoms.
Regardless of the therapy chosen in the acute care setting, step-up therapy should be continued for several days to weeks after discharge. Because exacerbations vary in severity, close communication between patients and physicians is required.
Symptoms may be controlled quickly, but airway inflammation may persist for two to three weeks. The National Guidelines Clearinghouse was searched for guidelines on asthma care. Ovid Medline was searched for new information related to the major recommendations of both. The Cochrane database and Essential Evidence Plus were searched for information pertaining to asthma exacerbations.
March and April Searches on select topics were performed weekly in May and June , with a repeat search in November Already a member or subscriber? Address correspondence to Susan M. Reprints are not available from the authors. Asthma prevalence, health care use and mortality: Accessed December 20, The state of childhood asthma, United States, — Emergency department revisits for pediatric acute asthma exacerbations: McCarren M, et al. Prediction of relapse within eight weeks after an acute asthma exacerbation in adults.
Assessing symptoms and peak expiratory flow rate as predictors of asthma exacerbations [published correction appears in J Gen Intern Med.
J Gen Intern Med. National Heart Lung and Blood Institute. Guidelines for the diagnosis and management of asthma.