The role of inhaled corticosteroids in the management of acute asthmaAsthma is a chronic inflammatory disease, which 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 common 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 corticosteroids for acute asthma of most current clinical practice guidelines, yet their use is clenbuterol use in australia universal. We will corticosteroids for acute asthma the evidence for the use of these agents that arises from the Cochrane Collaboration of Systematic Reviews contained in the Cochrane Library.
Corticosteroids in the treatment of acute asthma
Asthma is a prevalent chronic disease of the respiratory system and acute asthma exacerbations are among the most common causes of presentation to the emergency department ED and admission to hospital particularly in children. Bronchial airways inflammation is the most prominent pathological feature of asthma. Inhaled corticosteroids ICS , through their anti-inflammatory effects have been the mainstay of treatment of asthma for many years.
Systemic and ICS are also used in the treatment of acute asthma exacerbations. Several international asthma management guidelines recommend the use of systemic corticosteroids in the management of moderate to severe acute asthma early upon presentation to the ED.
On the other hand, ICS use in the management acute asthma has been studied in different contexts with encouraging results in some and negative in others. This review sheds some light on the role of systemic and ICS in the management of acute asthma and discusses the current evidence behind their different ways of application particularly in relation to new developments in the field. Asthma is a chronic respiratory disease that is prevalent worldwide.
It is considered as a major cause of morbidity and a main contributor to the high health care expenditure especially in developed countries. These features are interrelated, but not totally dependent on each other. The ratio of these cells may widely vary between patients indicating asthma heterogeneity. Eosinophilic, neutrophilic, and paucigranulocytic. The eosinophilic phenotype is characterized by increased eosinophilic infiltration of the airways.
Patients tend to be atopic, have asthma triggered by exposure to allergens and tend to respond well to corticosteroids. The neutrophilic phenotype is characterized by increased neutrophilic infiltration of the airways. Patients tend to have severe, more aggressive, and poorly controlled asthma.
They usually do not respond to corticosteroids as well as the eosinophilic type. In the paucigranulocytic phenotype, bronchial neutrophils, and eosinophils are much lower. Asthmatic patients frequently experience acute exacerbations. These exacerbations are usually triggered by allergens; including pollens, animal dander, dust mites, and mold; viral respiratory tract infections; irritants such as smoke and dust; cold air and exercise.
The most common cause of acute asthma exacerbation in both adults and children, but more in children, is viral respiratory tract infections. Airway epithelial cells play a major role in the pathology of virally induced asthma exacerbation.
In response to infection they secret chemokines like interleukin-8 and CCL-5 that can attract inflammatory cells including neutrophils and lymphocytes that could exacerbate the already existing allergic inflammation. The frequency in which exacerbations happen vary widely depending on the severity of disease,[ 15 ] the degree of control with prophylactic medications,[ 16 ] and exposure to triggers. Examination of patients with acute asthma may reveal increased respiratory rate, retractions accessory respiratory muscle use , wheezing, oxygen desaturation on pulse oximetry and in more severe cases, inability to speak, silent chest, with reduced respiratory lung volumes, cyanosis, and change in mental status.
Asthma exacerbations can be classified as mild, moderate, or severe based on the assessment of a group of signs and symptoms as illustrated in Table 1. The dose can be repeated 3 times every min. Levalbuterol, the R -enantiomer of albuterol is the effective form of the drug, but clinical trials did not show any advantage of using it over albuterol in terms of efficacy or side-effects.
However, it is recommended that patients who take them regularly or patients who fail initial treatment with albuterol should be given systemic corticosteroids. Systemic corticosteroids were found to speed resolution of symptoms, decrease the rate of admission and decrease the rate of relapse if administered for days after the acute exacerbation. More detailed discussion about the use of systemic corticosteroids in the treatment of acute asthma can be found below.
Patients with severe asthma exacerbation should obviously be treated more aggressively. Ipratropium bromide has been shown to decrease the rate of hospitalization and shorten the stay in the ED in patients with severe or moderate to severe asthma exacerbation in many clinical trials.
Its use in patients after admission to the hospital was not shown to make a difference. Systemic corticosteroids should be used as mentioned in patients with moderate exacerbation. Other treatment modalities may be considered like magnesium sulfate and helium oxygen heliox therapy in the more severe and nonresponsive patients. Moreover, oral montelukast given to patients post discharge for 5 days was also shown not to be helpful. An MDI dose of puffs depending on age is equivalent to a nebulized dose of 2.
Patients who maintain normal oxygen saturation, have no or minimal wheezing on chest auscultation, and have no or mild intercostal retractions can be discharged home after 1 h of assessment on no additional medications in the ED. However, these patients should have a step up in their maintenance medications to prevent relapse.
Patients who fail to achieve improvement after 4 h of treatment should be admitted to the hospital for further aggressive therapy. Shortly after the discovery of the structure of adrenal steroid hormones, Hench et al. The effect was remarkable and that work won the Nobel Prize the next year. It also started a series of trials of corticosteroids in various inflammatory conditions. The first use of corticosteroid to treat acute asthma exacerbation was in In , Clark showed for the 1 st time that inhaled beclomethasone was effective in the management of asthma with less adverse effects than systemic steroids.
These effects are mediated through various genomic and nongenomic mechanisms. Systemic corticosteroids given early in the course of treatment of acute asthma exacerbations in the ED were overall shown to be effective and are recommended by different asthma guidelines like GINA and EPR3.
Littenberg and Gluck initially showed that they decrease hospital admission rate. Rodrigo and Rodrigo reviewed all these six studies and concluded that there was no improvement in hospital admission rate or lung function. Hence, data in terms of lung function are more encouraging. On the other hand, Krishnan et al. For example, Marquette et al. Nine trials were included with a total patients' number of adults.
They found no difference between the different doses. Studies also showed no difference in the efficacy or onset of action between oral and IV administration. Fifty-two adults with severe acute asthma were treated with either IV hydrocortisone or prednisolone.
There was no difference in their peak flow measurements 24 h after admission. GINA and the EPR3 guidelines prefer oral administration because it is less invasive except in patients with absorption problems or those who are not able to take orally due to the severity of their respiratory distress or because they are vomiting.
Prescribing a short course of oral corticosteroids following the ED treatment of acute asthma exacerbations was found to reduce the rate of relapse. The use of ICS in the treatment of acute asthma was studied in four contexts:. In addition, a recent study found that preemptive use of high dose fluticasone mcg BID at the onset of an upper respiratory tract infection in children with recurrent virus induced wheezing and continuing it for 10 days, reduced the use of rescue oral corticosteroids.
When ICSs were compared with systemic corticosteroids in randomized and blinded studies the conclusions were conflicting. Some studies reported superiority of systemic steroids in reducing admission rate,[ 58 ] some reported equal efficacy in relation to admission rate as well,[ 59 , 60 , 61 ] and some reported superiority of ICS. Inhaled corticosteroids were also used as add on therapy to systemic corticosteroids in the ED and continued after discharge.
In this context, Rowe et al. There are few randomized and blinded studies examining only the short-term effect of ICS in the ED as add on therapy to systemic corticosteroids plus other standard acute asthma therapy. One study looked at the addition of high dose beclomethasone versus placebo to methylprednisolone in 60 adults and found no difference in FEV 1 or symptoms between the two groups. However, the patient number included was very small and PEFR is generally not reliable in young children.
Both groups had no difference in the pulmonary index score. In the other study by Upham et al. There was no difference in the asthma score[ 25 ] at 2 h after intervention or in the admission rate or time to discharge from the ED between the two groups. Collectively, it was hard to come up with a conclusion from these studies about whether adding ICS to systemic steroids in standard acute asthma therapy will add more benefit or not. Therefore, we recently performed a larger blinded and randomized study to look at this question.
However, when we looked at only the subgroup with severe acute asthma, budesonide was able to significantly decrease the admission rate of those patients and to lower their asthma score, suggesting an added value. More large trials specifically targeting patients with severe acute asthma are clearly needed.
Corticosteroids play an important role in the treatment of acute asthma exacerbations in the ED as well as post discharge from the ED.
Further research is greatly needed to shed more light on the use of ICS in those patients, their optimal dose and duration, as well as their concomitant use with systemic corticosteroids. In addition, more research is needed on the safety of dispensing oral corticosteroids for home use in case of asthma exacerbation.
The author holds exclusive copyright to this chapter. National Center for Biotechnology Information , U. Journal List Ann Thorac Med v. Box , Riyadh , Saudi Arabia. Received Dec 9; Accepted Mar This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Asthma is a prevalent chronic disease of the respiratory system and acute asthma exacerbations are among the most common causes of presentation to the emergency department ED and admission to hospital particularly in children.
Acute asthma, emergency department, inhaled corticosteroids, systemic corticosteroids. Pathophysiology of Acute Asthma: Brief Overview Asthma is a chronic respiratory disease that is prevalent worldwide. Open in a separate window. Introduction and Evolution of Corticosteroids in the Management of Asthma: Historical Background Shortly after the discovery of the structure of adrenal steroid hormones, Hench et al.
Common types of systemic corticosteroids and their relative properties. Clinical Evidence of the Effect of Corticosteroids in Acute Asthma Systemic corticosteroids Systemic corticosteroids given early in the course of treatment of acute asthma exacerbations in the ED were overall shown to be effective and are recommended by different asthma guidelines like GINA and EPR3.
Inhaled corticosteroids The use of ICS in the treatment of acute asthma was studied in four contexts: In comparison to placebo,. Conclusion Corticosteroids play an important role in the treatment of acute asthma exacerbations in the ED as well as post discharge from the ED.
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