Inhaled steroids in acute asthma following emergency department discharge

Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care

BACKGROUND

Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations.

OBJECTIVE

We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians.

METHODS

This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering.

RESULTS

Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period.

CONCLUSIONS

An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

A clinical audit of the management of acute asthmatic attacks in adults and children presenting to an emergency department

OBJECTIVE

To compare the guidelines in the University Hospital of the West Indies (UHWI) acute asthma management protocol with actual practice in the Accident and Emergency Department.

METHODS

A prospective docket audit was done of all consecutive medical records of patients, presenting with a diagnosed acute asthmatic attack between June 1 and September 30, 2010, to the emergency department of the UHWI. A convenient sample was used. The audit tool used was created from the UHWI protocol for the emergency management of asthma in adults and children, as well as the British Adult Asthma Audit Tool. The audit tool assessed three main sections: initial assessment, initial management, and discharge considerations. Data were coded and entered in Microsoft Excel 2007 and statistical analyses conducted using Stata version 10. Management patterns were compared to the actual protocol and then discussed.

RESULTS

A total of 15 864 patients were seen during the study period. Of these, a total of 293 patients were seen for a presentation of acute asthma. More females (57.3%) than males were seen, with the mean age of 33.53 years. Only 31% of patients were given a severity assessment of mild, moderate, or severe. Peak expiratory flow rate (PEFR) was attempted and recorded in 62%, but only 18.1% of patients had both pre and post PEFR done. Only 4.4% of patients were administered nebulizations within the suggested time frame. Positively, 94.2% of patients were given a prescription for inhaled corticosteroids and bronchodilators to continue post-discharge.

CONCLUSIONS

Acute asthma management still remains an area of medical practice that continues to have long-standing difficulties. Failure to assess and document the severity of asthma attacks along with the under-utilization of PEFR was noted.

Inhaled steroids for acute asthma following emergency department discharge

BACKGROUND

Patients with acute asthma treated in the emergency department (ED) are frequently treated with inhaled beta(2)-agonists and systemic corticosteroids after discharge. The use of inhaled corticosteroids (ICS) following discharge may also be beneficial in improving patient outcomes after acute asthma.

OBJECTIVES

To determine the effectiveness of ICS on outcomes in the treatment of acute asthma following discharge from the ED. To quantify the effectiveness of ICS therapy on acute asthma following ED discharge, when used in addition to, or as a substitute for, systemic corticosteroids.

SEARCH METHODS

Controlled clinical trials (CCTs) were identified from the Cochrane Airways Review Group register, which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by handsearching of respiratory journals and conference proceedings. In addition, primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews and texts also were searched. The searches have been conducted up to September 2012

SELECTION CRITERIA

We included both randomised controlled trials (RCTs) and quasi-RCTs. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids. Two review authors independently assessed articles for potential relevance, final inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors, or confirmed by the study authors. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager software. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) or relative risks (RR) 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 heterogeneity is reported using I-squared (I(2)) statistics.

MAIN RESULTS

Twelve trials were eligible for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus systemic corticosteroids versus oral corticosteroid therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to oral corticosteroid therapy in the trials. Relapses were reduced; however, this was not statistically significant with the addition of ICS therapy (OR 0.68; 95% CI 0.46 to 1.02; 3 studies; N = 909). In addition, no statistically significant differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores or adverse effects.Nine trials, involving a total of 1296 patients compared high-dose ICS therapy alone versus oral corticosteroid therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone versus oral corticosteroid therapy alone for relapse rates (OR 1.00; 95% CI 0.66 to 1.52; 4 studies; N = 684), admissions to hospital, or in the secondary outcomes of beta(2)-agonist use, symptoms or adverse events. However, the sample size was not adequate to exclude the possibility of either treatment being significantly inferior and people with severe asthma were excluded from these trials.

AUTHORS' CONCLUSIONS

There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard systemic corticosteroid therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as oral corticosteroid therapy when used in mild asthmatics upon ED discharge; however, the confidence intervals were too wide to be confident of equal effectiveness. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment following ED discharge. The review does not suggest any reason to stop usual treatment with ICS following ED discharge, even if a course of oral corticosteroids are prescribed.

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.

Common pediatric respiratory emergencies

Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.

An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses

BACKGROUND

Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation.

METHODS

Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms.

RESULTS

In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication.

CONCLUSIONS

More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.

[Adult asthma exacerbations in questions]

In this article a French working party critically review the international literature to revise the definition, pathophysiology, treatment and cost of exacerbations of adult asthma. The various guidelines do not always provide a consistent definition of exacerbations of asthma. An exacerbation can be defined as deterioration of clinical and/or functional parameters lasting more than 24 hours, without return to baseline, requiring a change of treatment. No single clinical or functional criterion can be used as an early marker of an exacerbation. Innate and acquired immune mechanisms, modified by contact with infectious, irritant or allergenic agents, participate in the pathogenesis of exacerbations, which are accompanied by bronchial inflammation. In 2010, mortality is related to progression of exacerbations, often occurring before the patient seeks medical attention. The objective of treatment is to control asthma and prevent exacerbations. However, many factors can trigger exacerbations and often cannot be controlled. The efficacy of inhaled corticosteroids has been demonstrated on reduction of the number of exacerbations and the number of asthma-related deaths. This treatment is cost-effective, especially in terms of reduction of exacerbations.

Comparative effectiveness of medical interventions in adults versus children

OBJECTIVE

To estimate the comparative effectiveness of medical interventions in adults versus children.

STUDY DESIGN

We identified from the Cochrane Database of Systematic Reviews (Issue 1, 2007) meta-analyses with data on at least 1 adult and 1 pediatric randomized trial with binary primary efficacy outcome. For each meta-analysis, we calculated the summary odds ratio of the adult trials and the pediatric trials, respectively; the relative odds ratio (ROR) of the adult versus pediatric odds ratios per meta-analysis; and the summary ROR across all meta-analyses. ROR <1 means that the experimental intervention is more unfavorable in children than adults.

RESULTS

Across 128 eligible meta-analyses (1051 adult and 343 pediatric trials), the summary ROR did not show a statistically significant difference between adults and children (0.96; 95% confidence intervals, 0.86 to 1.08). However, in all meta-analyses except for 1, the individual ROR's 95% confidence intervals could not exclude a relative difference in efficacy over 20%. In two-thirds, the relative difference in observed point estimates exceeded 50%. Nine statistically significant discrepancies were identified; 4 of them were also clinically important.

CONCLUSIONS

Treatment effects are on average similar in adults and children, but available evidence leaves large uncertainty about their relative efficacy. Clinically important discrepancies may occur.

[Readmissions to hospital for asthma in France, 2002-2005]

BACKGROUND

Most hospital admissions with asthma are avoidable. The objective of the analysis was to describe hospital readmissions for asthma.

METHODS

Using data from the French hospital information system, admissions for asthma or for acute respiratory failure associated with asthma that occurred in 2-44 years-old patients between 2002 and 2005 in France (excluding French overseas departments) were analysed. Readmission rates at 7 days and at 1 year were estimated using the Kaplan-Meier method.

RESULTS

The risk of readmission at 1 year was 15.0%. It varied according to age (higher in 2-4 year and 35-44 years-old patients) and sex (higher in 10-34 years-old females) and increased with the length of stay of the index admission. The risk of readmission at 7 days was 1.1% and was higher for the shortest lengths of stay.

CONCLUSION

Readmissions for asthma are pertinent indicators for the monitoring of asthma, especially the clinical management of the disease. Using data from an increasing number of years, together with linkage of hospital admissions and asthma drug reimbursement data, should allow a better understanding of severe asthma in France.

An umbrella review: corticosteroid therapy for adults with acute asthma

The objective of this "umbrella" review is to synthesize the evidence and provide clinicians a single report that summarizes the state of knowledge regarding the use of corticosteroids in adults with acute asthma. Systematic reviews in the Cochrane Library and additional clinical trials published in English from 1966 to 2007 in MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL, and references from bibliographies of pertinent articles were reviewed. Results indicate that the evidence base is frequently limited to small, single-center studies. Findings suggest that therapy with systemic corticosteroids accelerates the resolution of acute asthma and reduces the risk of relapse. There is no evidence that corticosteroid doses greater than standard doses (prednisone 50-100 mg equivalent) are beneficial. Oral and intravenous corticosteroids, as well as intramuscular and oral corticosteroid regimens, seem to be similarly effective. A nontapered 5- to 10-day course of corticosteroid therapy seems to be sufficient for most discharged patients. Combinations of oral and inhaled corticosteroids on emergency department/hospital discharge might minimize the risk of relapse.

Pulmonary diseases and corticosteroids

Steroids (corticosteroids) are anti-inflammatory drugs. Corticosteroids are used in many pulmonary conditions. Corticosteroids have a proven beneficial role in asthma, croup (Laryngotracheobronchitis), decreasing the risk and severity of respiratory distress syndrome (RDS), allergic bronchopulmonary aspergillosis, interstitial lung disease, hemangioma of trachea, Pulmonary eosinophillic disorders. Role of corticosteroids is controversial in many conditions e.g. idiopathic pulmonary hemosiderosis, bronchiolitis, hypersensitivity pneumonitis, hyperplasia of thymus, bronchiolitis, acute respiratory distress syndrome, aspiration syndromes, atypical pneumonias, laryngeal diphtheria, AIDS, SARS, sarcoidosis, meconium aspiration syndrome (MAS), pulmonary haemorrhage, bronchitis, bronchiolitis obliterans with organizing pneumonia in JRA, histiocytosis, alpha-1 antitrypsin deficiency, bordtella pertusis, pulmonary involvement in histiocytosis. However these are used empirically in many of these conditions despite lack of clear evidence in favour. There is concern about their side effects, especially on growth. Systemic steroids are associated with significant adverse effects. Pulmonary conditions have a strategic advantage that inhaled corticosteroids are useful in many of these. Although inhaled preparations of corticosteroids have been developed to maximise effective treatment of lung diseases characterised by inflammation and reduce the frequency of harmful effects, these have not been eliminated. There are situations where only systemic steroids are useful. Clinicians must weigh the benefits against the potential detrimental effects. It is recommended that standard protocols for use of steroids available in literature should be followed, always keeping a watch on the potential hazards of prolonged use.

Relapse after emergency department discharge for acute asthma

OBJECTIVES

The objectives were to determine patient and treatment-response factors associated with relapse after emergency department (ED) treatment for acute asthma.

METHODS

Subjects aged 18-55 years who were treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview and telephone contact 2 weeks later.

RESULTS

Of 695 enrolled patients, 604 (86.9%) were discharged from the ED; follow-up was available in 529 (87.5%); 63% were female and the median age was 29 years. Most patients were discharged on oral (70.8%) and inhaled (60.1%) corticosteroids (CS); 2-week treatment adherences were 93.3 and 80.9%, respectively. Relapse occurred in 9.2% at 1 week (95% confidence interval [CI] = 7.1% to 12.0%) and 13.9% (95% CI = 11% to 17%) at 2 weeks. In multivariable modeling, factors associated with relapse were ethnicity (risk ratio [RR] white = 0.66; 95% CI = 0.52 to 0.83); female gender (RR = 1.57; 95% CI = 1.14 to 2.09); any ED visits in the past 2 years (RR = 1.47; 95% CI = 1.18 to 1.80); ever admitted for asthma treatment (RR = 1.83; 95% CI = 1.09 to 2.84); use of combined inhaled CS plus long-acting beta(2)-agonists (RR = 1.39; 95% CI = 1.07 to 1.78) and of oral CS (RR = 1.35; 95% CI = 1.12 to 1.59) at the time of ED presentation.

CONCLUSIONS

Ethnicity (white), female gender, prior ED visits and admissions for asthma, and recent treatments (especially oral CS) were associated with asthma relapse, which remains relatively common. Future research is required to target this high-risk group.

Increasing the use of anti-inflammatory agents for acute asthma in the emergency department: experience with an asthma care map

PURPOSE

Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs).

METHODS

Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST(1)) and the 18 months after POST(1) (POST(2)). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge.

RESULTS

A total of 387 patient charts were included (PRE, n=150; POST(1), n=150; POST(2), n=87). Patient characteristics in the three groups were similar; however, patients in POST(1) and POST(2) showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST(1) and 70% during POST(2). The use of peak expiratory flow (PEF) was high during the PRE, POST(1) and POST(2) periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST(1) and 75% POST(2); P<0.01) in the POST(1,2) periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST(1) and 69% POST(2); P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST(1) and 61% POST(2); P<0.001) in the POST(1,2) periods. Discharge without any corticosteroids decreased over the three periods (32% PRE, 21% POST(1) and 17% POST(2); P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST(1) and 265 min POST(2); P<0.01) and admissions were infrequent (9% PRE, 13% POST(1) and 6% POST(2); P=0.50).

CONCLUSIONS

The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.

Commercial versus home-made spacers in delivering bronchodilator therapy for acute therapy in children

BACKGROUND

Strong evidence supports the use of metered-dose inhalers combined with a spacer for delivering rapid-acting inhaled beta-2 agonists in the treatment of acute exacerbations of asthma in children. The high cost and lack of availability of commercially produced spacers however, have limited their use in developing countries.

OBJECTIVES

The aim of this review was to compare the response to inhaled beta-2 agonists delivered through metered-dose inhaler using home-made spacers, to the use of commercially produced spacers, in children with acute exacerbations of wheezing or asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library Issue 3, 2007,(up to August 2007) MEDLINE , EMBASE, CINHAL, LILACS and reference lists of included studies. We contacted authors and known experts in the field, and approached pharmaceutical companies that manufacture inhalation spacers to identify additional published or unpublished data. No language restrictions were applied.

SELECTION CRITERIA

Trials comparing treatment with rapid acting beta 2-agonists delivered though MDI attached to home-made spacers, with the same bronchodilator therapy delivered with MDI and commercially produced spacers, in children under 18 years with acute exacerbations of wheezing or asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated from information available in published reports.

MAIN RESULTS

Six trials with 658 participants met the inclusion criteria . At the time of this report, five trials were published in full text, and one study was available in abstract form only. No significant differences were demonstrated between the two delivery methods in terms of need for hospital admission (RR 1.00, 95% CI 0.63 to 1.59), change in oxygen saturation (SMD -0.03, 95% CI -0.39 to 0.33), PEFR (SMD 0.04, 95% CI -0.72 to 0.80), clinical score (WMD 0.00, 95% CI -0.37 to 0.37), in terms of need for additional treatment (RR 1.18, 95% CI 0.84 to 1.65), or regarding change in heart rate per minute (SMD 0.09, 95% CI -0.24 to 0.42).

AUTHORS' CONCLUSIONS

Overall, this review supports did not identify a difference between these two methods for delivering bronchodilator therapy to children with acute asthma or lower airways obstruction attacks. Care should be taken in the interpretation and applicability of our results because of the small number of RCTs along with few events available meeting the criteria for inclusion in the review, absence of the primary outcome of interest and other clinically important outcomes in the majority of included studies. The possible need for a face-mask in younger children using home-made spacers should also be considered in practice.

Comparison of Canadian versus American emergency department visits for acute asthma

BACKGROUND

Acute asthma is a common emergency department (ED) presentation in both Canada and the United States.

OBJECTIVE

To compare ED asthma management and outcomes between Canada and the United States.

METHODS

A prospective cohort study of 69 American and eight Canadian EDs was conducted. Patients aged two to 54 years who presented with acute asthma underwent a structured ED interview and telephone follow-up two weeks later.

RESULTS

A total of 3031 patients were enrolled. Canadian patients were more likely to be white (89% versus 22%; P<0.001), have health insurance (100% versus 69%; P<0.001) and identify a primary care provider (89% versus 64%; P<0.001) than American patients. In addition, Canadian patients were more likely to be using inhaled corticosteroids (63% versus 44%; P<0.001) and had higher initial peak expiratory flow (61% versus 48%; P<0.001). In the ED, Canadians received fewer beta-agonist (one versus two; P<0.001) and more anticholinergic (two versus one; P<0.001) treatments in the first hour; use of systemic corticosteroids was similar (60% versus 68%; P=0.13). Canadians were less likely to be hospitalized (11% versus 21%; P=0.02). Corticosteroids were prescribed similarly at discharge (60% versus 69%; P=0.13); however, Canadians were discharged more commonly on inhaled corticosteroids (63% versus 11%; P<0.001) and relapses were similar.

CONCLUSIONS

Canadian patients with acute asthma have fewer barriers to primary care and are more likely to be on preventive medications, both before the ED visit and following discharge. Admissions rates are higher in the United States; however, relapse after discharge is similar between countries. These findings highlight the influences of preventive practices and heath care systems on ED visits for asthma.

State of the evidence on acute asthma management in children: a critical appraisal of systematic reviews

OBJECTIVE

Our goal was to evaluate clinical, methodologic, and reporting aspects of systematic reviews on the management of acute asthma in children.

METHODS

We undertook a systematic review of systematic reviews on acute asthma management in children. We identified eligible reviews by searching the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, Medline, and Embase 1990 to March 2006. Data were extracted on clinical issues, methodologic characteristics, and results of the reviews. Methodologic quality was assessed with the Overview Quality Assessment Questionnaire and with additional questions on heterogeneity. Separate reporting on children in mixed adult-pediatric population reviews was assessed. Methodologic quality of systematic reviews published in peer-reviewed journals was compared with Cochrane reviews.

RESULTS

A total of 23 systematic reviews were included: 14 were published in the Cochrane Library, and 9 were published in peer-reviewed journals. Eight reviews included children only, and 15 were mixed-population reviews. The majority of reviews defined the study population as having "acute asthma" without a more precise definition, and 16 different health outcomes were reported. The overall quality according to the Overview Quality Assessment Questionnaire was good, with Cochrane reviews showing minimal flaws and journal reviews showing minor flaws (median scores: 7 vs 5). Results on children were reported separately in 8 of 15 mixed-population reviews. Clinical heterogeneity was explored in only 2 of 23 reviews, and the methods used to identify and address heterogeneity were diverse.

CONCLUSIONS

The methodologic quality of both the Cochrane and journal reviews on the management of acute asthma in children seems good, with Cochrane reviews being more rigorous. However, their usefulness for clinical practice is hampered by a lack of clear definitions of included populations, clinically important health outcomes, and separate reporting on children in mixed reviews. A major threat to these reviews' validity is the insufficient identification and handling of heterogeneity.

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%.

Asthma severity scores for preschoolers displayed weaknesses in reliability, validity, and responsiveness

OBJECTIVE

To evaluate the measurement properties of asthma severity scores for use in preschool children.

METHODS

A Medline search was used to identify published asthma severity scores for use in preschool children. The measurement properties of the scores (item development, reliability, validity, responsiveness, and usability) were evaluated using a published framework.

RESULTS

Ten asthma severity scores were identified, with 19 different clinical variables used as items. Interrater agreement was assessed by five scores. Only two scores--Clinical Asthma Score (CAS) and Respiratory Distress Assessment Index (RDAI)--reported good agreement based on weighted kappa-statistics (0.64-0.90). Construct validity was reported by the CAS, Clinical Asthma Evaluation Score (CAES), the Clinical Symptom Grading System (CSGS), and the Preschool Respiratory Assessment Measure (PRAM). Correlation coefficients between asthma severity scores and clinical measures (length of stay, drug dosing interval, O2 saturation, health professional assessment, PaO2, PaCO2) ranged from 0.47 to 0.70. Responsiveness was formally demonstrated for two scales (PRAM, CAS).

CONCLUSIONS

Most asthma severity scales for use in preschool children have been informally developed. Recently developed scores (CAS, PRAM) have more rigorously evaluated their measurement properties. Research is needed to directly compare the asthma severity scores developed for use in preschool children.

Antibiotics for acute asthma

BACKGROUND

Antibiotics are often prescribed to patients who are admitted to hospital with acute asthma. Their exacerbation is often precipitated by a viral upper respiratory infection (URTI), but in some instances antibiotics are prescribed in spite of questionable efficacy. A lack of strong evidence either to support or to refute the use of treatments in acute asthma leaves room for discussion and debate as to how effective antibiotics are in an acute setting. This review assesses what evidence is available.

OBJECTIVES

To determine the efficacy of antibiotics prescribed in the treatment of acute asthma

SEARCH STRATEGY

Electronic databases (MEDLINE, EMBASE and CINAHL) were searched to identify all possible randomised control trials.

SELECTION CRITERIA

Only RCTs or quasi RCTs were eligible for inclusion. Studies were included if patients were treated for acute asthma in the ED or its equivalent with antibiotics or placebo. Two reviewers independently assessed articles for potential relevance, final inclusion, and methodological quality.

DATA COLLECTION AND ANALYSIS

Two reviewers completed trial quality assessment and data extraction independently.

MAIN RESULTS

From 128 potential studies, two trials were identified for inclusion in the review. Both trials reported numbers of exacerbations and not patient numbers due to re admissions over the course of the trials. The total number of patients in this review was 97, but values were recorded for 115 exacerbations.

REVIEWER'S CONCLUSIONS

The role of antibiotics in the treatment of acute asthma is difficult to assess from the current literature. Recommendations regarding antibiotic use in acute asthma will remain consensus driven until more research is conducted which includes larger numbers of patients.