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Communications to the Editor |

Corticosteroid Therapy in Acute Asthma FREE TO VIEW

Gene R. Pesola, MD, MPH; Robert Y. Lin, MD, MS; Richard E. Westfal, MD
Author and Funding Information

St. Vincent’s Hospital & Medical Center New York, NY

Correspondence to: Gene R. Pesola, MD, MPH, Assistant Professor of Emergency Medicine, St. Vincent’s Hospital & Medical Center, Smith Pavilion 120, New York, NY 10011



Chest. 2000;117(6):1821-1822. doi:10.1378/chest.117.6.1821-a
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To the Editor:

We read with interest the meta-analysis by Rodrigo and Rodrigo (August 1999)1evaluating 16 randomized control trials on the effect of steroids in acute asthma. Their conclusion, based on effect size (ES) estimates of pulmonary function, was that systemic steroid effects do not seem to manifest themselves until ≥ 6 h after use. This is consistent with what is known about the time course of steroids in asthma, including our evaluation of IV steroid effects at 1 h.2We recently finished evaluating the effect of IV steroids in acute asthmatic patients over 2 h using a randomized, double-blind, placebo-controlled trial, and noted a significant increase in peak flow measurements in the steroid group over 2 h. The ES estimate of peak flow was small, however, at 0.32 at the 2-h time point, when adjusting for baseline peak flow rates.3 (It was unclear from their methods section how the 95% confidence intervals were calculated, ie, what standard error was used, so we could not include them here.) This ES of 0.32, assuming normality, suggests that the average asthmatic patient’s peak flow in the steroid group would be > 62% of the peak flows of asthmatic patients in the control group. Assuming this a study of high quality as graded by Rodrigo and Rodrigo,,1 this result probably would not have changed their conclusion due to the small ES estimates for the other studies using systemic steroids under 6 h. It is unclear to us why our study showed a slight improvement in peak flow with steroids at this time point. Possibilities include an unknown confounder that theoretically was controlled for during randomization, but can have an effect with small sample sizes,4 a postrandomization selection bias of some type that we did not detect, chance, and the possibility that we actually found a steroid effect at 2 h.

One strength of our study that is not followed in other asthma studies was the recruitment of patients with acute asthma who had a poor peak flow response after one nebulizer treatment with albuterol.3 This excluded the subset of patients who have a markedly improved peak flow response after one treatment and are less likely to need steroid therapy. From a statistical standpoint, if steroid vs control response detection by pulmonary function studies is evaluated in both arms of therapy for all patients with a poor peak flow response before albuterol therapy, and some patients respond dramatically in both groups, the ability to detect a difference will be minimized due to the large range of outcome data in both groups. By implementing this initial inclusion/exclusion criteria in our study design, we increased our chances of finding a difference in peak flow response between treatment and control. This is another possibility for our study findings compared to others.

We congratulate Rodrigo and Rodrigo1 for their evidence-based effort. Despite our possible finding, the weight of the evidence reveals no effect of systemic steroids in improving pulmonary function in patients with acute asthma in the first 6 h. Even if our finding turns out to be real, the effect on improving pulmonary function compared to standard therapy would probably be marginal.

References

Rodrigo, G, Rodrigo, C (1999) Corticosteroids in the emergency department therapy of acute adult asthma: an evidence-based evaluation.Chest116,285-295
 
Lin, RY, Pesola, GR, Westfal, RE, et al Early parental corticosteroid administration in acute asthma.Am J Emerg Med1997;15,621-625
 
Lin, RY, Pesola, GR, Bakalchuk, L, et al Rapid improvement of peak flow in asthmatic patients treated with parenteral methylprednisolone in the emergency department: a randomized controlled study.Ann Emerg Med1999;33,487-494
 
Rothman, KJ, Greenland, S Accuracy considerations in study design. Rothman, KJ Greenland, S eds.Modern epidemiology1998,135-145 Lippincott-Raven. Philadelphia, PA:
 

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Tables

References

Rodrigo, G, Rodrigo, C (1999) Corticosteroids in the emergency department therapy of acute adult asthma: an evidence-based evaluation.Chest116,285-295
 
Lin, RY, Pesola, GR, Westfal, RE, et al Early parental corticosteroid administration in acute asthma.Am J Emerg Med1997;15,621-625
 
Lin, RY, Pesola, GR, Bakalchuk, L, et al Rapid improvement of peak flow in asthmatic patients treated with parenteral methylprednisolone in the emergency department: a randomized controlled study.Ann Emerg Med1999;33,487-494
 
Rothman, KJ, Greenland, S Accuracy considerations in study design. Rothman, KJ Greenland, S eds.Modern epidemiology1998,135-145 Lippincott-Raven. Philadelphia, PA:
 
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