Purpose of the Study
The purpose of the study was to prospectively investigate the efficacy and safety of inhaled corticosteroids in controlling moderately severe acute asthma attacks in children.
The study population included children 6 to 16 years of age with diagnosed asthma who were treated in the emergency department with a moderately severe acute asthma attack, defined as a peak expiratory flow rate (PEFR) of 35 to 75% of predictive values and a pulmonary index score of 8 to 13 with a maximum score of 15.
Children were treated in the emergency department with moderately severe asthma attacks with inhaled terbutaline. Children were then allocated to receive a dose of either 1600 μg of budesonide by turbohaler or 2 mg/kg of prednisolone. The pulmonary index score and PEFR were measured hourly for the first 4 hours. After discharge the children were treated with the same initial dose divided four times daily followed by a 25% reduction in dose every second day for 1 week. The parents recorded asthma symptoms and the frequency of the use of β-agonists on a daily diary card. Serum cortisol concentrations were measured at the end of weeks 1 and 3.
Twenty-two children, 11 in each group, with similar baseline parameters completed the study. There was a similar improvement in pulmonary index score and PEFR in the two groups. Children treated with budesonide showed an earlier clinical response than those given prednisolone. Those treated with prednisolone also showed a decrease in serum cortisol concentration.
Children with moderately severe asthma attacks who were treated in the emergency room with inhaled budesonide starting at 1600 μg appeared to be as effective as oral prednisolone without suppressing serum cortisol concentrations.
This is an extremely interesting study that echoes observations made in Canada concerning the use of high-dose inhaled corticosteroids for acute exacerbations of asthma. This question really becomes a practical one with the introduction high-dose inhaled corticosteroids whose onset of action is relatively quick; namely, budesonide and fluticasone. In patients who have a significant decrease in pulmonary function but are not demonstrating life-threatening deterioration, it may be a reasonable approach to use high-dose inhaled corticosteroids, especially the faster acting agents. Even if there is an effect on the HPA axis with the high-dose inhaled corticosteroids, it is very unlikely that one would see as much adrenal suppression as one would with 60 mg of prednisone a day. It will be interesting to see if the observations made in Canada and in this study are confirmed in studies with larger numbers of patients.