Macias CG, Felner EI, Gan V. Pediatr Asthma Allergy Immunol. 2003;16:121–128
Purpose of the Study.
To compare the efficacy of inhaled corticosteroids with that of orally or intravenously administered corticosteroids in the treatment of acute moderate/severe asthma.
The 135 subjects were 6 to 17 years of age, with at least 1 previous episode of wheezing, and were recruited from 1 of 2 emergency centers (ECs) after presentation with acute asthma symptoms.
Patients were randomized, after receiving an initial dose of albuterol, to 1 of 3 corticosteroid treatment groups if their Wood asthma scores were 4 or 5. All patients received their corticosteroid dose within 15 minutes after the initial albuterol dose. Group A received triamcinolone (600 μg, 100 μg/puff) via inhaler with a spacer, group B received orally administered prednisone (2 mg/kg), and group C received intravenously administered methylprednisolone (2 mg/kg). The decision to hospitalize was made by the EC attending physician, without input from investigators. After EC discharge, group A patients continued to receive triamcinolone (6 puffs 3 times daily for 1 day and then 4 puffs 3 times daily for 3 days); group B and C patients continued to receive orally administered prednisone (1 mg/kg twice daily for 4 days). Outcomes measured were the number of patients hospitalized from each treatment group and the number of unscheduled return visits 1 week after discharge from the EC.
Seven percent of group A patients were hospitalized, compared with 22% and 29% of patients in groups B and C, respectively (P = .020). There were significantly more unscheduled return visits in groups B and C (41.5% combined), compared with group A (12%; P = .007). Hospitalizations or unscheduled return visits were considered treatment failures; rates were 19%, 62%, and 70% in groups A, B, and C, respectively (P = .001).
Patients who received inhaled triamcinolone were less likely to be hospitalized for treatment of acute asthma, compared with those who received orally or intravenously administered corticosteroids. Patients who received inhaled triamcinolone had significantly fewer unscheduled return visits 1 week after EC discharge, compared with patients in the oral or intravenous corticosteroid treatment groups.
This was a small, prospective, clinical trial, suggesting that children with asthma could be effectively treated with inhaled corticosteroids in an acute care setting and might experience fewer treatment failures, compared with those who received orally or intravenously administered corticosteroids. One major limitation of the study was the lack of blinding. The attending EC physician might have been biased and more likely to discharge patients from the EC if they were in the inhaled corticosteroid group. Other limitations included the small number of patients and a poorly defined asthma diagnosis. A larger, prospective, double-blind study in a well-defined asthma population would strengthen these findings and might change acute asthma treatment.