Unit of Clinical Epidemiology, University of Oxford, Oxford OX3 7LF JEAN FEDRICK, MA, research epidemiologist J A BALDWIN, FFCM, FRCPSYCH, medical directorComparison of intravenous and nebulised salbutamol in initial treatment of severe asthma Salbutamol has been assessed in the initial treatment of acute severe asthma1 2 but the optimum route and duration of administration have not been established. We have compared the effects of salbutamol given by intravenous infusion with those of wet, nebulised salbutamol in a randomised, double-blind trial on patients admitted to the emergency department with acute severe asthma. Patients, methods, and resultsSixteen patients were included in the study, which was approved by the hospital's ethical committee. Informed consent was obtained. Criteria for admission were: age 15-65 years; asthma unresponsive to normal daily medication; no administration of hydrocortisone in previous six hours or recent change in dosage of other oral corticosteroids; and a peak flow (Wright meter) 120 1 or less/min. Medication before admission was noted.All patients received 40 % oxygen through a Mix-o-mask (Blease Medical Equipment Ltd) for five minutes before arterial puncture, and all were given hydrocortisone 250 mg intravenously. Pulse rate, peak flow, and forced expiratory volume in one second (FEV1) were measured. The contents of a numbered ampoule containing either 900 Hg salbutamol or placebo were injected into an infusion bag containing 500 ml physiological saline. The contents of a similarly numbered bottle containing either placebo or 10 mg salbutamol in 10 ml saline were placed in a plastic nebuliser (Sandoz Products Ltd), which was attached to the mask. Patients received either placebo by nebuliser and salbutamol by intravenous infusion or vice versa. The infusion and nebulisation were adjusted to run for 45 minutes. At the end of treatment the observations were repeated while the patients breathed 40 % oxygen.There was no difference in the severity of asthma between the two groups before treatment as judged by peak flow, FEV1, blood gas tensions, and pulse rate (see table). Treatment before admission was similar in the two groups. Both groups showed significant improvemeht in FEV1 after treatment (P < 0-02, paired t test). There was no difference between the effects ofnebulised and intravenously administered salbutamol as measured by changes in FEV1, peak flow, and blood gas tensions in respect of either the mean results or the proportion of patients showing a favourable response. Mean pulse rate fell in the nebuliser group and rose in the intravenously-treated group; this difference was significant (P < 0-02).All but one of the patients given nebulised salbutamol said that their breathing had become much easier, whereas out of seven given intravenous salbutamol, two felt no better or felt tighter in the chest, and two had dizziness or shaking at the end of treatment. The trial was abandoned in two patients, in one case because of uncontrollable shaking, and in the other because ...

SUMMARY The effects of intra-articular methotrexate (MTX) were compared with saline in 20 patients with persistent knee effusions due to rheumatoid arthritis (15) and psoriasis (5) Intra-articular (i.a.) injection of corticosteroids is often followed by transient relief of symptoms and reduction of local synovitis (Hollander, 1972), but not in all cases. A few patients with persistent knee effusions which did not respond to i.a. corticosteroids were given MTX i.a. and the effusions did not reappear for several months (Hall and Head, 1975). MTX, a folic acid antagonist, has been used successfully in controlling the rash of psoriasis (Weinstein, 1977) and has been used systemically to control the arthropathy of psoriasis (Sigler, 1972) but with severe side effects (Black et al., 1964

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