Randomised pragmatic comparison of UK and US treatment of acute asthma presenting to hospital

Abstract

Background: Systemic corticosteroids and inhaled β 2 agonists are accepted first line treatments for acute severe asthma, but there is no consensus on their optimum dosage and frequency of administration. American regimens include higher initial dosages of β 2 agonists and corticosteroids than UK regimens. Methods: In a prospective, pragmatic, randomised, parallel group study, 170 patients of mean (SD) age 37 (12) years with acute asthma (peak expiratory flow (PEF) 212 (80) l/min) presenting to hospital received treatment with either high dose prednisolone and continuous nebulised salbutamol as recommended in the US or lower dose prednisolone and bolus nebulised salbutamol as recommended in the UK by the BTS. Results: Outcome measures were: ∆PEF at 1 hour (BTS 89 l/min, US 106 l/min, p=0.2, CI -8 to 41) and at 2 hours (BTS 49 l/min, US 101 l/min, p<0.0001, CI 28 to 77); time to discharge if admitted (BTS 4 days, US 4 days); rates of achieving discharge PEF (>60%) at 2 hours (BTS 64%, US 78%, p=0.04); time to regain control of asthma as measured by PEF >80% best with <20% variability (BTS 3 days, US 4 days, p=0.6); PEF at 24 hours in patients admitted (BTS 293 l/min, US 288 l/min, p=0.8); and control of asthma in the subsequent month (no significant differences). Conclusions: Treatment with higher doses of continuous nebulised salbutamol leads to a greater immediate improvement in PEF but the degree of recovery at 24 hours and speed of recovery thereafter is achieved as effectively with lower corticosteroid doses as recommended in the British guidelines.

Oral montelukast in acute asthma exacerbations: a randomised, double-blind, placebo-controlled trial

“…It was calculated that 200 patients would need to be enrolled, to allow for withdrawals, in order to have a 80% chance of detecting a difference of 25 l/min in PEF at a 5% level of significance, assuming an SD of 60 l/min from previous work in our department 20. Data collection and entry was performed by DP and SM, and data analysis was performed by AMW.…”

Acute Asthma in Adults

“…126 Doses and dosing intervals should be individualized using objective measures of airflow obstruction as guides. 136 A substantial body of evidence [1][2]118,125,137 supports the use of high and repeated doses. The aim of treatment is to induce maximal stimulation of ␤ 2 receptors without causing significant side effects.…”

Inhaled budesonide in the management of acute worsenings and exacerbations of asthma: A review of the evidence

“…Debate remains over which dosages of the systemic corticosteroids available should be used. 6 Questions relating to the optimum balance between corticosteroids and b 2 -agonists also remain to be answered definitively, 7 with British and American guidelines differing on this point. 2,3 In this review, we critically evaluate the rationale for the use of ICS in the management of acute asthma exacerbations and evaluate the role of budesonide in the management of such exacerbations in both adults and children.…”