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Am Fam Physician. 2004;69(7):1756

Corticosteroids have become the cornerstone of treatment for acute exacerbations of asthma. When these medications are started early, they reduce the morbidity of acute asthma. Multiple studies have shown that administration of oral, intramuscular, or intravenous steroids in the emergency department reduces the frequency of hospital admissions, improves pulmonary function, and decreases the relapse rate after discharge from the emergency department. However, all forms of corticosteroids have drawbacks, including pain with injections and an unpleasant taste with oral formulations. Furthermore, concern about systemic side effects may limit the use of these agents. Aerosolized corticosteroids are used to manage chronic asthma. Aerosol delivery has not been used to treat acute exacerbations because of concerns that aerosolized steroids may not provide the same rapid and effective therapy as oral steroids. Nakanishi and associates evaluated the effectiveness of inhaled corticosteroids in the management of acute asthma exacerbations in children.

The trial was a randomized, masked, placebo-controlled, parallel-group study of children who presented with acute exacerbation of asthma. Baseline data included spirometry, peak expiratory flow (PEF), heart and respiratory rate, pulse oximetry, and height and weight. Patients received albuterol and, at the treating physician's discretion, ipratropium bromide. The bronchodilators were repeated until the PEF was greater than 70 percent of predicted. The patients then were randomized into two groups. The first group received oral prednisone in a dosage of 2 mg per kg per day (up to 60 mg per day) for seven days, along with a placebo metered-dose inhaler to be used in four inhalations twice daily (eight inhalations per day). The second group received flu-nisolide (with a valved holding chamber) to be used in four inhalations twice daily for seven days, along with placebo tablets to be taken daily. Patients were provided with peak flow meters and instructions on how to use them. In addition, patients were given an albuterol inhaler to use on an as-needed basis for a PEF of less than 80 percent predicted. The patients were instructed to record symptoms and twice-daily PEF measurements on diary cards. Spirometry was repeated on days 3 and 7 of the study. At the end of the study, patients returned the diary cards and study drugs.

Of the 58 participants, 27 received inhaled flunisolide. At baseline, there were no differences between the two groups with regard to asthma severity, race, sex, and age. There were no significant differences between the two groups with regard to symptom severity during the study, and the morning PEF measurements were similar for the two groups. At days 3 and 7 of the study, the forced expiratory volume in one second (FEV1) percentage of predicted was higher in the oral corticosteroid group than in the inhaled corticosteroid group. Reported side effects were minimal in both groups.

Based on clinical examination, the authors conclude that there is no difference between inhaled and oral corticosteroids in the treatment of acute asthma exacerbations in children. They add that spirometry data were better in the oral corticosteroid group, which suggests that this method provides more rapid resolution of asthma.

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