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2
-agonists. Further research should be encouraged.
o In addition, studies of acute asthma should stratify patients by presenting severity of the
exacerbation and specify outcomes which are clinically valid, such as relapse or hospital
admission. Research should focus on short term outcomes such as change in pulmonary
function.
o There is a strong argument for asthma researchers to develop a consensus regarding the
reporting of pulmonary function results.
4.3. Magnesium Sulfate for Treating Exacerbations of Acute Asthma in the Emergency
Department
A. Authors:
Brian H Rowe1, Jennifer Bretzlaff2, Christopher Bourdon2, Gary Bota2, Sandra Blitz3, Carlos
A Camargo4
1Department of Emergency Medicine, University of Alberta, Edmonton, Canada. 2St Joseph's
Site, Sudbury Regional Hospital, Sudbury, Canada. 3Division of Emergency Medicine,
University of Alberta, Edmonton AB, Canada. 4EMNet Coordinating Center, Massachusetts
General Hospital, Boston, Massachusetts, USA
Chapter 22: Evidence Based Medicine 232
B. Authors' Conclusions:
Implications for practice:
o In this review, parenteral magnesium sulfate was provided as 2 gm IV over 20 minutes
to adults and 25-100 mg/kg IV to children.
o Many patients who present to the emergency department for asthma exacerbation
assessment and treatment may not benefit from early treatment with magnesium sulfate.
o Patients with severe acute asthma appear to benefit by using Magnesium sulfate, in
terms of pulmonary function improvements and reduced admissions. In this context,
severe asthma is defined as peak expiratory flow rates of less than 25-30% predicted
after initial beta
2
-agonist therapy in adults and/or non-response to treatment (adults and
children), or peak expiratory flow rates of less 60% predicted (children).
o A clinical approach may be to identify candidates for magnesium sulfate therapy among
patients who do not respond to initial beta
2
-agonists treatment.
o Two studies examined the use of magnesium in children. Given the similarity of the
findings in children, Magnesium Sulfate is used in children in the same manner that it is
used in the adult population. Only one study examined its use in children aged less than
six, but the numbers were small.
o In addition to any magnesium intervention, standard acute asthma therapy must be
administered to these patients early in emergency department treatment.
Implications for research:
Many questions regarding the treatment of acute asthma with magnesium remain
unanswered.
o Most importantly, additional research is required to determine the optimal dose and
duration of therapy.
o Additional studies are needed to confirm the sub-group findings from this review
suggesting a beneficial effect of magnesium sulfate only in severe acute asthma. In
future studies, severity must be clearly defined and based on presenting pulmonary
function results AND response to initial beta-agonist therapy whenever possible.
o Studies involving very young children need to be performed to determine the effect of
magnesium sulfate in this age group.
o Further studies are required to examine the effect of magnesium sulfate based on the
prior inhaled steroid use in patients presenting to the emergency department with an
asthma exacerbation. The effect of treatment may differ based on inhaled steroid use,
and the answer to this question remains unclear. Inhaled steroids are increasingly
employed and the development of high dose inhaled steroids with lower systemic
activity suggests that this would be an important area for future research.
o Future research on acute asthma must concentrate on well defined outcomes, which may
lead to more informative reviews in the future. More specifically, criteria for discharge
and reporting of lung function test data in a systematic fashion would assist in further
work. Finally, better description of the methodology would also be beneficial.
Chapter 22: Evidence Based Medicine 233
4.4. Early Emergency Department Treatment of Acute Asthma with Systemic Corticosteroids
A. Authors:
Brian H Rowe1, Carol Spooner2, Francine Ducharme3, Jennifer Bretzlaff4, Gary Bota4
1Department of Emergency Medicine, University of Alberta, Edmonton, Canada. 2Division of
Emergency Medicine, 1G1.52 Walter Mackenzie Health Centre, Edmonton, Canada.
3Department of Pediatrics, McGill University Health Centre, Montreal, Canada. 4St Joseph's
Site, Sudbury Regional Hospital, Sudbury, Canada
B. Authors' Conclusions:
Implications for practice:
o This overview reconfirms evidence from earlier systematic reviews (Rowe 1992; Engel
1991) and supports the use of steroids for treatment of emergency department patients
assessed with acute asthma.
o Therapy with high dose systemic steroids should be commenced within one hour of
presentation to the emergency department.
o Unless the patient fails to respond to early therapy, deteriorated, or presenting case
delineate admission, the decision to admit may be delayed until 6 hours after treatment.
o In children, oral therapy appears to be very effective, although there is no data to provide
guidance as to the efficacy of oral therapy for adults in this setting.
Implications for research:
Further studies in this area will need to consider the results of the subgroup analyses. Studies
which stratify patients into those recently receiving oral steroids vs. those receiving
maintenance inhaled steroids would seem appropriate. Documentation of asthma severity at
presentation needs to be standardized to permit generalization of trial results. Standardized
assessment times would also be useful. A better description of admission criteria is required.
4.5. Early Use Of Inhaled Corticosteroids In The Emergency Department Treatment of Acute
Asthma
A. Authors:
Marcia Edmonds1, Carlos A Camargo2, Charles V Pollack3, Brian H Rowe4
1Schulich School of Medicine & Dentistry, London, Canada. 2EMNet Coordinating Center,
Massachusetts General Hospital, Boston, Massachusetts, USA. 3Department of Emergency
Medicine, Pennsylvania Hospital, Philadelphia, USA. 4Department of Emergency Medicine,
University of Alberta, Edmonton, Canada
B. Authors' Conclusions:
Implications for practice:
o Systemic corticosteroids should be given to all patients with acute asthma presenting to
the emergency department.
o Inhaled steroid therapy decreases admission rates in patients compared to treatment with
placebo.
Chapter 22: Evidence Based Medicine 234
o The additive benefit of inhaled steroids when used with systemic corticosteroids remains
uncertain, although the results of this systematic review suggest an additive effect.
o Inhaled steroids are well tolerated with few short term side-effects.
o There is insufficient evidence to determine whether the effect of (ICS) therapy is
different in certain populations (e.g. children vs. adults, or mild vs. severe asthmatics).
o There is insufficient evidence that (ICS) therapy alone can be used to replace systemic
(CS) therapy.
References 235
References