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Study objective: Corticosteroids are thought to exert their physiologic effects in asthma over the course of several hours. In this study we tested the hypothesis that intravenous methylprednisolone improves airflow in a shorter time frame (2 hours) in adults with acute asthma. Methods: In a randomized, double-blind, placebo-controlled trial, 56 adult asthmatic patients with peak expiratory flow rates (PEFRs) less than 50% predicted after an initial albuterol aerosol treatment were studied. These patients were randomly assigned to treatment with either 125 mg of intravenous methylprednisolone or an equivalent volume of normal saline solution (placebo). Patients were also treated with identical schedules of nebulized ipratropium and albuterol. Patients were recruited from an emergency department at an urban academic medical center. The primary endpoints were changes in PEFR and in percent predicted PEFR over time. PEFRs were assessed at baseline and at 1 and 2 hours. Heart rate changes over time and the proportion of admissions in the 2 groups were also compared. Results: The increases in PEFR and percent predicted PEFR over time were both significantly greater in the methylprednisolone treatment group ( P =.002 and P =.005, respectively). The increases in geometric mean peak flow at 60 and 120 minutes were 79 and 96 L/min for the methylprednisolone group and 54 and 68 L/min for the placebo group. There was also a significantly different change in heart rates with time between the methylprednisolone and placebo groups ( P =.029), with the placebo group showing a moderate increase in heart rate over time. Although the proportion of patients admitted for status asthmaticus was less in the methylprednisolone treatment group (8/30) compared with the placebo group (10/26), this difference in proportions (–.118, 95% confidence interval –.363 to .127) was not significant. Conclusion: These data suggest that use of corticosteroids should be considered relatively early in the treatment of patients with acute asthma in whom initial bronchodilator therapy fails to produce an adequate response. [Lin RY, Pesola GR, Bakalchuk L, Heyl GT, Dow AM, Tenenbaum C, Curry A, Westfal RE: Rapid improvement of peak flow in asthmatic patients treated with parenteral methylprednisolone in the emergency department: A randomized controlled study. Ann Emerg Med May 1999;33:487-494.]

Study objective: The use of nebulized ipratropium in combination with β-agonists for the treatment of acute asthma in adults is controversial. We wished to test the hypothesis that combined aerosol treatment results in a greater rate of airflow improvement and a lower proportion of hospital admission in adults with acute asthma. Methods: In a randomized, double-blind, placebo-controlled trial, 55 adult asthmatic patients with peak expiratory flow rate (PEFR) less than 200 L/min were randomly assigned to nebulization treatment with albuterol alone (2.5 mg initial dose followed by 2 more doses at 20-minute intervals), or the same albuterol regimen plus ipratropium (.5 mg combined with the initial dose of albuterol only). Patients were recruited from an emergency department at an urban academic medical center. The primary endpoints were changes in PEFR and in percent predicted PEFR over time (ie, treatment by time effect). PEFRs were assessed at baseline and at 20-minute intervals for a 1-hour period. The proportion of admissions in the two groups were examined as secondary endpoints. Results: The increases in PEFR and percent predicted PEFR over time were both significantly greater in the combined ipratropium plus albuterol treatment group ( P ≤.001). In addition, the proportion of admitted patients was less in this group (3/27) than the proportion in the albuterol-only group (10/28). The 95% confidence interval for the absolute difference of 25% in the proportion admitted was 3% to 46%, P =.03. Most of the baseline clinical and historical features in the two groups were similar. Conclusion: These data suggest that ipratropium should be combined with initial albuterol nebulization in the ED treatment of acute asthma in adults, especially those with PEFRs less than 200 L/min. [Lin RY, Pesola GR, Bakalchuk L, Morgan JP, Heyl GT, Freyberg CW, Cataquet D, Westfal RE: Superiority of ipratropium plus albuterol over albuterol alone in the emergency department management of adult asthma: A randomized clinical trial. Ann Emerg Med February 1998;31:208-213.]