Inhaled steroids are the most effective and safe therapy for managing acute asthma, contrary to the belief that they are a last resort. The document discusses the terminology used for asthma exacerbations and emphasizes the importance of early high-dose inhaled corticosteroids in emergency settings to reduce hospitalization needs. Additionally, it highlights the ongoing prescription of inhaled corticosteroids after discharge to prevent future exacerbations.

1. INHALED STEROIDS IN
MANAGEMENT OF ACUTE
ASTHMA
Dr. MOHAMED MOSTAFA KAMEL
MBBCH, M.Sc, MD, FCCP
Professor of Pulmonology
Kasr AL Aini Faculty of Medicine
Cairo University
mmkhope@hotmail.com

4. • Inhalation therapy is the most widely misunderstood
of all therapies used for the treatment of asthma. It
is considered by many to be the last resort for an
asthmatic patient.
• On the contrary, inhalation therapy is the most
effective, safe and cost effective of all therapy.

6. Glucocorticoids
inhibit the main steps in the
asthma inflammatory response

7. • Reversibility of airways’ obstruction
– Increased PEF >15% 15-20 minutes after inhaling ß2-agonist
• Variability of airways’ obstruction
– PEF varies between morning and evening
>20% in patients taking bronchodilator
>10% in patients not taking bronchodilator
• Exercise-induced airways’ obstruction
– Decreased PEF >15% after 6 minutes of exercise
GINA Guidelines
Is it asthma?

8. Inhaled steroids
GINA 2002

9. ASTHMA EXACERBATIONS ;
ACUTE SEVERE ASTHMA

10. Terminology about exacerbations
• The academic term ‘exacerbation’ is commonly used in scientific and
clinical literature, although hospital-based studies more often refer
to ‘acute severe asthma’. However, the term ‘exacerbation’ is not
suitable for use in clinical practice, as it is difficult for many patients
to pronounce and remember.
• The term ‘flare-up’ is simpler, and conveys the sense that asthma is
present even when symptoms are absent. The term ‘attack’ is used
by many patients and health care providers but with widely varying
meanings, and it may not be perceived as including gradual
worsening.
• In pediatric literature, the term ‘episode’ is commonly used, but
understanding of this term by parent/carers is not known.

11. Definition of asthma exacerbations
• Exacerbations of asthma are episodes characterized
by a progressive increase in symptoms of shortness
of breath, cough, wheezing or chest tightness and
progressive decrease in lung function, i.e. they
represent a change from the patient’s usual status
that is sufficient to require a change in treatment.
• Severe exacerbations can occur in patients with mild
or well-controlled asthma.
Reddel H, Ware S, Marks G, Salome C, Jenkins C, Woolcock A. Differences between asthma exacerbations and poor asthma control [erratum
in Lancet 1999;353:758]. Lancet 1999;353:364-9.
Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and
exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009;180:59-99.

15. Self-management of worsening
asthma in adults and adolescents
with a written asthma action plan

18. MANAGEMENT OF ASTHMA
EXACERBATIONS IN PRIMARY CARE

21. MANAGEMENT OF ASTHMA
EXACERBATIONS IN THE
EMERGENCY DEPARTMENT

24. Inhaled corticosteroids
• Within the emergency department: high-dose ICS given
within the first hour after presentation reduces the need for
hospitalization in patients not receiving systemic
corticosteroids (Evidence A).
• When given in addition to systemic corticosteroids,
evidence is conflicting (Evidence B).
• Overall, ICS are well tolerated; however, cost is a significant
factor, and the agent, dose and duration of treatment with
ICS in the management of asthma in the emergency
department remain unclear.
Edmonds ML, Milan SJ, Camargo CA, Jr., Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency
department treatment of acute asthma. Cochrane Database Syst Rev 2012;12:CD002308.

27. Ann Thorac Med 2009; 4(4): 216-233

28. Nebulised corticosteroids
• Rapid effects: 1-2 hrs to produce therapeutic effects.
• Topical effect: Vasoconstriction in airway mucosa
• Earlier onset & shorter duration
• Very effective in all patients with asthma attacks.
• A potential alternative to SCS in acute asthma not requiring hospitalization.
• Helpful in steroid dependent asthmatic patients to reduce their
maintenance dose of oral steroids thereby reducing the risk of long term
adverse effects.
Chest 2006; 130:1301–1311
Clin Cornerstone 4 (6) :1-17, 2002
Expert Rev Clin Immunol 4 (6):723-729, 2008
Curr Opin Allergy Clin Immunol 3 (3): 169-175, 2003

29. 0
100
90
80
70
60
50
40
30
20
10
Pulmicort
Prednisolon
EndobronchealDosemg/ml
Bai et al. ATS 2001
Pulmicort
Respules
(4 mg TID)
Prednisolone
(60 mg / day)
ICS & PO steroid in acute asthma
Local & systemic concentration
w.sinagroup.net
SystemicDosemg/ml
100
90
80
70
60
50
40
30
20
10
0

30. On discharge home
• The majority of patients should be prescribed regular ongoing ICS
treatment since the occurrence of a severe exacerbation is a risk factor for
future exacerbations (Evidence B) and ICS-containing medications
significantly reduce the risk of asthma-related death or hospitalization
(Evidence A).
• For short-term outcomes such as relapse requiring admission, symptoms,
and quality of life, a systematic review found no significant differences
when ICS were added to systemic corticosteroids after discharge.
• There was some evidence, however, that post-discharge ICS were as
effective as systemic corticosteroids for milder exacerbations, but the
confidence limits were wide (Evidence B).
• Cost may be a significant factor for patients in the use of high-dose ICS,
and further studies are required to establish their role.
Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N
Engl J Med 2000;343:332-6.
Edmonds ML, Milan SJ, Brenner BE, Camargo CA, Jr., Rowe BH. Inhaled steroids for acute asthma following
emergency department discharge. Cochrane Database Syst Rev 2012;12:CD002316.

31. THANK YOU
THANK YOU