Written by Alex Clark
Spoon Feed
Nebulized high-dose inhaled corticosteroid plus a short acting beta-agonist reduced emergency department length of stay in adult asthma exacerbation.
Breathe easy budesonide
Guidelines for moderate to severe asthma recommend a single inhaler containing combination inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) for both maintenance and rescue rather than traditional single short acting beta-agonist (SABA) alone. However, evidence supporting the addition of nebulized high-dose ICS in acute adult exacerbation is limited.
This triple-blinded, randomized controlled trial performed at an academic medical center in Thailand examined nebulized high-dose ICS (3000µg budesonide; n = 44) versus placebo (n = 44) in adult emergency department (ED) patients with acute asthma exacerbation. Both arms also received systemic corticosteroids and a nebulized combination of fenoterol/ipratropium. They excluded patients requiring intubation or with COVID-19, tuberculosis, or steroids within 7 days.
The high-dose ICS group had shorter ED length of stay (difference -133.6 min, p = 0.016) and more ED discharges within 8 (p<0.001) and 16 hours (0.009). No significant differences were seen in admission rates, ED revisits, pulmonary function testing, length of hospital stay, or exacerbations after ED discharge. This trial is underpowered, has low external validity, and high potential for bias due to a sicker control arm and outcomes centered on operational metrics (ie. ED length of stay) that are susceptible to confounding extrinsic factors.
How does this change my practice?
I currently treat acute asthma exacerbations with SABAs, systemic steroids (IV vs. PO), +/- adjuncts including magnesium, epinephrine, BiPAP, and an ICS-LABA single maintenance and reliever therapy prescription if discharged. Given the limitations above, I am skeptical that a 7 vs. 9-hour length of ED stay is clinically meaningful enough to justify the addition of nebulized high-dose ICS. Especially when prolonged high-dose ICS is associated with MACE, PE, pneumonia, and arrhythmia. I need more evidence before adding nebulized ICS in my ED practice.
Source
Nebulised high-dose corticosteroids as add-on therapy for adults with asthma exacerbation: a randomised controlled trial. Emerg Med J. 2025 Jan 21;42(2):91-97. doi: 10.1136/emermed-2024-213893. PMID: 39694823
