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AbstractBackground: Us f isids in ashma is a mus hwv h u f adminisain f sid in auxaain is a ma f da. Inavnus sids usd vy fqunly in linial pai may n ffany advanag v al sids.

Aim: t mpa h ffiay f al vs inavnus sids in aduls admid wih au xaain fnhial ashma.

Methods: Aduls admid hspial wih au xaain f ashma w andmizd iv alpdnisln 100 mg n daily hydisn 100 mg IV 6 huly f 72 hs fllwing admissin. All painsnunly ivd inhald isids and nhdilas. Impvmns in pak xpiay flw a(PeF) fm aslin w mpad f 72 hs.

Results: A al f 65 pains w andmizd, 34 ivd al pdnisln and 31 ivd inavnushydisn. bh gups w mahd a aslin f ag (4013.11 vs 4416.23, p 0.27) and pnagpdiin h p (20.11%6.17 vs 20.58%4.78, p 0.73) and ps nhdila (24.35%5.43 vs 25.38%5.01,p 0.43). Af 72hs h gups had impvmn in PeF whih was saisially insignifian (53.23%9.54 vs55.87%10.34, p 0.28)

Conclusion: cisids adminisd ally and IV had simila ffiay in h amn f aduls hspializdwih au xaain f nhial ashma.

*Ps gadua Sudn, **Pfss, ***Pfss and Had fDpamn, Pfss, Dp. f Gnal Mdiin, NKPSIMS andrc, Laa Mangshka Hspial, Nagpurivd: 23.06.2010; Apd: 27.10.2010

Introduction

Wih h advn f nw invsigaiv hniqus liknhspy and nhalvla lavag h hasn a adial hang in h pviusly hld viw gading hpahgnsis f nhial ashma. thus, h mphasis has nw

shifted from smooth muscle contraction to airway inammation.I has nw n pvd ynd du ha h aiway suinin asthma is caused by airway inammation leading to mucosalinltration and edema with mucus hypersecretion combinedwih smh musl hypphy and nhial hyp aiviy.It is therefore, logical that in a disease where inammationplays a maj l in h pahgnsis, isids y hvirtue of their potent anti-inammatory eects would helpin h lif f h sympms. bh inhald and sysmiisids hav vluinizd h amn f ashma.cunly sysmi isids addd nhdilatherapy are the cornerstones of management of signicantashma xaains.1 Several studies have shown the ecacyf sysmi isid hapy in minain wih

nhdila amns in pvning hspial admissin,duing laps a and hasning vy. 2 Sysmiisids als failia impvmn f ashma sympmsand lung funin and dud nd f a-agnis hapy.2-3oal isids a nvnin adminis and pniallysaf as mpad high ds ina vnus isids.4-7Alhugh al isids ak lng ah hapuilvls in ld han inavnus isids d, i ds nappear to be clinically signicant.

I is nw gnizd ha us f al isids in auasthma because of their virtue of potent anti-inammatoryeects, cost eectiveness and ease of administration makes themthe rst line of drugs in acute exacerbation of bronchial asthmain resource poor seings.

Materials and MethodsStudy design

this sudy was a andmizd, paalll mpaisn f alpdnisln vsus inavnus hydisn f 72 hs in htreatment of adults admied to hospital with acute exacerbationf ashma. th sudy was ndud in a mmuniy asd,ahing hspial, NKPSIMS and Laa Mangshka Hspial,Nagpu fm Jun 2007 Nvm 2009. th sudy wasapproved by the Institute Ethics Commiee. A wrien informednsn was akn fm all h sudy paiipans. Pains wnlld if hy m h ligiiliy iia. All pains ligiland willing paiipa in h sudy w nlld andandmizd ih f h sudy gup ading a mpugnad andmizain al. Pains w andmly assignd iv IV hydisn 100 mg 6 huly pdnisln 100mg orally daily for the rst 72 h after admission to hospital. After72 hus, pains in h gups ivd al pdnisln 50mg daily f 2 days. th ds f pdnisln was hn dud z in 5 mg dmns vy snd day.

All ashma amn apa fm u f adminisain fisids was kp h sam du h nfundingeect of other treatments .All patients received bronchodilatorhapy wih nulisd Saluaml 2.5 mg/2.5 ml fu imsa day and as quid. All pains als ivd inhaldisids hughu h sudy. If pains waking inhald isids pi andmizain hy

Original Article

Oral Versus Intravenous Steroids in AcuteExacerbation of Asthma Randomized Controlled Study

Gaurav Dembla*, RP Mundle**, HR Salkar***, DV Doifoide

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and pn impvmn) v h sudy pid. All PeFmasumns usd in analysis a ps-nhdilamasumns. Impvmns in PeF w alulad f ahpatient as the dierence between the rst and nal measurements

performed during the study period. Dierences between thew amn gups w mpad wih Wilxn ank-sumss as ms daa was n nmally disiud. chi-squadtests were used for comparison of proportions. Signicance was

s a alpha lss han qual 0.05 . Daa was analyzd usingMdcal 11.1.

ResultsDuing h sudy pid fm Jun 2007 Nvm 2009,

68 pains w nlld, hwv 3 sujs w wihdawnfm h sudy fllwing andmizain, n psn was unalto perform the peak expiratory ow while other two werewithdrawn after the rst dose of hydrocortisone as they were

fl hav adigaphi hangs nsisn wih pnumnia.th maining 65 pains w sussfully sudid as ph pl. of hs 34 pains ivd al pdnislnwhil 31 pains ivd inavnus hydisn. thw gups w wll mahd a aslin, wih sp ag,sx, high and aslin PeF. th p valu was fund nsignicant with respect to age, sex and height (Table 1). The PEF(ps nhdila) impvd fm 108.5327.32 a z h 23537.26 a 72 h in al pdnisln gup vsus 116.7729.26a z h 257.7466.72 a 72 h in hydisn gup (Fig.1). th pnag impvmn in PeF wih al pdnislnwas fm 24.355.43% 53.239.54% y day h (p 200 mg/dl.

Patients

Patients admied to hospital with acute asthma were enrolledif hy m h ligiiliy iia duing h sudy pid. t inludd in sudy pains ag shuld wn 18 70 ys,h was a dumnd hisy f nhial ashma, painsshuld hav a sh m vsiiliy in pak xpiayow > 20%. All patients having changes on chest X-Ray consistentwih pnumnia w xludd fm h sudy, als painswih ashma quiing ndahal inuain duing hspialstay, history of signicant chronic obstructive pulmonary disease(COPD), patients having signicant other disease like unstabledias, ishmi ha disas, malignany, hpai nalfailu and pains wh had ivd m han a al f 70mg pdnisln in n wk pi admissin w xluddfm h sudy.

Measurements

In all h pains, Pak expiay Flw (PeF) was masudusing hand-hld PeF ms (Pak Flw Mas; cipla) fand af saluaml in h mgny dpamn, oPD/IPD.Once admied to the ward all patients had their PEF measured6 huly, f and 10 min af nulisain wih saluamlf 72 hs and hn wi daily ill dishag. Pdid valusf PeF w alulad using fn quains fm heupan cmmuniy f Sl and cal f PeF.8 Length ofhospitalization was alulad f vy pain.

Sample Size calculation

A man impvmn in PeF f 50 L/min wn htwo groups after 72 hrs of treatment was dened as clinicallysignicant. To detect this dierence after 72 hours of treatment,with an of 0.05 and power of 80% an estimated sample size of68 pains (34 in ah sudy gup) was alulad.

Analysis

th pimay ndpins w PeF masumns a h ndf h 72 h and impvmn in PeF (aual masumn

Table 1 : Patient characteristics on admission

Group A(n= 34)

Group B(n= 31)

pvalue

Ag (ys) 4013.11 4416.23 0.27

Sx 0.38

Mal 15 19

Fmal 19 12

High (m) 1643.88 164.324.91 0.44

P bnhdila

PeF(L/min) 85.8822.31 94.8427.43 0.06

PeF % Pdid 20.116.17 20.584.78 0.73

Ps bnhdila

PeF(L/min) 108.5327.32 116.7729.26 0.14

PeF % Pdid 24.355.43 25.385.01 0.43

Fig. 1 : Comparison of percentage prediction of PEF

70.00

60.00

50.00

40.00

30.00

20.00

10.00

0.00

Oral IV

PEF

PercentPredicted

0 24 48 72

Hours after admission

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anti-inammatory drugs should be used in the management ofnhial ashma.6 this is in kping wih h suls f hpublished studies that have concluded that there is no signicantclinical benet in giving corticosteroids IV instead of orally inaduls wih au ashma.

A siking svain in u sudy is ha pains had alw PeF a psnain as mpad any f h sudis dnpviusly highlighing ha Indians hav lw PeF10 as mpad wsn ppulain whih may du limai ndiins,nuiinal and gni fas lading dasd lung andhs ag siz; hf h magniud f impvmn inPeF sn in u sudy ppulain is likly lss han hasn in any h sudis, as hy sa fm a high aslin apsnain. this als salishs h fa ha al sids a aseective as intravenous even if the PEF is as low as 80- 100 L/min.Alhugh un nsnsus guidlins f h managmn fashma gniz ha i is apppia us al isidsin au ashma1,9 h has n n Indian sudy valida his.

Indians as mpad wsn ppulain a nsiuinallyshorter and have less peak expiratory ow rates.10

th man lngh f hspial say in pains f auxaain f ashma is alms qual wih h us f al inavnus sids.

th sngh f u sudy is ha i is a andmizd, paallldsign. this dus h liklihd f ias in h sulsaind and is a mhdlgially sund way f nduing acomparative study between the ecacies of dierent drugs. Afuh sngh is h laivly lw ds f isids usdand h us f inhald isids as nmian ashmatreatment, as these reect current clinical practice making theresults more relevant and more generalized to adults admied

hspial wih au ashma. th ds f isids usdin his sudy was asd upn h mmnly usd inavnusds f hydisn 100 mg 6 huly and al ds washn s as pdnisln 100 mg daily, a ds wih quivalngluiid and minaliid ppis 400 mgf hydisn, 80 mg mhylpdnisln. Alhughh ds f pdnisln is high han mmnly usd andmmndd in linial pai, w fl i was impan ush ds f isids ha was h sam givn IV and allys ha his sudy mpas u f adminisain wihu hconfounding eect of unequal dosing.

Alhugh a dul-lind sudy is pfal, a andmizd,nnlind sudy an valid whn h daa a jiv. thadmiing criteria in this study were similar for the two groups,

Fig. 2 : Post-bronchodilator peak expiratory ow rate measurementsover the rst 72 h of admission. No signicant dierences between

treatments at any point. Means with standard error bars.

PEF Post Bronchodilator

350.00

300.00

250.00

200.00

150.00

100.00

50.00

0.00

Oral

PEF

0 24

Hours after admission

48 72

IV

as was hi amn, h han h dsag f sids. Dspiusing lw dss f sysmi isids and nmianmdiains u suls a nsisn wih h sudis dnpviusly.

th maj waknss f u sudy is ha w w unal exclude a small dierence in PEF improvement between groupsdu h lag vaiailiy in spns sn wn individualsand h laivly small num f pains sudid. Anhdawak in his sudy is ha af mahing f ag, sx and

high h PeF masumn was high in hydisn gupas mpad pains in pdnisln gup a h im fadmissin whih suggsd ha h pains in hydisngup w lss sv as mpad pdnisln gup.Hwv h vall magniud f impvmn sn in hprednisolone group was not dierent to that seen in less severehydisn gup and h w n amn failus inpdnisln gup.

In this study oral corticosteroids were eective in the treatmentof acute asthma in adults, and appeared to be at least as eectiveas isids adminisd inavnusly vn whn hasal PeF was fund lw. Givn ha al adminisain fisids has advanags v inavnus adminisain

in ms f s, as f adminisain, and pain mf; hus f al isids f au xaain f nhialashma is mmndd whv pssil spially in sulimited seings. However since this study was carried on a smallsus f ppulain and w uld n ahiv h ag samplsize so we cannot exclude a small dierence in eectivenesswn al and IV isids n lung funin in aduls72 h af admissin hspial f au ashma; hffurther studies on a larger scale and on dierent subsets of Indianppulain a quid.

References1. Nainal Ashma eduain and Pvnin Pgam: exp panl

p III: Guidlins f h diagnsis and managmn f ashma.

bhsda, MD: Nainal Ha, Lung, and bld Insiu, 2007.J Allergy Clin Immunology 2007;1220:S94-S138. www.nhli.nih.gv/guidlins/ashma/ashgdln.hm.

2. Rowe BH, Keller JL, Oxman AD. Eectiveness of steroid therapyin au ashma: a ma-analysis.Am J Emerg Med 1992;10:301310.

3. rdig c, rdig G. ealy adminisain f hydisn inh mgny m amn f au ashma: a nlld linialial. Respir Med 1994;88:75561.

4. Anku Shh, Savi rddymasu, r Jaksn. Wsning fashma wih sysmi isids: A as p and viw fliau.J Gen Intern Med 2006;21:c11-c13.

5. Hidy Nakamua, Yasushi oas, Kazuk Misuda, Shinyatmai: clinial valuain f anaphylai ains inavnusisids in adul ashmais. Respiration 2002;69:309-313.

6. GL Kamm, Ko Hagmy. Allgi-yp ains isids:th Annals f Phamahapy 1991;33:451-460.

7. Sphan M edmann, Fais Auzahaa, Hans F Mk. Anaphylaxisindud y gluiids:J Am Board Fam Practice 2005;18:143-6.

8. Quanj PH, tammling GJ, cs Je, Pdsn oF, Pslin r,Yernault JC. Lung volumes and forced ventilatory ows. ReportWking Pay sandadizain f lung funin ss, eupanCommunity for Steel and Coal. Ocial statement of the Europeanrspiay Siy. Eur Respir J Suppl 1993;16:540. wwwdgims..uk/dgims/linial/PeFr_aual_pdid.hm.

9. British Thoracic Society and Scoish Intercollegiate GuidelinesNwk. biish guidlins n h managmn f ashma 2003.

10. Debidas Ray, Abel Rajaratnam, J Richard: Peak expiratory ow inual sidns f tamil Nadu, India. Thorax 1993;48:163-166.