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INHALED STEROIDS IN ACUTE ASTHMA
Letters to the editor BABYHALER, HIDDEN HAZARDS To the Editor: Allergic small airways disease is an important and increasing chronic illness in childhood. Hong Kong is one of the developed areas of the world experiencing increased prevalence of this problem in young children.1 Inhalation devices are the best way to deliver prophylactic therapy.1,2 Patient coordination and cooperation required in the use of conventional inhalation devices preclude their use in very young children. Portable devices such as the Babyhaler provide a convenient, economical and portable alternative to compressors with nebulizers.2 Babyhalers recently were introduced into our community. I have over the past month been concerned with instances when parents whose children had been prescribed metered-dose inhaled drugs via Babyhalers found it ineffective. When I reviewed the techniques of use I found that parents were inserting the meter-dose inhalers with their caps in situ into the Babyhaler, preventing drug delivery. Although there is written instruction on every Babyhaler about the proper use of the spacer device, patients are not always able to follow these directions. Clinicians must review with patients and parents how to use such devices however simple they may appear to be. ROBERT YING MEI TSENG, FRCP Consultant paediatrician Evangel Hospital, Hong Kong Honorary Lecturer in paediatrics Chinese University of Hong Kong JUDY TSENG MEI YING Clinic Nurse REFERENCES 1. Tseng RYM. Prevention of childhood asthma: facts, fantasies and prospects. Paediatr Rev Commun (UK) 1990;4: 183–99.
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2. Clarke JR, Aston H, Silverman M. Delivery of salbutamol by metered dose inhaler and valved spacer to wheezy infants: effect on bronchial responsiveness. Arch Dis Childhood 1993;69: 125–9.
INHALED STEROIDS IN ACUTE ASTHMA To the Editor: The review by Dr. Cockcroft on “Management of acute severe asthma” was very informative.1 I would like to ask if he is aware of any specific references for why in Figure 1, the discharge treatment plan, part B3, recommends “initiate” 500 –1,000 g/day of inhaled corticosteroids. If so, are inhaled corticosteroids acutely helpful? Neither the Global Initiative for Asthma nor the International Guidelines mention using inhaled corticosteroids acutely. Furthermore, inhaled beclomethasone can often produce coughing and bronchospasm.2,3 NEIL L. KAO, MD Asst Prof Clinical Medicine U Illinois College of Medicine at Rockford Rockford, Illinois REFERENCES 1. Cockcroft DW. Management of acute severe asthma. Ann Allergy Asthma, Immunol 1995;75:83–9. 2. Shim C, Williams MH Jr. Cough and wheezing from beclomethasone aerosol. Chest 1987;91:207–9. 3. Clark RJ. Exacerbation of asthma after nebulised beclomethasone dipropionate. Lancet 1986;2:574.
Response: I would like to thank Dr. Kao for his comments on the review of “Management of acute severe asthma.” The discharge treatment guidelines (B3) recommend continuing or introducing inhaled corticosteroids, beclomethasone dipropionate (BDP) or budesonide, in a dose of 500 to 1000 g or
more per day. As noted, this is considered “an integral part of long-term management.” This is intended to be in addition to a short course of ingested corticosteroids, generally prednisone as noted under B1. I am not aware of any references dealing with the treatment of acute severe exacerbations with inhaled corticosteroids alone, and would think that this would have some risks. There is little doubt, however, that high doses of inhaled corticosteroids, where they are available, may be quite effective in management of unstable chronic asthma.1 They are routinely used in our country for the management of less severe exacerbations, and a stepup in dosage early during an exacerbation is a routine component of asthma selfmanagement programs.2,3 I would suggest that inhaled corticosteroids alone are not recommended for treatment of acute severe exacerbations except under the most unusual of circumstances. On a couple occasions, when faced with a patient who refused to take ingested corticosteroids, we have reluctantly relied on high-dose inhaled corticosteroids (2 mg per day of BDP) to treat such an exacerbation, fortunately with success. DW COCKCROFT, MD Division of Respiratory Medicine Royal University Hospital 103 Hospital Drive, Ellis Hall Saskatoon, SK S7N 0W8 Canada REFERENCES 1. Salmeron S, Guerin J-C, Godard P, et al. High doses of inhaled corticosteroids in unstable chronic asthma. Am Rev Respir Dis 1989;140:167–71. 2. Woolcock A, Rubinfeld AR, Seal JP, et al. Asthma management plan, 1989. Med J Austr 1989;151:650. 3. Hargreave FE, Dolovich J, Newhouse MT, eds. The assessment and treatment of asthma: a conference report. J Allergy Clin Immunol 1990;85: 1098 –111.
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
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2. Clarke JR, Aston H, Silverman M. Delivery of salbutamol by metered dose inhaler and valved spacer to wheezy infants: effect on bronchial responsiveness. Arch Dis Childhood 1993;69: 125–9.
INHALED STEROIDS IN ACUTE ASTHMA To the Editor: The review by Dr. Cockcroft on “Management of acute severe asthma” was very informative.1 I would like to ask if he is aware of any specific references for why in Figure 1, the discharge treatment plan, part B3, recommends “initiate” 500 –1,000 g/day of inhaled corticosteroids. If so, are inhaled corticosteroids acutely helpful? Neither the Global Initiative for Asthma nor the International Guidelines mention using inhaled corticosteroids acutely. Furthermore, inhaled beclomethasone can often produce coughing and bronchospasm.2,3 NEIL L. KAO, MD Asst Prof Clinical Medicine U Illinois College of Medicine at Rockford Rockford, Illinois REFERENCES 1. Cockcroft DW. Management of acute severe asthma. Ann Allergy Asthma, Immunol 1995;75:83–9. 2. Shim C, Williams MH Jr. Cough and wheezing from beclomethasone aerosol. Chest 1987;91:207–9. 3. Clark RJ. Exacerbation of asthma after nebulised beclomethasone dipropionate. Lancet 1986;2:574.
Response: I would like to thank Dr. Kao for his comments on the review of “Management of acute severe asthma.” The discharge treatment guidelines (B3) recommend continuing or introducing inhaled corticosteroids, beclomethasone dipropionate (BDP) or budesonide, in a dose of 500 to 1000 g or
more per day. As noted, this is considered “an integral part of long-term management.” This is intended to be in addition to a short course of ingested corticosteroids, generally prednisone as noted under B1. I am not aware of any references dealing with the treatment of acute severe exacerbations with inhaled corticosteroids alone, and would think that this would have some risks. There is little doubt, however, that high doses of inhaled corticosteroids, where they are available, may be quite effective in management of unstable chronic asthma.1 They are routinely used in our country for the management of less severe exacerbations, and a stepup in dosage early during an exacerbation is a routine component of asthma selfmanagement programs.2,3 I would suggest that inhaled corticosteroids alone are not recommended for treatment of acute severe exacerbations except under the most unusual of circumstances. On a couple occasions, when faced with a patient who refused to take ingested corticosteroids, we have reluctantly relied on high-dose inhaled corticosteroids (2 mg per day of BDP) to treat such an exacerbation, fortunately with success. DW COCKCROFT, MD Division of Respiratory Medicine Royal University Hospital 103 Hospital Drive, Ellis Hall Saskatoon, SK S7N 0W8 Canada REFERENCES 1. Salmeron S, Guerin J-C, Godard P, et al. High doses of inhaled corticosteroids in unstable chronic asthma. Am Rev Respir Dis 1989;140:167–71. 2. Woolcock A, Rubinfeld AR, Seal JP, et al. Asthma management plan, 1989. Med J Austr 1989;151:650. 3. Hargreave FE, Dolovich J, Newhouse MT, eds. The assessment and treatment of asthma: a conference report. J Allergy Clin Immunol 1990;85: 1098 –111.
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY