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Abstract

Abstract

Objectives Asthma is an important health problem in Australia with more than 2.2. million Australians currently diagnosed with Asthma. Asthma is associated with significant mortality and frequent use of emergency medical services. The objectives of this paper were to: a) present a case study of a near-fatal episode of severe acute asthma in which the patient was administered corticosteroids by an Ambulance Service of New South Wales Extended Care Paramedic; b) review the epidemiology and pathophysiology of acute asthma as well as current pharmacotherapy in asthma management; and c) conduct a literature search and critical appraisal of existing evidence supporting the out-of-hospital administration of corticosteroids for acute asthma by paramedics.

Methods The purpose of the literature search was to identify comparative studies of adult patients with "acute" asthma treated by paramedics with corticosteroids prior to arrival at the emergency department (ED) to evaluate whether this intervention is associated with improved outcomes. A literature search of databases included the Cochrane Database of Systematic Reviews (Cochrane Reviews Issue 4 2008), Cochrane Central Register of Controlled Trials (Clinical Trials), Medline (1950- November 2008), EMBASE and CINAHL. A pre-hospital filter was applied to increase the sensitivity of the searches as appropriate. MeSH headings included exp/asthma, exp/hydrocortisone, exp/prednisone, exp/prednisolone and exp/glucocorticoids. Searched text words included asthma, hydrocortisone, prednisone and prednisolone. Titles and abstracts of interest were inspected to identify relevant articles with the full text of selected articles retrieved. Identified papers were independently appraised by two reviewers.

Results Only two original studies were identified. The first was a retrospective comparative study of adult patients with moderate to severe asthma who received 125 mg methylprednisolone prior to transport to hospital or after arrival in the ED. The second study was a retrospective chart review to determine whether the out-of-hospital administration of systemic steroids to asthmatic patients had any effect on hospital admission rates.

Conclusion Corticosteroids have been widely used in the hospital setting for many years in the treatment of acute asthma and there is good evidence to support their early administration in an ED setting. Out-of-hospital studies provide only weak evidence of benefit. There is insufficient evidence of adequate quality to determine if corticosteroids should be routinely used by paramedics. A prospective randomised controlled trial is needed to determine the true value of early corticosteroid administration in the ambulance setting.

Author Biography

Dr Jason Bendall FACAP Adv.Dip.Paramed.Sc. (ASNSW), B.Med.Sc. (Hons) (USyd), MBBS, Ph.D (Med) (USyd).

Dr Bendall is an Intensive Care Paramedic for the Ambulance Service of NSW. Dr Bendall was the foundation Project Manager for the ASNSW's Extended Care Paramedic program. Dr Bendall is also a medial graduate and works part-time as a Medical Officer for the Australian Defence Force. Dr Bendall has more recently undertaken further education in Clinical Epidemiology and Biostatistics at the University of Sydney. Dr Bendall is an Adjunct Senior Lecturer, School of Biomedical Sciences, Charles Sturt University. Dr Bendall's research interests include extended roles for paramedics, cardiac arrest management, analysis of large data sets and linked data analysis.

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