Enough oral steroids for asthma attacks

Introduction

Oral steroids (corticosteroids) are needed when treating acute asthma attacks

Oral steroids are usually needed for treating acute asthma attacks. Most importantly they should be continued until the attack (exacerbation) has resolved.

Treatment of acute asthma exacerbations

Asthma attacks (also known as exacerbations) should be managed by treating the acute symptoms with drugs; and also by establishing why the person had an attack; and whether any preventable risk factors can be addressed to regain control. In my opinion, and the findings of the NRAD, not enough effort is put into the last two aspects of treatment of asthma attacks. In this item, I discuss the drugs and will address the other issues in a later blog.

Note for people with asthma and families:

This blog  is not intended as medical advice for individual people with asthma. Always consult your own doctor for advice, but please do feel free to  use this blog as a basis for discussion.

Drug treatment of asthma attacks includes

  • High doses of reliever medication (short acting bronchodilators, salbutamol – usually delivered via an oxygen driven nebuliser or a blue inhaler using a spacer device.)
  • Oxygen (Ideally used to drive a nebuliser at flow rates over 6L/min)
  • Corticosteroids (prednisolone, cortisone) –  life saving drugs during attacks which help to clear up the inflammation that occurs before and during attacks.

Corticosteroid tablets or injections take about 6 hours to work

So its really important to start the oral corticosteroids as soon as possible. however there are often delays in starting these drugs in hospital so an obvious solution is to provide patients with a course of oral corticosteroids so they can start these themselves.

No one knows how long an asthma attack lasts

Many doctors prescribe oral corticosteroids for 3, 5 or 7 days without any follow up evaluation. This is illogical since no one can predict how long an attack will last.

Tamara Mills had 47 asthma attacks in her last 4 1/2 years of life

24/47 were attendances at A&E (ED) and 21/47 were hospital admissions

With permission of Tamara’s mother I share her sad story. Tamara died just before her 14th birthday. Of her 47 flare-ups (Attacks/exacerbations) 20 were re-attendances due to incomplete treatment of attacks. With the exception of one of these attacks she was prescribed 3 or 5 days of oral corticosteroids without any follow up by an asthma doctor. The only time she got 14 days post attack treatment was after she had a near fatal attack while in hospital.

A respiratory paediatrician was fortuitously on duty on one occasion

The morning after Tamara was resuscitated after having a life threatening asthma attack while in hospital she saw a paediatrician with a special interest in asthma for the first time

This was the only time she got 14 days of oral corticosteroids for acute asthma

Tamara was prescribed 14 days of prednisolone (oral corticosteroid) only once. This was the only time her asthma was taken seriously. That was by chance because she saw a paediatrician with a special interest in asthma that morning. See the coroners report here. However, she was never referred to an asthma specialist after this admission to hospital.

Why it is inappropriate to prescribe oral steroids for a fixed time

The problem being that a proportion of people have another attack soon after being treated for one. One of the explanations for this is that the first attack wasn’t treated until completely resolved . For more on this see here.

Conclusion

So what do people with asthma and health professionals need to do in order to try to reduce the number of preventable asthma attacks?

In my opinion, three things:

  1. People treated for asthma attacks should see their doctor (or asthma nurse) before they run out of corticosteroid (cortisone) tablets so they can be advised whether their attack has resolved, whether to continue or stop these tablets and also so that the health professional can identify what went wrong/what led to the attack and optimise the treatment.
  2. To be provided with a peak flow meter and symptom diary chart when sending someone home after treatment of an asthma attack. This could help patients, their carers and health care professionals determine whether the attack has resolved based on the readings as well as symptoms. These readings can help decide when the attack is over and when to discontinue corticosteroids.
  3. The health care professional should do a detailed asthma review (see here how to do a post attack review)after the attack to determine what went wrong and to optimise treatment based on the assessment.

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