Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis

Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis. Baggott, C., Hardy, J. K., Sparks, J., Sabbagh, D., Beasley, R., Weatherall, M., & Fingleton, J. Thorax, 77(6):563–572, June, 2022.

Paper doi abstract bibtex

Background International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β 2 -agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β 2 -agonist in acute asthma. Methods We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β 2 -agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death. Results Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I 2 =56%. The pooled Peto’s OR for treatment failure with epinephrine versus selective β 2 -agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β 2 -agonist improved outcomes. Conclusion The low-quality evidence available suggests that epinephrine and selective β 2 -agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β 2 -agonist improves outcome. PROSPERO registration number CRD42017079472.

@article{baggott_epinephrine_2022,
	title = {Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis},
	volume = {77},
	issn = {0040-6376, 1468-3296},
	shorttitle = {Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma},
	url = {https://thorax.bmj.com/lookup/doi/10.1136/thoraxjnl-2021-217124},
	doi = {10.1136/thoraxjnl-2021-217124},
	abstract = {Background 
               
                International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β 
                2 
                -agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β 
                2 
                -agonist in acute asthma. 
               
             
             
              Methods 
               
                We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β 
                2 
                -agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death. 
               
             
             
              Results 
               
                Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I 
                2 
                =56\%. The pooled Peto’s OR for treatment failure with epinephrine versus selective β 
                2 
                -agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β 
                2 
                -agonist improved outcomes. 
               
             
             
              Conclusion 
               
                The low-quality evidence available suggests that epinephrine and selective β 
                2 
                -agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β 
                2 
                -agonist improves outcome. 
               
             
             
              PROSPERO registration number 
              CRD42017079472.},
	language = {en},
	number = {6},
	urldate = {2024-05-30},
	journal = {Thorax},
	author = {Baggott, Christina and Hardy, Jo Katherine and Sparks, Jenny and Sabbagh, Doñah and Beasley, Richard and Weatherall, Mark and Fingleton, James},
	month = jun,
	year = {2022},
	pages = {563--572},
}

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However, administration of intramuscular epinephrine in addition to nebulised selective β 2 -agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β 2 -agonist in acute asthma. Methods We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β 2 -agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death. Results Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I 2 =56%. The pooled Peto’s OR for treatment failure with epinephrine versus selective β 2 -agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β 2 -agonist improved outcomes. Conclusion The low-quality evidence available suggests that epinephrine and selective β 2 -agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β 2 -agonist improves outcome. PROSPERO registration number CRD42017079472.","language":"en","number":"6","urldate":"2024-05-30","journal":"Thorax","author":[{"propositions":[],"lastnames":["Baggott"],"firstnames":["Christina"],"suffixes":[]},{"propositions":[],"lastnames":["Hardy"],"firstnames":["Jo","Katherine"],"suffixes":[]},{"propositions":[],"lastnames":["Sparks"],"firstnames":["Jenny"],"suffixes":[]},{"propositions":[],"lastnames":["Sabbagh"],"firstnames":["Doñah"],"suffixes":[]},{"propositions":[],"lastnames":["Beasley"],"firstnames":["Richard"],"suffixes":[]},{"propositions":[],"lastnames":["Weatherall"],"firstnames":["Mark"],"suffixes":[]},{"propositions":[],"lastnames":["Fingleton"],"firstnames":["James"],"suffixes":[]}],"month":"June","year":"2022","pages":"563–572","bibtex":"@article{baggott_epinephrine_2022,\n\ttitle = {Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis},\n\tvolume = {77},\n\tissn = {0040-6376, 1468-3296},\n\tshorttitle = {Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma},\n\turl = {https://thorax.bmj.com/lookup/doi/10.1136/thoraxjnl-2021-217124},\n\tdoi = {10.1136/thoraxjnl-2021-217124},\n\tabstract = {Background \n \n International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β \n 2 \n -agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β \n 2 \n -agonist in acute asthma. \n \n \n \n Methods \n \n We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β \n 2 \n -agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death. \n \n \n \n Results \n \n Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I \n 2 \n =56\\%. The pooled Peto’s OR for treatment failure with epinephrine versus selective β \n 2 \n -agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β \n 2 \n -agonist improved outcomes. \n \n \n \n Conclusion \n \n The low-quality evidence available suggests that epinephrine and selective β \n 2 \n -agonists have similar efficacy in acute asthma. 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