Magnesium sulfate for treating exacerbations of acute asthma in the emergency department

B H Rowe, J A Bretzlaff, C Bourdon, G W Bota, C A Camargo Jr, B H Rowe, J A Bretzlaff, C Bourdon, G W Bota, C A Camargo Jr

Abstract

Background: Treatment of acute asthma is based on rapid reversal of bronchospasm and arresting airway inflammation. There is some evidence that intravenous magnesium can provide additional bronchodilation when given in conjunction with standard bronchodilating agents and corticosteroids. No systematic review of this literature has been completed on this topic.

Objectives: To examine the effect of additional intravenous magnesium sulfate in patients with acute asthma managed in the emergency department.

Search strategy: Randomised controlled trials were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews and texts were searched. Primary authors and content experts were contacted.

Selection criteria: Randomised controlled trials or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with IV magnesium sulfate vs placebo.

Data collection and analysis: Data were extracted and methodological quality was assessed independently by two reviewers. Missing data were obtained from authors.

Main results: Seven trials were included (5 adult, 2 pediatric). A total of 665 patients were involved. Patients receiving magnesium sulfate demonstrated non-significant improvements in peak expiratory flow rates when all studies were pooled (weighted mean difference: 29.4 L/min; 95% confidence interval: -3.4 to 62). In studies of people with severe acute asthma, peak expiratory flow rate improved by 52.3 L/min (95% confidence interval: 27 to 77.5). The forced expiratory volume in one second also improved by 9.8 % predicted (95% confidence interval: 3.8 to 15.8). Overall, admission to hospital was not reduced, odds ratio: 0.31 (95% confidence interval: 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (odds ratio: 0.10, 95% confidence interval: 0.04 to 0.27). No clinically important changes in vital signs or adverse side effects were reported.

Reviewer's conclusions: Current evidence does not support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the emergency department. Magnesium sulfate appears to be safe and beneficial in patients who present with severe acute asthma.

Conflict of interest statement

The authors who have been involved in this review have done so without any known conflicts of interest. They are neither involved with the primary studies nor affiliated with any pharmaceutical company that produces magnesium sulfate.

Figures

1.1. Analysis
1.1. Analysis
Comparison 1 Intravenous MgSO4 vs placebo, Outcome 1 Admission to hospital.
1.2. Analysis
1.2. Analysis
Comparison 1 Intravenous MgSO4 vs placebo, Outcome 2 Pulmonary function testing.
1.3. Analysis
1.3. Analysis
Comparison 1 Intravenous MgSO4 vs placebo, Outcome 3 Vital signs.
1.4. Analysis
1.4. Analysis
Comparison 1 Intravenous MgSO4 vs placebo, Outcome 4 Major Side Effects.
1.5. Analysis
1.5. Analysis
Comparison 1 Intravenous MgSO4 vs placebo, Outcome 5 ED Treatment Time.
2.1. Analysis
2.1. Analysis
Comparison 2 Intravenous MgSO4 vs Placebo (Severe Asthma subgroup), Outcome 1 Pulmonary function testing.

References

References to studies included in this review Bloch 1995 {published data only}

    1. Bloch H, Silverman R, Mancherje N, Grant S, Jagminas L, Scharf SM. Intravenous magnesium sulfate as an adjunct in the treatment of acute asthma. Chest 1995;107:1576‐81.
Ciarallo 1997 {published data only}
    1. Ciarallo L, Sauer AH, Shannon MW. Intravenous magnesium therapy for moderate to severe pediatric asthma: Results of a randomized, placebo‐controlled trial. The Journal of Pediatrics 1996;129:809‐14.
Devi 1997 {published data only}
    1. Devi PR, Kumar L, Singhi SC, Prasad R, Singh M. Intravenous magnesium sulfate in acute severe asthma not responding to conventional therapy. Indian Pediatrics 1997;34:389‐97.
Green 1992 {published data only}
    1. Green SM, Rothrock SG. Intravenous magnesium for acute asthma: Failure to decrease emergency treatment duration or need for hospitalization. Annals of Emergency Medicine 1992;21(3):260‐5.
Silverman 1996 {published and unpublished data}
    1. Silverman R, Osborne H, Runge J, Feldman J, Scharf S, Mancherje N, et al. Magnesium sulfate as an adjunct to standard therapy in acute severe asthma [abstract]. Academic Emergency Medicine 1996;3:467‐8.
Skobeloff 1989 {published data only}
    1. Skobeloff EM, Spivey WH, McNamara RM, Greenspoon L. Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department. JAMA 1989;262:1210‐3.
Tiffany 1993 {published data only}
    1. Tiffany BR, Berk WA, Todd IK, White SR. Magnesium bolus or infusion fails to improve expiratory flow in acute asthma exacerbations. Chest 1993;104:831‐4.
References to studies excluded from this review Bernstein 1995 {published data only}
    1. Bernstein WK, Khastgir T, Khastgir A, et al. Lack of effectiveness of magnesium in chronic stable asthma. A prospective, randomized, double‐blind, placebo‐controlled, crossover trial in normal subjects and in patients with chronic stable asthma. Archives of Internal Medicine 1995;155:271‐6.
Brunner 1985 {published data only}
    1. Brunner EH, Delabroise AM, Haddad ZH. Effect of parenteral magnesium on pulmonary function, plasma cAMP, and histamine in bronchial asthma. Journal of Asthma 1985;22:3‐11.
Cairns 1996 {published data only}
    1. Cairns CB, Kraft M. Magnesium attenuates the neutrophil respiratory burst in adult asthmatic patients. Academic Emergency Medicine 1996;3:1093‐7.
Chande 1992 {published data only}
    1. Chande VT, Skoner DP. A trial of nebulized magnesium sulfate to reverse bronchospasm in asthmatic patients. Annals of Emergency Medicine 1992;21:1111‐5.
Hicks Keen 1995 {published data only}
    1. Hicks Keen J. Intravenous magnesium sulfate for acute asthma. Journal of Emergency Nursing 1995;21:44‐6.
Kufs 1990 {published data only}
    1. Kufs WM. Intravenous magnesium sulfate in acute asthma (letter). Journal of American Medical Association 1990;263:516‐7.
Kuitert 1991 {published data only}
    1. Kuitert LM, Kletchko SK. Intravenous magnesium sulfate in acute, life‐threatening asthma. Annals of Emergency Medicine 1991;20:1243.
Landon 1993 {published data only}
    1. Landon RA, Young EA. Role of magnesium in regulation of lung function. Journal of the American Dietetic Association 1993;93:674‐7.
McDonald 1994 {published data only}
    1. McDonald AJ. New approaches to emergency management of asthma. Respiratory Management 1994;21:52‐8.
McLean 1994 {published data only}
    1. McLean RM. Magnesium and its therapeutic uses: A review. The American Journal of Medicine 1994;96:63‐76.
McNamara 1989 {published data only}
    1. McNamara RM, Spivey WH, Skobeloff E, Jacubowitz S. Intravenous magnesium sulfate in the management of acute respiratory failure complicating asthma. Annals of Emergency Medicine 1989;18:197‐9.
Meral 1996 {published data only}
    1. Meral A, Coker M, Tanac R. Inhalation therapy with magnesium sulfate and salbutamol sulfate in bronchial asthma. Turkish Journal of Pediatrics 1996;38:169‐75.
Noppen 1990 {published data only}
    1. Noppen M, Vanmaele L, Impens N, Schandevyl W. Bronchodilating effect of intravenous magnesium sulfate in acute severe bronchial asthma. Chest 1990;97:373‐6.
Okayama 1987 {published data only}
    1. Okayama H, Aikawa T, Okayama M, Sasaki H, Mue S, Takishima T. Bronchodilating effect of intravenous magnesium sulfate in bronchial asthma. Journal of American Medical Association 1987;257:1076‐8.
Pabon 1994 {published data only}
    1. Pabon H, Monen G, Kissoon N. Safety and efficacy of magnesium sulfate infusions in children with status asthmaticus. Pediatric Emergency Care 1994;10:200‐3.
Rolla 1987 {published data only}
    1. Rolla G, Bucca C, Bugiani M, Arossa W, Spinachi S. Reduction of histamine‐induced bronchoconstriction by magnesium in asthmatic patients. Allergy 1987;42:186‐8.
Rolla 1988 {published data only}
    1. Rolla G, Bucca C, Caria E, Arossa W, Bugiani M, Cesano L, et al. Acute effect of intravenous magnesium sulfate on airway obstruction of asthmatic patients. Annals of Allergy 1988;61:388‐91.
Schiermeyer 1994 {published data only}
    1. Schiermeyer RP, Finkelstein JA. Rapid infusion of magnesium sulfate obviates need for intubation in status asthmaticus. American Journal of Emergency Medicine 1994;12:164‐8.
Sharma 1994 {published data only}
    1. Sharma SK, Bhargava A, Pande JN. Effect of parenteral magnesium sulfate on pulmonary functions in bronchial asthma. Journal of Asthma 1994;31:109‐15.
Sydow 1993 {published data only}
    1. Sydow M, Crozier TA, Zielmann S, Radke J, Burchardi H. High‐dose intravenous magnesium sulfate in the management of life‐threatening status asthmaticus. Intensive Care Medicine 1993;19:467‐71.
Additional references Beveridge 1996
    1. Beveridge RC, Grunfeld AF, Hodder RV, Verbeek PR. Guidelines for the emergency management of asthma in adults. Canadian Medical Association Journal 1996;155:25‐37.
BTS 1997
    1. BTS. The British guidelines on asthma management: 1995 review and position statement. Thorax 1997;52:152‐6.
Camargo 1998
    1. Camargo CA Jr, on behalf of the MARC Investigators. Management of acute asthma in US emergency departments: The Multicenter Asthma Research Collaboration [abstract]. American Journal of Respiratory and Critical Care Medicine 1998:157.
Cates 1998
    1. Cates C. Comparison of holding chambers and nebulisers for beta‐agonists in acute asthma (Cochrane Review). Cochrane Library 1998, Issue Issue 3.
Jadad 1996
    1. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Controlled Clinical Trials 1996;17:1‐12.
Lipworth 1997
    1. Lipworth BJ. Treatment of acute asthma. Lancet 1997;350(Suppl):18‐23.
Littenberg 1988
    1. Littenberg B. Aminophylline treatment in severe acute asthma: A meta‐analysis. Journal of American Medical Association 1988;259:1678‐84.
NAEPP 1997
    1. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health 1997:Bethesda, MD.
Oxman 1992
    1. Oxman AD, Guyatt GH. A consumer's guide to subgroup analyses. Annals of Internal Medicine 1992;116:78‐84.
Plotnik 1998
    1. Plotnik LH, Ducharme FM. Efficacy and safety of combined inhaled anticholinergics and beta‐2‐agonists in the initial management of acute pediatric asthma (Cochrane Review). The Cochrane Library 1998, Issue Issue 3.
Rowe 1992
    1. Rowe BH, Keller JL, Oxman AD. Steroid use in the emergency department treatment of asthma exacerbations: A meta‐analysis. American Journal of Emergency Medicine 1992;10:301‐10.
Rowe 1997
    1. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. The effectiveness of corticosteroids in the treatment of acute exacerbations of asthma: A meta‐analysis of their effect on relapse following acute assessment (Cochrane Review). Cochrane Library 1997, Issue Issue 2.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel