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Three Part Question

In [emergency department patients with uncomplicated acute bronchitis], how does [administration of systemic steroids compared to supportive care alone] affect [duration of symptoms]?

Clinical Scenario

A 60-year-old male with noncontributory past medical history presents with two weeks of productive cough. His initial course of illness included additional upper respiratory tract infection symptoms, all of which improved within the first five days apart from the cough. He has an albuterol inhaler and Tessalon Perles available at home though has not perceived any significant benefit from these therapies. The patient has stable vitals, unremarkable exam apart from frequent productive cough, unremarkable basic labs (COVID negative), and chest x-ray negative for consolidation. He is diagnosed with uncomplicated acute bronchitis. He is frustrated with the frequent coughing and asks if there are any other available therapies. Oral steroids are considered.

Search Strategy

Medline 1966-01/24 using PubMed, Cochrane Library (2023), and Embase
[("acute bronchitis" OR "acute lower respiratory tract infection" OR "acute cough" OR "subacute cough" OR "post infectious cough") AND (steroids OR corticosteroids OR glucocorticoids OR prednisone OR prednisolone OR methylprednisolone OR dexamethasone OR betamethasone)] LIMIT to English language.

Search Outcome

Fifteen total papers were found, two of which were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hay AD, et al August 2017 United Kingdom	401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years.	RCT	Duration of moderately bad or worse cough	5 days in both groups (P=0.36)	Limited sample size; selection bias in recruiting; higher than expected number of participants with zero duration of moderately bad or worse cough; baseline biomarkers (eg, inflammatory, microbiological, spirometric, or radiographic) were not measured; some patients with chronic or postinfectious cough may have been included.
			Mean severity of symptoms on days 2 to 4	1.99 points in the prednisolone group and 2.16 points in the placebo group (P=0.05).
			Duration and severity of acute lower respiratory tract infection symptoms	No significant treatment effects
			Duration of abnormal peak flow	No significant treatment effects
			Antibiotic use	No significant treatment effects
			Adverse events	There were no serious adverse events
El-Gohary M, et al October 2013 United Kingdom	Four RCTs (335 participants) investigating the effects of inhaled corticosteroids. None investigated the use of oral corticosteroids	Systematic review	Mean cough score	Two reporting equivalence and two reporting benefits (P=0.012)	The trials were generally of limited quality, with unclear or high risks of bias, and most were conducted from hospital outpatient departments, where patients may differ from those seen in primary care. The limited number of trials meant that publication bias could not be determined and the SR was underpowered to detect the rare adverse effects of corticosteroid therapy.
			Cough frequency	Two reporting equivalence and two reporting benefits (P=0.047)

Comment(s)

Steroids work by suppressing the immune response and reducing inflammation. However, in the case of acute bronchitis, the inflammation is often a result of the body's immune response to the viral infection. Since steroids suppress the immune system, they may not be beneficial in the context of a viral infection. Systemic steroids also come with potential side effects and risks, and their use for lower respiratory tract infections may expose patients to unnecessary adverse effects. In addition, there is insufficient evidence to recommend the routine use of inhaled corticosteroids for acute infective cough in adults at the current time.

Clinical Bottom Line

Though more research is needed, systemic steroids do not appreciably affect the duration of symptoms when administered to patients without history of asthma or COPD and with uncomplicated acute bronchitis.

References

1. Hay AD, Little P, Harnden A, Thompson M, Wang K, Kendrick D, Orton E, Brookes ST, Young GJ, May M, Hollinghurst S, Carroll FE, Downing H, Timmins D, Lafond N, El-Gohary M, Moore M. Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial. JAMA 2017 Aug 22;318(8):721-730
2. El-Gohary M, Hay AD, Coventry P, Moore M, Stuart B, Little P. Corticosteroids for acute and subacute cough following respiratory tract infection: a systematic review. Fam Pract 2013 Oct;30(5):492-500