Are corticosteroids necessary in the treatment of severe acute asthma?

Abstract

In clinical medicine, perhaps more than in any other area of scientific endeavour, we are prone to become prisoners of our traditional preconceptions. Gradually in most cases, but rapidly in a few, many of these preconceptions have been swept away. It took centuries for bed rest in the treatment of many serious diseases, such as pulmonary tuberculosis and coronary thrombosis, to be discredited, and decades for the barbarous practice of removing healthy tonsils from healthy children to be abandoned. In contrast, the discovery that high-concentration oxygen therapy in patients with ventilatory failure could cause coma and death had an immediate impact. In some of these instances, and in many others, therapeutic policy has turned full circle and forms of treatment once considered logical and beneficial have come to be regarded as irrational or even positively harmful. The iconoclast in medicine, although not always a popular figure in the profession, has often helped to open the way to major therapeutic advances. Yet it is important to realize that there can be false iconoclasts as well as false icons and that in their separate ways both can be dangerous. George Bernard Shaw, although not a doctor, was a powerful opponent of vaccination against smallpox, asserting in his well-publicized ignorance that the decline in the incidence of that disease was the result not of vaccination but of improved sanitation. He has now been proved completely wrong, but one of my most painful personal recollections is that of witnessing the death of an intelligent and well-read young soldier from haemorrhagic smallpox in India during the War after he had refused vaccination in the belief that the opinion of a man with the intellect of Shaw was more to be trusted than that of a Regimental Medical Officer. Although that is, of course, a bizarre example of the damage which can stem from a misinformed iconoclastic approach, it epitomizes the grave responsibility which doctors must accept when they publicize views which are diametrically opposed to those of the majority of their colleagues. No such crisis of conscience arises when a doctor, even perhaps quite wrongly, deems dangerous a drug which has been used uncritically for many years, but for which there is an adequate substitute. It is a different matter, however, to condemn a form of treatment which in certain circumstances may be life-saving, but, even if it is not, can do no harm if administered for short periods. The views expressed in Dr Luksza’s two articles, questioning the value of corticosteroids in the treatment of severe acute asthma, come into the second category. In purely scientific terms there is a lot to be said in his support. It has never been proved by a controlled clinical trial that corticosteroids in this condition actually save lives, and