Archives of Academic Emergency Medicine. 2023; 11(1): e56 OR I G I N A L RE S E A RC H Effects of Pre-Hospital Dexamethasone Administration on Outcomes of Patients with COPD and Asthma Exacerba- tion; a Cross-Sectional Study Thongpitak Huabbangyang1, Agasak Silakoon1∗, Chunlanee Sangketchon1, Jareeda Sukhuntee1, Jukkit Kumkong2, Tanut Srithanayuchet2, Parinya Chamnanpol2, Theeraphat Meechai2 1. Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand. 2. Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand. Received: June 2023; Accepted: July 2023; Published online: 12 August 2023 Abstract: Introduction: Chronic obstructive pulmonary disease (COPD) and asthma exacerbation are two common emergency situations. This study aimed to investigate the impact of pre-hospital dexamethasone initiation on treatment outcomes of these patients. Methods: In this retrospective cross-sectional and comparative study, data from the emergency med- ical service (EMS) care report of patients with a final diagnosis of asthma or COPD, coded with Thailand’s emergency medical triage protocol, collected between January 1, 2021, and October 31, 2022, were used. Data on baseline charac- teristics, emergency department length of stay (ED-LOS), and hospital admission rates were collected from electronic medical records and compared between cases with and without pre-hospital dexamethasone administration by EMS. Results: 200 patients with COPD (n = 93) and asthma (n = 107) exacerbation were enrolled. The dexamethasone-treated group had a lower but statistically non-significant hospital admission rate (71.0% versus 81.0%, absolute difference: 10%, 95% confidence interval (CI): 21.76, 1.76; p = 0.100). In patients with asthma, the dexamethasone-treated had lower median ED-LOS time (235 (IQR: 165.5–349.5) versus 322 (IQR: 238–404) minutes; p = 0.003). Dexamethasone-treated asthma patients had lower but statistically non-significant hospital admission rates (60.4% versus 78.0%, absolute dif- ference: 17.55%, 95% CI: 34.96, 0.14; p = 0.510). In COPD patients the dexamethasone-treated and untreated groups had non-significantly lower hospital admission rates (80.8% versus 85.40%, absolute difference: 4.60%, 95% CI: 19.82, 10.63; p = 0.561) and non-significantly lower ED-LOS (232 (IQR: 150 – 346) versus 296 (IQR: 212 – 330) minutes, absolute differ- ence: 59 (130.81, 12.81); p = 0.106). Conclusion: The dexamethasone administration by EMS in pre-hospital setting for management of asthma and COPD patients is beneficial in reducing the ED-LOS and need for hospital admission but its effects are not statistically significant, except regarding the ED-LOS of asthma exacerbation cases. Keywords: Asthma; Pulmonary disease, chronic obstructive; Dexamethasone; Emergency medical services; Length of stay Cite this article as: Huabbangyang T, Silakoon A, Sangketchon C, Sukhuntee J, et al. Effects of Pre-Hospital Dexamethasone Administra- tion on Outcomes of Patients with COPD and Asthma Exacerbation; a Cross-Sectional Study. Arch Acad Emerg Med. 2023; 11(1): e56. https://doi.org/10.22037/aaem.v11i1.2037. 1. Introduction Chronic respiratory diseases are defined by the World Health Organization as diseases that affect the respiratory tract and other pulmonary structures and have acute exacerbations. Aside from smoking, other risk factors include air pollution, occupational chemicals and dust, and incurable infections ∗Corresponding Author: Agasak Silakoon; Department of Disaster and Emer- gency Medical Operation, Faculty of Science and Health Technology, Nava- mindradhiraj University, Bangkok 10400, Thailand. Tel: +66 2-244-3000, Email: agasak@nmu.ac.th, ORCID: https://orcid.org/0000-0002-7817-7944. (1). The most common types of chronic respiratory diseases seen in the emergency department (ED) include asthma and chronic obstructive pulmonary disease (COPD). In the United States of America alone, approximately 4 million pa- tients visit the ED each year due to asthma and COPD, which reduce health-related quality of life and significantly increase mortality risk (2). According to an Australian study, asthma and COPD were found to be associated with an increased mortality rate, and one million patients died from asthma or COPD exacerbations while being frequently served by emer- gency medical services (EMSs) (3), which were able to initi- ate diagnosis and treatment at the scene (4). In patients with acute COPD exacerbations who called on EMS, prompt treat- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index T. Huabbangyang et al. 2 ment by the advanced life support (ALS) team influenced the ED length of stay (ED-LOS) and the hospital admission rate (5). According to standard treatment guidelines, the treatment of patients with asthma and COPD in the context of EMS differed in each area. In hospitals, corticosteroids are used to treat patients with asthma and COPD, and their benefits have been widely accepted (6). Since the main pathophys- iologic mechanisms are airway inflammation in asthma (7) and mucus hypersecretion, airflow obstruction and hyperin- flation, and an abnormal inflammatory response in the lungs in COPD (8), corticosteroids are the medications of choice for these disorders (9, 10). Early corticosteroid administration would help reduce the need for hospitalization and improve outcomes (5). A systematic review found that initiating corti- costeroids within one hour of arrival at the ED was associated with a lower need for hospitalization (11). Corticosteroids are natural hormones secreted from the adrenal cortex that have anti-inflammatory, metabolic, and immunological ef- fects (3). In Thai EMS, dexamethasone was used as an alter- native to treat patients with acute asthma and COPD exac- erbations (12). The present study aimed to evaluate the out- comes of initiating dexamethasone injection in pre-hospital setting on ED-LOS and hospital admission rates in patients with asthma and COPD. 2. Methods 2.1. Study design and settings The retrospective cross-sectional comparative study was conducted at the Vajira emergency medical service (V-EMS) unit, Faculty of Medicine Vajira Hospital, Navamindradhi- raj University, Bangkok, Thailand. Of nine EMS areas in Bangkok, V-EMS was the leader of EMS unit zone area 1, dispatched from Erawan Center, Bangkok, networking with a total of six public and private hospitals in the entire re- sponsible area, which was 50 square kilometers and included 500,000 people (13, 14). In patient-managing operations, the EMS team of V-EMS in the area included at least three staff members who were paramedics or Emergency Nurse Prac- titioners (ENPs) as operation team leaders and emergency medical technicians for each operation. In each operation, paramedics, or ENPs followed offline, and online medical protocols as directed by emergency physicians. In the study area, there were standard prehospital patient management guidelines endorsed by the National Institute for Emergency Medicine for patients with asthma and COPD (12). These guidelines allowed paramedics or ENPs to diagnose COPD or asthma exacerbations based on pertinent symptoms, wheez- ing lung sounds, shortness of breath, poor air entry, and un- derlying COPD, or asthma. They also allowed for the evalua- tion of initial management, including airway, breathing, and circulation, and the monitoring of vital signs, oxygen satu- ration, and end-tidal CO2, as well as the administration of salbutamol or ipratropium bromide (Berodual) via nebuliza- tion or a metered dose inhaler (MDI) with a spacer. Fur- thermore, they allowed immediate intravenous (IV ) admin- istration one dose of 8 mg IV dexamethasone at the scene. If patients did not respond to treatments and their symp- toms worsened, a prehospital intubation was considered un- der the online medical protocol. In this study, we compared the outcomes of COPD and asthma cases with and without pre-hospital administration of dexamethasone by EMS be- tween January 1, 2021, and October 31, 2022. 2.2. Ethical statement This study was conducted in accordance with the tenets of the Helsinki Declaration of 1975 and its revisions in 2000. It was approved by the Institutional Review Board of the Fac- ulty of Medicine, Vajira Hospital, Navamindradhiraj Univer- sity (COA no. 006/2566). The informed consent requirement was waived because of the retrospective nature of the study and anonymity of all patient data. 2.3. Participants Data of patients with acute COPD and asthma exacerba- tions were collected from EMS patient care reports. Adult patients over the age of 18 with a final diagnosis of acute COPD or asthma exacerbations, symptom group 5 red 1 – 5 red 9, treated by V-EMS, and transported to the ED, Fac- ulty of Medicine Vajira Hospital, Navamindradhiraj Univer- sity, Bangkok, Thailand, were eligible to participate. Patients who refused treatment or transportation to the hospital, were unable to provide medical history by themselves or had no relatives to provide previous medical history, had incomplete or missing data, or were receiving end-of-life, or palliative care were excluded from this study. 2.4. Data collection The data were collected from the EMS patient care report, which was a standard form used for recording the data of ad- vanced EMS operations in the Bangkok EMS (Erawan Cen- ter) and the Bangkok advanced emergency operation unit. This form included data on EMS operation units, patients, vital signs, and all EMS treatments as recorded by dispatch- ers and paramedics, or ENPs, at the scene. These data were part of the remuneration for EMS operation units. All data were filled in Microsoft Excel, including patients’ general characteristics (gender, age, prehospital diagnosis, comor- bidities, treatment period, smoking history, bronchodilator use prior to EMS arrival, and history of severe exacerba- tion), patients’ prehospital parameters (systolic blood pres- sure [SBP], diastolic blood pressure [DBP], heart rate [HR], respiratory rate [RR], temperature, pulse oximetry, wheez- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 3 Archives of Academic Emergency Medicine. 2023; 11(1): e56 ing, prehospital intubation, fluid resuscitation, bronchodila- tor type, bronchodilator dose, and bronchodilator adminis- tration method), patients’ ED parameters (SBP, DBP, HR, RR, temperature, pulse oximetry, wheezing, intubation, bron- chodilator), and patient disposition (ED-LOS time in minutes and hospital admission). All data were reviewed by a princi- pal investigator from the Vajira Hospital’s electronic medical records (EMRs). 2.5. Outcome measures The primary outcome was ED-LOS, while the secondary out- come was hospital admission rate. 2.6. Definitions - Thailand’s emergency medical triage protocol and criteria- based dispatch code were severity codes derived from data on prehospital situation evaluation and patients’ symptoms at the scene. It includes 26 symptom groups. ED-LOS was de- fined as the time between patient arrival and discharge from the ED, whereas hospital admission rate was defined as rate of hospitalization following ED treatment (15). - Comorbidities are coexistent diseases in patients with COPD and asthma. The data were collected from history tak- ing from patients or patients’ relatives. - History of severe exacerbation is having a history of emer- gency department visit by themselves or being transported by emergency medical service with acute asthma and COPD exacerbations before the emergency call. 2.7. Statistical analysis The sample size in the present study was estimated using sample size estimation from G power Version 3.1.9.4, with an alpha confidence level of 0.05 and a power of 90%. The allocation ratio was 1 and the effect size (d) was 0.5 (medium) (16) because there have been no studies referring to the statistical data used to calculate the effect size. Thus, the calculated sample size from the program was at least 86 per group, and after 10% of the sample size was added, the sample size was at least 96. Therefore, in the present study, the sample size of patients with acute COPD and asthma exacerbation was 200 in total, where the EMS had admin- istered dexamethasone for 100 and 100 had not received dexamethasone at the scene. Continuous variables were presented as means and standard deviations, or medians and interquartile ranges (IQRs), while categorical variables were presented as frequencies and proportions. The two groups were compared using the independent t-test or Mann-Whitney U test for numeric variables and the chi-squared test or Fisher’s exact test for categorical variables. ED-LOS and vital sign changes were compared between dexamethasone-treated and untreated groups using the independent t-test or Mann-Whitney U test, as appropriate, and were analyzed using multivariable logistic regression analysis. Hospital admission rates were compared between dexamethasone-treated and untreated groups using the chi-squared test or Fisher’s exact test, as appropriate, and were analyzed using the multivariable logistic regression analysis and median regression model. IBM Statistical Package for the Social Sciences software (IBM SPSS Statistics for Windows, Version 26.0; Armonk, NY, USA: IBM Corp.) was used for statistical analysis. All statistical tests were considered statistically significant if the p-value was less than 0.05. 3. Results 3.1. Patients’ baseline characteristics 200 patients with COPD (n = 93) and asthma (n = 107) exac- erbation were enrolled. Table 1 compares the baseline char- acteristics of patients between cases with and without pre- hospital dexamethasone administration. COPD cases COPD cases treated with dexamethasone (n = 52) in pre- hospital setting had lower mean ages (p = 0.016), higher male/female ratio (p = 0.035), higher comorbidity (p = 0.006), higher smoking history (p = 0.001), higher mean SBP (p = 0.002), higher mean DBP (p = 0.003), higher mean heart rate (p = 0.024), higher wheezing frequency (p < 0.001), and re- ceived more than one dose of the bronchodilator (p = 0.043). Asthma cases In patients with asthma exacerbation, the dexamethasone- treated group had higher male to female ratio (p = 0.034), higher rate of received a bronchodilator prior to EMS arrival (p = 0.004), higher mean SBP (p < 0.001), higher mean DBP (p < 0.001), lower mean temperature (p = 0.046), lower me- dian pulse oximetry (p = 0.015), higher wheezing frequency (p < 0.001), higher median bronchodilator dose received (p < 0.001), and lower bronchodilator administration via a nebu- lizer (p < 0.001). 3.2. Patient outcomes Table 2 compares the ED-LOS and need for hospital admis- sion between cases with and without prehospital dexametha- sone administration by EMS. Overall, the dexamethasone- treated group had a lower but statistically non-significant hospital admission rate (71.0% versus 81.0%, absolute differ- ence: 10%, 95% CI: 21.76, 1.76; p = 0.100) and significantly lower ED-LOS (235 versus 313.5 minutes; absolute difference: 77%, 95% CI: 118.55, 35.45; p = 0.100). In patients with asthma, the dexamethasone-treated had lower median ED-LOS time (235 (IQR: 165.5–349.5) versus 322 (IQR: 238–404) minutes; p = 0.003). Dexamethasone- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index T. Huabbangyang et al. 4 Table 1: Comparing the Baseline characteristics of patients with chronic obstructive pulmonary disease (COPD) and asthma exacerbation between cases with and without prehospital dexamethasone administration Variables COPD (n = 93) Asthma (n = 107) Treated (n = 52) Untreated (n = 41) P-value Treated (n = 48) Untreated (n = 59) P-value Gender Male 44 (84.6) 27 (65.9) 0.035 31 (64.6) 26 (44.1) 0.034 Female 8 (15.4) 14 (34.1) 17 (35.4) 33 (55.9) Age (years) Mean ± SD 69.79 ± 11.79 75.73 ± 11.35 0.016 68.67 ± 14.30 70.73 ± 15.74 0.484 Comorbidities No 0 (0.0) 6 (14.6) 0.006 10 (20.8) 7 (11.9) 0.207 Yes 52 (100) 35 (85.4) 38 (79.2) 52 (88.1) Treatment period From 8 a.m. to 4 p.m. 18 (34.6) 16 (39.0) 0.760 18 (37.5) 20 (33.9) 0.920 From 4 to 12 p.m. 19 (36.5) 12 (29.3) 18 (37.5) 24 (40.7) From 12 p.m. to 8 a.m. 15 (28.8) 13 (31.7) 12 (25.0) 15 (25.4) Smoking history No 10 (19.2) 21 (51.2) 0.001 35 (72.9) 49 (83.1) 0.204 Yes 42 (80.8) 20 (48.8) 13 (27.1) 10 (16.9) Bronchodilator use prior to EMS arrival No 21 (40.4) 21 (51.2) 0.279 20 (41.7) 41 (69.5) 0.004 Yes 31 (59.6) 20 (48.8) 28 (58.3) 18 (30.5) History of severe exacerbation No 39 (75.0) 30 (73.2) 0.841 30 (62.5) 42 (71.2) 0.341 Yes 13 (25.0) 11 (26.8) 18 (37.5) 17 (28.8) Vital signs at ED SBP (mmHg) 153.46 ± 31.17 133.39 ± 27.42 0.002 161.10 ± 30.97 128.58 ± 30.28 <0.001 DBP (mmHg) 90.33 ± 25.05 77.27 ± 16.74 0.003 94.58 ± 23.69 75.36 ± 21.68 <0.00 HR (bpm) 115.88 ± 23.82 104.44± 23.99 0.024 112.48 ± 18.96 109.78 ± 24.63 0.534 Temperature (°C) 37.05 ± 0.48 37.15 ± 0.61 0.383 36.96 ± 0.57 37.23 ± 0.79 0.046 RR (bpm) 31.98 ± 5.70 30.15 ± 7.20 0.173 32.42 ± 4.59 30.58 ± 6.66 0.095 Pulse oximetry Median (IQR) 94 (90–96) 93 (88–96) 0.352 92 (88–94) 94 (90–97) 0.015 > 94% 24 (46.2) 15 (36.6) 0.353 10 (20.8) 28 (47.5) 0.004 <94% 28 (53.8) 26 (63.4) 38 (79.2) 31 (52.5) Wheezing No 10 (19.2) 26 (63.4) <0.001 10 (20.8) 48 (81.4) <0.001 Yes 42 (80.8) 15 (36.6) 38 (79.2) 11 (18.6) Intubation in the prehospital setting No 46 (88.5) 39 (95.1) 0.459 48 (100.0) 55 (93.2) 0.126 Yes 6 (11.5) 2 (4.9) 0 (0.0) 4 (6.8) Fluid resuscitation No 20 (38.5) 24 (58.5) 0.054 22 (45.8) 19 (32.2) 0.149 Yes 32 (61.5) 17 (41.5) 26 (54.2) 40 (67.8) Bronchodilator type Berodual 50 (96.2) 37 (90.2) 0.400 42 (87.5) 51 (86.4) 0.872 Salbutamol 2 (3.8) 4 (9.8) 6 (12.5) 8 (13.6) Bronchodilator dosage (dose) Median (IQR) 2 (1–2.5) 1 (1–2) 0.101 2 (1–3) 1 (1–1) <0.001 1 dose 22 (42.3) 26 (63.4) 0.043 15 (31.3) 47 (79.7) <0.001 > 1 dose 30 (57.7) 15 (36.6) 33 (68.8) 12 (20.3) Bronchodilator administration method Nebulizer 36 (69.2) 30 (73.2) 0.678 30 (62.5) 54 (91.5) <0.001 MDI 16 (30.8) 11 (26.8) 18 (37.5) 5 (8.5) Data are presented as numbers (%), means ± standard deviations, or medians (interquartile ranges). SBP: systolic blood pressure; DBP: diastolic blood pressure; HR: heart rate; RR: respiratory rate; MDI: metered dose inhaler; SD: standard deviation; EMS: emergency medical service; IQR: interquartile range; ED: emergency department. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 5 Archives of Academic Emergency Medicine. 2023; 11(1): e56 Table 2: Comparing the emergency department length of stay and need for hospital admission between asthma and COPD cases with and without prehospital dexamethasone administration Outcomes Treated Untreated Absolute difference (95% CI) Effect estimate (95% CI) P-value COPD (n = 93) ED-LOS (minutes) 232 (150 – 346) 296 (212 – 330) 59 (130.81, 12.81) - 0.106 Hospital admission 42 (80.8) 35 (85.4) 4.6 (19.82, 10.63) 0.72 (0.24–2.18) 0.561 Asthma (n = 107) ED-LOS (minutes) 235 (165.5 – 249.5) 322 (238 – 404) 85 (139.53, 30.47) - 0.003 Hospital admission 29 (60.4) 46 (78.0) 17.55 (34.96, 0.14) 0.43 (0.19–1.00) 0.510 Total ED-LOS (minutes) 235 (158–324.5) 313.5 (222–375) 77 (118.55, 35.45) - 0.003 Hospital admission 71 (71.0) 81 (81.0) 10.00 (21.76, 1.76) 0.57(0.30–1.11) 0.510 Data are presented as numbers (%) or medians (interquartile ranges). ED-LOS: Emergency Department length of stay; CI: confidence interval; COPD: chronic obstructive pulmonary disease. treated asthma patients had lower but statistically non- significant hospital admission rates (60.4% versus 78.0%, ab- solute difference: 17.55%, 95% CI: 34.96, 0.14; p = 0.510). In COPD patients the dexamethasone-treated and untreated groups had non-significantly lower hospital admission rates (80.8% versus 85.40%, absolute difference: 4.60%, 95% CI: 19.82, 10.63; p = 0.561) and non-significantly lower ED-LOS (232 (IQR: 150 – 346) versus 296 (IQR: 212 – 330) minutes, ab- solute difference: 59 (130.81, 12.81); p = 0.106). 4. Discussion Dexamethasone administration by EMS in pre-hospital set- ting for management of asthma and COPD patients is benefi- cial in reducing the ED-LOS and need for hospital admission but its effects are not statistically significant, except regard- ing the ED-LOS of asthma exacerbation cases. The present study found that immediate initiation of IV dex- amethasone administration by EMS at the scene could re- duce ED-LOS only in patients with asthma. Patients with asthma exacerbations who received IV dexamethasone had a significantly shorter median ED-LOS time than those who did not. These findings were consistent with a previous study finding that patients receiving corticosteroid injections, such as dexamethasone, or hydrocortisone, in the ED had a lower risk of hospitalization and exacerbation recurrence (17, 18). In patients with asthma, COPD, and anaphylaxis, offline pro- tocols in some areas, such as Australia (3), Thailand (12), and Florida (19), allowed EMS personnel to initiate IV adminis- tration of systemic corticosteroids, such as dexamethasone, methylprednisolone, or prednisolone. However, there have been limited studies on the initiation of IV systemic corti- costeroids in the ED for patients with asthma exacerbations, as recommended by the latest Global Initiative for Asthma (GINA) update 2023, because the anti-inflammatory effect can relieve the symptoms more quickly and reduce the risk of exacerbation recurrence (20). A previous study demon- strated that patients with asthma who received IV dexam- ethasone had a lower risk of disease exacerbation after ED discharge and a lower ED-LOS time (21). Similarly, a sys- tematic review and meta-analysis reported that children un- der the age of 18 years with asthma exacerbations, who re- ceived a two-dose regimen of dexamethasone in the ED had a shorter ED-LOS time, less symptom persistence, a lower risk of return visits or hospital readmissions, and a higher qual- ity of life. These findings suggested that dexamethasone be administered immediately in the ED (22). However, studies on the outcomes of initiating corticosteroids, such as dexam- ethasone, by EMS in patients with asthma exacerbations are scarce. A study on EMS found that administering corticos- teroids as part of the EMS protocol was not associated with vital sign changes or ED-LOS time in pediatric patients with asthma. Protocols in the area allowed only IV methylpred- nisolone administration, which was usually reserved for pa- tients with severe asthma (19). The EMS protocol in the study area allowed paramedics or ENPs to use IV dexamethasone (8 mg) as an alternative for adult patients with asthma and COPD exacerbations at the scene. Although no benefit was found for systemic use of corticosteroids in the present study, Thai EMS used dexamethasone in patients with COPD exac- erbations to decrease ED-LOS time. Despite this, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (The 2020 GOLD Science Committee Report) supports the initia- tion of systemic corticosteroids in the acute phase or in the ED, and corticosteroids are regularly used in clinical practice for the management of COPD exacerbations, as previously recommended (23). A previous randomized clinical trial compared the efficacy of methylprednisolone with that of dexamethasone in manage- ment of COPD exacerbations and found no significant dif- ference in terms of ED-LOS time. Patients receiving dexam- ethasone had better dyspnea control (p = 0.02), but the group receiving methylprednisolone had better cough control (p = 0.035). There was no significant difference between the two This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index T. Huabbangyang et al. 6 drugs in terms of side effects on the 7th and 14th days. Fur- thermore, the authors suggested that physicians should con- sider the most prominent symptoms of COPD patients un- der treatment when selecting each type of corticosteroid (24). The present study was consistent with a previous study in a Thai province that compared patients with COPD exacerba- tions in the ED and found that patients receiving IV dexam- ethasone had no difference in terms of ED-LOS time (25). A narrative review reported that both short- and long-term cor- ticosteroid use had relatively high side effects, including new or aggravated diabetes, hypertension, fractures, particularly in the elderly, venous thrombosis, sepsis, and gastrointesti- nal hemorrhage. Accordingly, corticosteroid administration should be reduced, particularly in patients with COPD exac- erbations (26). The use of corticosteroids, such as dexam- ethasone, in patients with COPD exacerbations may not be beneficial in the prehospital setting in terms of reduced ED- LOS time. Furthermore, drug administration should be initi- ated on a case-by-case basis and with the permission of the local EMS protocol in each area. In the present study, initiating prehospital IV dexamethasone administration by EMS in patients with asthma and COPD exacerbations had no beneficial effect on hospital admis- sion rates. This was consistent with a previous ED study that reported a significantly lower rate of hospitalization in pediatric patients with mild and moderate asthma who re- ceived corticosteroids (27). In addition, a previous study in the ambulance setting on pediatric patients aged 2–18 years with asthma exacerbations found that hospital admission rates were significantly lower in those who received corticos- teroids by paramedics than in those who did not. Besides, initiating prehospital corticosteroid administration by EMS has been suggested to reduce hospital expenses for treating patients with acute asthma (26). Furthermore, a previous study comparing the administration of IV methylprednisolone (125 mg) by EMS to IV methylpred- nisolone in the ED found that initiating methylprednisolone administration by EMS helped decrease hospital admission rates in patients with moderate to severe asthma (28). Ac- cording to the present standard recommendations of Global Initiative for Asthma (GINA) update 2023, IV systemic cor- ticosteroid administration should be initiated immediately in patients with asthma exacerbations because it could re- duce hospital and intensive care unit admission rates (20). In patients with COPD exacerbations, the present study re- ported a reduced risk of hospitalization with IV dexametha- sone administration by EMS. This was in contrast with a pre- vious study demonstrating that patients with COPD exacer- bations at the ED receiving IV dexamethasone did not reduce overall hospital and intensive care unit admission rates (25), which may be due to the fact that patients with COPD and asthma exacerbations serviced by EMS mostly have severe symptoms. According to the present study, the incidence of prehospital intubation in patients with COPD was 16.4%, while it was only 6.8% in patients with asthma. In addition, no asthmatic patients receiving IV dexamethasone adminis- tered by EMS required prehospital intubation. Furthermore, in patients with COPD, and asthma, vital signs, such as RR, oxygen saturation levels, HR, and wheezing, did not differ between groups that received and did not receive IV dexam- ethasone administered by EMS. This is because all of these patients were treated with a bronchodilator, salbutamol, or ipratropium bromide + fenoterol (Berodual) via nebulizer or MDI with a spacer before initiating dexamethasone adminis- tration, as well as a relatively delayed dexamethasone effect that would take an hour (29), resulting in no clear difference in prehospital and ED vital signs. 5. Limitations This study has some limitations. First, the present study was a retrospective single-center study that used two data sources: the EMS patient care report and the EMR database, which could introduce a selection bias. Second, there may be unmeasured confounding factors associated with ED-LOS times and hospital admission rates, such as emergency room triage severity, patient overcrowding at the ED, the order of medical investigation, the order of additional laboratory tests, and so on, that influenced the outcomes. Third, pa- tients in this study were only transported to the Vajra Hospi- tal’s ED. Patients delivered to other hospitals’ EDs should be collected because the level of the hospital ED may potentially affect ED-LOS times and hospital admission rates. Fourth, in the present study, there was no classification of severity level of patients with asthma attacks and COPD exacerba- tions (classified as mild, moderate, and severe) due to the retrospective nature of this observational study. Paramedics or ENPs did not record the data regarding severity level in prehospital patient record. Fifth, there was no data collec- tion about receiving systemic corticosteroid before acute ex- acerbation, which was believed to affect results of the study. Sixth, for COPD patients in dexamethasone group, there was higher prevalence of smoking history and also significantly lower age in dexamethasone group. These were believed to affect the results of the study and may cause bias. Finally, since not all patients, or relatives could provide a clear med- ical history, it was difficult for paramedics or ENPs to distin- guish between asthma and COPD in the prehospital setting, particularly, in patients without treatment history or new pa- tients. Hence, the final diagnosis in the hospital was chosen as the criterion for differentiating these two diseases. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 7 Archives of Academic Emergency Medicine. 2023; 11(1): e56 6. Conclusion Dexamethasone administration by EMS in pre-hospital set- ting for management of asthma and COPD patients is benefi- cial in reducing the ED-LOS and need for hospital admission but its effects are not statistically significant, except regard- ing the ED-LOS of asthma exacerbation cases. 7. Declarations 7.1. Acknowledgments The authors are grateful to the Navamindradhiraj Univer- sity Research Fund for Pub. We would like to thank the paramedics at V-EMS, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, for facilitating in data collec- tion and access in the present study, Gawin Tiyawat, MD., chief of Department of Disaster and Emergency Medical Op- eration, Faculty of Science and Health Technology, Nava- mindradhiraj University, and Chunlanee Sangketchon, MD., deputy dean of Faculty of Science and Health Technology, Navamindradhiraj University, for support and suggestions in the research development and Aniwat Berpan, MD. for sug- gestions on English for the present study. 7.2. Conflict of interest The authors have no conflicting interests to declare. 7.3. Funding and support This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 7.4. Authors’ contribution Conceptualization: Thongpitak Huabbangyang, Jukkit Kumkong, Tanut Srithanayuchet, Parinya Chamnanpol and Theeraphat Meechai; Methodology: Thongpitak Huab- bangyang and Agasak Silakoon; Software: Thongpitak Huab- bangyang; Validation: Thongpitak Huabbangyang; Agasak Silakoon and Jareeda Sukhuntee; Formal analysis: Thong- pitak Huabbangyang; Investigation: Thongpitak Huab- bangyang, Jukkit Kumkong, Tanut Srithanayuchet, Parinya Chamnanpol and Theeraphat Meechai; Resources: Thongpi- tak Huabbangyang, Jukkit Kumkong, Tanut Srithanayuchet, Parinya Chamnanpol and Theeraphat Meechai; Data Cu- ration: Thongpitak Huabbangyang; Writing – Original Draft: Thongpitak Huabbangyang; Writing - Review Edit- ing: Thongpitak Huabbangyang and Agasak Silakoon; Visualization: Thongpitak Huabbangyang and Jareeda Sukhuntee; Supervision: Thongpitak Huabbangyang and Chunlanee Sangketchon; Project administration: Thong- pitak Huabbangyang; Funding acquisition: Thongpitak Huabbangyang. All authors read and approved the final version of manuscript. 7.5. Data Availability Not applicable. 7.6. Using artificial intelligence chatbots None. References 1. WHO. Chronic respiratory diseases 2020 [cited 2021 10 Nov]. Available from: https://www.who.int/health- topics/chronic-respiratory-diseases#tab=tab_1. 2. Martins LC, de Oliveira MdRD, do Nascimento Saldiva PH, Braga ALF. Air pollution and emergency room visits due to chronic lower respiratory diseases in the elderly: an ecological time-series study in São Paulo, Brazil. J Oc- cup Environ Med. 2002;44(7):622-7. 3. Long D, Bendal J, Bower A. Out-of-hospital administra- tion of corticosteroids to patients with acute asthma: A case study and literature review. Australas J Paramed. 2008;6:1-11. 4. Stead L, Whiteside T. Evaluation of a new EMS asthma protocol in New York City: a preliminary report. Prehosp Emerg Care. 1999;3(4):338-42. 5. Phipps P, Garrard C. The pulmonary physician in critical care• 12: acute severe asthma in the intensive care unit. Thorax. 2003;58(1):81-8. 6. Manser R, Reid D, Abramson M. Corticosteroids for acute severe asthma in hospitalised patients. Cochrane Database Syst Rev. 2001;2001(1):CD001740. 7. Barrios RJ, Kheradmand F, Batts LK, Corry DB. Asthma: pathology and pathophysiology. Arch Pathol Lab Med. 2006;130(4):447-51. 8. Hogg JC, Timens W. The pathology of chronic obstructive pulmonary disease. Annu Rev Pathol. 2009;4:435-59. 9. Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, et al. Global Initiative for Asthma Strategy 2021: executive summary and rationale for key changes. Eur Respir J. 2022;59:2102730. 10. Adeloye D, Song P, Zhu Y, Campbell H, Sheikh A, Rudan I. Global, regional, and national prevalence of, and risk fac- tors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med. 2022;10(5):447-58. 11. Rowe B, Spooner C, Ducharme F, Bretzlaff J, Bota G. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001(1):CD002178. 12. Medicine NIfE. EMS protocol in Thailand 2020 [cited 2021 10 Nov]. Available from: https://www.niems.go.th/1/Ebook/Detail/1162?group=21. 13. Huabbangyang T, Sangketchon C, Piewthamai K, Saeng- manee K, Ruangchai K, Bunkhamsaen N, et al. Percep- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index T. Huabbangyang et al. 8 tion and Satisfaction of Patients’ Relatives Regarding Emergency Medical Service Response Times: A Cross- Sectional Study. Open Access Emerg Med. 2022;14:155- 63. 14. Huabbangyang T, Klaiangthong R, Silakoon A, Sreti- mongkol S, Sangpakdee S, Khiaolueang M, et al. The comparison of emergency medical service responses to and outcomes of out-of-hospital cardiac arrest before and during the COVID-19 pandemic in Thailand: a cross- sectional study. Int J Emerg Med. 2023;16(1):9. 15. Plongthong K, Chenthanakij B, Wittayachamnankul B, Tianwibool P, Phinyo P, Tangsuwanaruk T. Factor Affect- ing Length of Stay More Than 6 Hours in Emergency De- partment. JHSR. 2021;15(3):381-90 [Thai]. 16. Cohen J. Statistical power analysis for the behavioral sci- ences (revised ed.). New York: Academic Press; 1977. 17. Alangari AA. Corticosteroids in the treatment of acute asthma. Ann Thorac Med. 2014;9(4):187-92. 18. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. N Engl J Med. 1991;324(12):788-94. 19. Fishe JN, Gautam S, Hendry P, Blake KV, Hendeles L. Emergency medical services administration of systemic corticosteroids for pediatric asthma: A statewide study of emergency department outcomes. Acad Emerg Med. 2019;26(5):549-51. 20. Levy ML, Bacharier LB, Bateman E, Boulet L-P, Brightling C, Buhl R, et al. Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) up- date. NPJ Prim Care Respir Med. 2023;33(1):7. 21. Kirkland SW, Cross E, Campbell S, Villa-Roel C, Rowe BH. Intramuscular versus oral corticosteroids to reduce re- lapses following discharge from the emergency depart- ment for acute asthma. Cochrane Database Syst Rev. 2018;6(6):CD012629. 22. Keeney GE, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3):493-9. 23. Halpin DM, Criner GJ, Papi A, Singh D, Anzueto A, Mar- tinez FJ, et al. Global initiative for the diagnosis, man- agement, and prevention of chronic obstructive lung disease. The 2020 GOLD science committee report on COVID-19 and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;203(1):24-36. 24. Ardestani ME, Kalantary E, Samaiy V, Taherian K. Methyl prednisolone vs Dexamethasone in Management of COPD Exacerbation; a Randomized Clinical Trial. Emerg (Tehran). 2017;5(1):e35. 25. Kowjiriyapan Y. Comparative efficacy of metered dose in- haler with spacer and nebulized bronchodilator in the treatment of COPD acute exacerbation in the emer- gency department, Chiangrai Prachanukroh Hospital. CMJ. 2022;13(3):117-31 [Thai]. 26. Fishe JN, Hendry P, Brailsford J, Salloum RG, Vogel B, Fin- lay E, et al. Early administration of steroids in the ambu- lance setting: Protocol for a type I hybrid effectiveness- implementation trial with a stepped wedge design. Con- temp Clin Trials. 2020;97:106141. 27. Tyler A, Cotter JM, Moss A, Topoz I, Dempsey A, Reese J, et al. Outcomes for pediatric asthmatic inpatients after im- plementation of an emergency department dexametha- sone treatment protocol. Hosp Pediatr. 2019;9(2):92-9. 28. Knapp B, Wood C. The prehospital administration of intravenous methylprednisolone lowers hospital admis- sion rates for moderate to severe asthma. Prehosp Emerg Care. 2003;7(4):423-6. 29. Moore SG. Intravenous dexamethasone as an analgesic: a literature review. AANA j. 2018;86(6):488-93. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index Introduction Methods Results Discussion Limitations Conclusion Declarations References