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A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
Asthma: An Evidence-Based
Management Update
February 2001
Volume 3, Number 2
Authors
Mary K. Reilly, MD
Chief Resident, Emergency Medicine, Case Western
Reserve University/MetroHealth Medical Center,
Cleveland, OH.
Michael A. Kaufmann, MD
Chief Resident, Emergency Medicine, Case Western
Reserve University/MetroHealth Medical Center,
Cleveland, OH.
Rita K. Cydulka, MD, FACEP
Associate Professor, Case Western Reserve University;
Attending Physician, MetroHealth Medical Center;
Consultant, Cleveland Clinic Foundation; Cleveland, OH.
Peer Reviewers
Alfred Sacchetti, MD, FACEP
Research Director, Our Lady of Lourdes Medical Center,
Camden, NJ; Assistant Clinical Professor of Emergency
Medicine, Thomas Jefferson University, Philadelphia, PA.
Jeffrey Mann, MD
Attending Emergency Physician, Somerset Medical
Center, Somerville, NJ.
CME Objectives
Editor-in-Chief
Stephen A. Colucciello, MD, FACEP,
Assistant Chair, Director of
Clinical Services, Department of
Emergency Medicine, Carolinas
Medical Center, Charlotte, NC;
Associate Clinical Professor,
Department of Emergency
Medicine, University of North
Carolina at Chapel Hill, Chapel
Hill, NC.
Associate Editor
Andy Jagoda, MD, FACEP, Professor
of Emergency Medicine; Director,
International Studies Program,
Mount Sinai School of Medicine,
New York, NY.
Editorial Board
Judith C. Brillman, MD, Residency
Director, Associate Professor,
Department of Emergency
Differential Diagnosis
Although wheezing, cough, and dyspnea are the clinical
hallmarks of asthma, all that wheezes is not asthma.
Other common conditions present in a similar fashion.
Differential diagnoses include pneumonia, bronchitis,
croup, bronchiolitis, chronic obstructive lung disease,
congestive heart failure, pulmonary embolism, allergic
reactions, and upper airway obstruction. Less common
entities include cystic fibrosis, hypersensitivity pneumonitis, and carcinoid syndrome. Even those with no
predisposition to asthma may develop wheezing after
Relevance to treatment
Interaction of mast cells with IgE
molecules leading to the flood of
pro-inflammatory molecules in the
pulmonary system10,13
Infectious disease
Social
Public health
February 2001
Prehospital Care
The prehospital care of the asthmatic closely parallels the
ED management. Medics should either give oxygen to
patients with asthma, measure their oxygen saturation
using pulse oximetry, or both. Patients with minimal
symptoms, however, may require neither.
Clinical trials demonstrate that the prehospital
administration of either aerosolized albuterol or subcutaneous terbutaline significantly reduces respiratory
distress.23 In this study, albuterol provided greater
subjective improvement.
Some limited data suggest that 125 mg of intravenous methylprednisolone given by paramedics may
reduce the need for admission in asthmatics.24 Once
again, patients with mild exacerbations would not
require this intervention.
ED Evaluation
The acute asthmatic can present with an array of signs
and symptoms. Some patients complain of wheezing and
shortness of breath, while others report a relentless
cough. The degree of dyspnea will dictate the ability to
perform a thorough history and physical. Immediate
attention must be directed to the patients appearance,
vital signs, and chest examination. If needed, aggressive
therapy directed at relieving airway obstruction must
begin as soon as the diagnosis is suspected.
History
The patients history will not only help determine the
course of immediate treatment in the ED, but it will also
place the exacerbation in the context of the disease.
Past Exacerbations
The patients history offers the backdrop for his current
exacerbation. Does the patient have a history of asthma?
Many patients will report no history of asthma but admit
February 2001
General Appearance
The patients general appearance will often determine the
pace of subsequent interventions. Upon entering the room,
assess for the general level of distress. A patient who is
sweating and unable to speak in full sentences is in trouble.
The number of seconds a patient can spend counting
correlates well with pulmonary function.30 In the first
several moments, quickly appraise the patients mental
status. Both lethargy and agitation presage respiratory
failure. Cyanosis is a very late finding in asthma. By the
time it appears, it is likely that the patient is moribund.31
While these suggestions are considered common
knowledge, studies that focus on clinical examination
show that inter-observer agreement regarding respiratory
signs in adults is low.32 However, one study indicates that
inter-observer agreement may be better in the assessment
of acute asthma in children.33
Vital Signs
Tachycardia and tachypnea do not always correlate with
the degree of airway obstruction.34,35 Tachycardia will
often resolve with appropriate -agonist therapy, not
worsen. A decreasing respiratory rate can simply mean
the patient is tiring, rather than improving.
There is little research that examines the relationship
of blood pressure to respiratory distress. However, if the
blood pressure is extremely high (or extremely low),
consider cardiac etiologies such as CHF or cardiogenic
shock in the differential diagnosis of wheezing.
If the determination of fever is important, consider
obtaining a rectal temperature. Oral temperatures are
notoriously inaccurate in patients with tachypnea.
Pulse Oximetry
Pulse oximetrythe fifth vital signis often useful in
the assessment of asthma. It will rapidly alert the ED staff
to hypoxia and the need for supplemental oxygen.
Hypoxemia generally reflects the extent of ventilation/
perfusion mismatch.36 Remember, however, that pulse
oximetry does not reflect ventilation status. Patients with
near-normal saturations while on oxygen may be
hypercarbic and in danger of incipient respiratory failure.
Pulse oximetry may also predict the need for
admission in children. Children with initial low oxygen
saturation (below 90% or 91% depending on the study)
often require admission regardless of their response to
therapy.37-39 In one study, children who presented with an
oxygen saturation level of 92% or less had a greater-thansixfold relative risk for requiring prolonged treatment.40
Another study showed that in children, a posttreatment
SpO2 level of 91% or less increased the odds of admission
16-fold.41 As opposed to some previous studies, this
study found pretreatment SpO2 levels to be a relatively
poor predictor of admission.
The initial room air pulse oximetry can accelerate
Physical Examination
Be wary when performing the physical exam. A patients
ventilatory status can change rapidly. Remember that
patients with no wheezing may actually be in extremis;
they cannot move enough air to produce the turbulent
whistle of asthma. Such patients, however, will appear
dyspneic and will not be able to speak normally. Others
who are just holding their own may tire and rapidly
become acidotic and hypercarbic. Many experienced
physicians use their gestalt to rapidly assess the severity
of distress. They may overtly or subliminally incorporate
February 2001
treatment intervention in adults (if low) or provide reassurance (if high). However, the initial oxygen saturation has
little prognostic utility in the adult asthmatic.42
Diagnostic Studies
Chest Radiography
February 2001
Treatment
The most urgent goal in the ED is to rapidly reverse
airflow obstruction and ensure adequate oxygenation.
The initial therapeutic interventions in any asthmatic
should include the basic ABCs, with intravenous access,
oxygen, and cardiac monitoring instituted for those
in severe distress. It is useful to quickly identify the
asthmatic as either unstable or stable (recognizing that
the initial designation is subject to rapid change). The
clinical pathway Management Of Patients With An
Acute Asthma Exacerbation on page 14 begins with
this classification.
The unstable patient mandates emergency airway
equipment at the bedside (including the availability of
rapid-sequence intubation agents). Systemic -agonists
(e.g., subcutaneous terbutaline or epinephrine) may
replace or be combined with aerosolized treatments.
Assess the improvement of that patient with several
measures: mental status, air exchange, oxygenation, and
ventilation. Progressive deterioration or failure to
improve with maximal therapy may require intubation.
Thankfully, the majority of asthmatics who present to the
ED will not require such extreme measures.
The most standard therapies can be grouped
into three primary categories: -adrenergic agonists,
glucocorticoids, and anticholinergics. A fourth category
of drugs, the methylxanthines, has no significant role in
emergency management, while a fifth and sixth category
of drugs, the cromones and leukotriene modifiers, are
generally reserved for maintenance therapy. Magnesium
is emerging as a treatment for very severe asthma
exacerbations. The role of other agents, including agonist isomers (e.g., levalbuterol), heliox, anesthetics,
and anti-hypertensive agents are currently the topics of
intensive clinical research in the management of acute
asthma exacerbations.
Patients with COPD are more likely to have abnormalities on chest film, and their need for chest radiography depends on a variety of factors.65
-agonists
Types Of Agents
February 2001
Dosage
The most effective dose of inhaled -agonist remains
unknown. Standard doses of albuterol for adults range from
2.5-5.0 mg per treatment; however, continuous nebulization
may involve administering 20 mg or more per hour. In one
study, two 5.0 mg treatments of aerosolized albuterol at a
40-minute interval were more effective than three treatments of 2.5 mg given every 20 minutes. The high-dose
regimen improved pulmonary function more rapidly and to
a greater extent than standard-dose therapy and resulted in
shorter ED length of stay (in addition to lower charges to
third-party payors).85
-agonist doses may be administered nebulized
every 15-20 minutes or as a continuous aerosol.86 Recent
literature has failed to demonstrate the superiority of
either method.87 Continuous nebulization has a theoretical advantage in departments with limited personnel; if
the respiratory therapist or nurse is unable to return
every 20 minutes to initiate additional treatments,
continuous nebulization can potentially bridge these
gaps in the patient who is in moderate distress.
One study showed that 2.5 mg of nebulized albuterol
is therapeutically equivalent to 1 mg of salbutamol by
MDI/spacer (11 puffs). In this randomized trial of acute
severe asthma, the MDI-spacer group received four puffs
of albuterol at 10-minute intervals (24 puffs per hour).
Although patients in the MDI and nebulizer group
showed similar improvement, nebulizer therapy produced greater adverse side effects.88 Other studies have
employed 6-12 puffs per treatment using an albuterol
MDI, even in children.89
Routes Of Administration
Aerosol therapy (either nebulization or via metered-dose
inhaler [MDI]) is the preferred route for ED use. This is
because aerosols achieve topical administration of drug
in small doses and produce local bronchodilation with
minimal systemic absorption and side effects. The addition
of a spacer chamber is an important adjunct when using the
MDI, dramatically increasing effective drug delivery.76,77
Worldwide, healthcare providers are transitioning
from chlorofluorocarbons (CFCs) as propellants for
metered-dose inhalers to non-CFC devices. Two choices
February 2001
Parenteral Therapy
Parenteral -agonist therapy usually involves subcutaneous
injections of epinephrine or terbutaline. These are sometimes given in the distressed patient when aerosol therapy is
Oral Therapy
Oral administration of -agonists is generally discouraged.94 Short-acting oral agents such as oral albuterol do
not improve quality of life when added to inhaled
therapy and significantly increase side effects such as
tremor and palpitations.95 Children with wheezing
should receive home therapy using an MDI with spacer
(and mask in the case of the younger child), not oral
agents. In certain situations, long-acting oral agents such
as bambuterol (not yet available in the United States) can
be helpful in nocturnal asthma.96
Glucocorticoids
Early administration (within one hour) of glucocorticoids in the
treatment of acute reactive airway disease results in fewer hospital
admissions and a lower rate of relapse after ED discharge.97-99
Therefore, steroids should be administered to all asthmatics
whose acute exacerbation is not relieved by one nebulized
bronchodilator aerosol and given urgently to those who
appear in moderate to severe distress.
While the exact mechanism of action is unclear, one
theory proposes a reduction of airway inflammation, as
well as restoration of -adrenergic responsiveness in the
constricted airways. Accepted dosage regimens in adults
include prednisone (40-60 mg PO), a 60-125 mg intravenous bolus of methylprednisolone, or a 60-125 mg
intramuscular dose of methylprednisolone. No clear
benefit has been demonstrated by using high-dose
steroids (> 80 mg/d of methylprednisolone) for those
patients requiring hospitalization for their exacerbation,100 though it is commonplace for adult patients to
receive 120 mg of methylprednisolone in the ED.
Oral, intravenous, and intramuscular routes of
administration of steroids share equal efficacy and have
an onset of action of approximately four hours.98,101 In
prolonged ED stays or ED observation units, steroids
should be re-administered every 6-8 hours, whether they
are given orally or intravenously. In one study, 125 mg of
intravenous methylprednisolone increased PEFR and
percent-predicted PEFR over time compared to placebo.102 However, because no well-designed trial has
demonstrated a head to head superiority of one route
Anticholinergics
Anticholinergic therapy, including ipratropium bromide
and glycopyrrolate, antagonizes the neuromuscular
transmitter acetylcholine at the postganglionic parasympathetic receptor, which reduces vagally mediated
bronchoconstriction in the larger central airways. Anticholinergic bronchodilation peaks within 1-2 hours. Simultaneous treatment with -adrenergic agents and anticholinergics may produce an additive effect.113,114 The pooled
results of five randomized, controlled trials (RCTs) showed
February 2001
Controversies/Cutting Edge
Heliox
Heliox, an 80:20 mixture of helium and oxygen, can be
considered in patients with respiratory acidosis who fail
conventional therapy. Helium is a low-density, inert gas
that lowers airway resistance and decreases respiratory
work.124 Significant improvement may be noted within
10-20 minutes of initiating therapy in the asthmatic with
severe bronchospasm.125
Kass and Terregino compared the effect of heliox to
30% oxygen in asthmatics with severe symptoms. Patients
who received heliox had significant improvement in PEFRs
compared to controls.126 In contrast, Henderson et al did not
demonstrate a difference in spirometry or admission rates
for mild-to-moderate asthmatics treated with heliox.127 This
disparity may relate to differences in disease severity
between the study populations. Ultimately, further studies
are necessary to determine the role of heliox in current
asthma management.
Nitric Oxide
Inhaled nitric oxide (NO) may be valuable in status
asthmaticus refractory to other therapies. In one series,
it was administered to five consecutive children with
life-threatening status asthmaticus who required mechanical ventilation. Four showed a greater than 20%
decrease in baseline PaCO2 soon after the administration
of inhaled NO.128
Anesthetics
Certain anesthetic agents such as halothane and
isoflurane are potent bronchodilators.129,130 These agents
produce rapid bronchodilatation but are also myocardial
depressants. Halothane can produce arrhythmias and
intrapulmonary shunting of blood. Close monitoring of
heart rate and blood pressure is essential when using
anesthetics to treat status asthmaticus.129
Though general anesthetics have theoretical benefits
in the acute treatment of an intubated asthmatic, it is
unlikely that such agents will be available in the ED.
They are most appropriate for an intensive-care setting in
consultation with the anesthesiologist.
Magnesium
Magnesium sulfate is efficacious for the relief of severe
bronchoconstriction but adds little to the treatment of mildto-moderate bronchospasm.119-121 This medication regulates
intracellular calcium flux, inhibits the release of histamine
from mast cells, inhibits the action of acetylcholine, and
directly inhibits bronchial smooth-muscle contraction.
Bronchodilation is observed within 2-5 minutes after
the initiation of therapy but disappears rapidly after
termination of treatment. Side effects of magnesium therapy
potentially include hypotension, malaise, and a warm,
flushing sensation. Monitoring of cardiac rhythm, blood
pressure, pulse, neurologic status, and renal function is
prudent, but a recent systematic review demonstrated no
clinically significant changes in vital signs or presence of
side effects with the administration of magnesium.122
In a systematic review of 27 studies and seven trials,
the authors found that magnesium reduced hospital
admission rates and improved pulmonary function for
patients with severe asthma. However, no difference was
shown for patients with mild-to-moderate asthma.120 For
patients with severe asthma, consider giving 2 g of
February 2001
Leukotriene-Receptor Antagonists
Leukotriene modifiers result in improved lung function,
diminished symptoms, and less need for short-acting
-agonists over a wide spectrum of asthma severity.
However, they are not currently indicated for acute
exacerbations.131 In one ED study, patients were given
either 10 mg chewable montelukast or placebo within 20
minutes of presentation (in addition to standard therapy).
There were no significant differences in the final PEFR
Airway Management
Intubation
If the patient deteriorates or fails to improve despite
intensive therapy, intubation and mechanical ventilation
must be considered. Fortunately, fewer than 1% of asthmatics require mechanical ventilation. Although there are no
absolute criteria other than respiratory arrest and coma, the
following are indications for acute airway intervention:
Worsening pulmonary function tests despite vigorous bronchodilator therapy
Decreasing PaO2
Increasing PaCO2
Progressive respiratory acidosis
Declining mental status
Increasing agitation
10
February 2001
February 2001
11
12
February 2001
Non-Invasive Ventilation
Non-invasive ventilation (NIV) offers an attractive
alternative to intubation in the patient with a severe
asthma exacerbation. The trials evaluating this method of
ventilatory support are small but promising; most
involve bi-level positive airway pressure (BiPAP).171-173
Initial settings can begin at 8 or 10 cmH2O inspiratory
positive airway pressure (IPAP), while the expiratory
positive airway pressure (EPAP) can be set at 3 or 5
cmH2O. The settings are then adjusted according to
clinical response. In one study, the authors suggested that
for hypoxemic patients, EPAP should be raised in
increments of 2 cmH2O while maintaining the IPAP at a
fixed interval above EPAP (i.e., the difference between
IPAP and EPAP is kept at 5 cmH2O). For hypercapnic
patients, IPAP was raised in increments of 2 cmH2O with
EPAP increased at a slower rate (1 cm increase in EPAP
for every 2.5 cm increase in IPAP).172 -agonists given
via BiPAP appear to be more effective than those administered by small-volume nebulizers.174 At this time, NIV
represents a reasonable alternative to invasive ventilation
for selected asthmatics.175 However, such patients must
be monitored very closely, as some will ultimately
require intubation.
Elderly Patients
Pregnant Patients
Pediatric Patients
February 2001
13
ABCs
IV/O2/Monitor*
Physical exam
Vital signs
No
Yes
Repeat evaluation
Clinical examination
May include evaluation of PEFR or FEV1 (Class IIb)
Yes
No
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2001 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited
copying privileges for educational distribution within your facility or program. Commercial distribution to
promote any product or service is strictly prohibited.
Emergency Medicine Practice
14
February 2001
Moderate exacerbation?
Moderate symptoms present
PFTs 50%-80% predicted/
personal best
2-agonists
(Class IIa)
Anticholinergics
(Class IIa)
Systemic
corticosteroids
(Class IIa)
Monitor FEV1 and
O2 saturations
(Class IIb)
Reassess need
for in tubation
Continued ED
therapy (Class
indeterminate)
OR
Admit to clinical
observation unit
(Class indeterminate) OR
Admit to hospital
floor (Class
indeterminate)
Poor response
PCO2 > 42mmHg
Drowsiness or confusion
FEV1 or PEFR < 50%
Incomplete response
Mild to moderate symptoms
Persistent wheezing
FEV1 or PEFR > 50% and < 70%
Discharge to home
2-agonist MDIs (Class IIa)
Systemic corticosteroids
(Class IIa)
Patient education (Class
indeterminate)
Early outpatient follow-up
Consider inhaled steroids
(Class indeterminate)
Continue treatments OR
Continuous aerosols with 2-agonists
(Class IIb)
Multiple-dose anticholinergics
(Class IIb)
Intravenous corticosteroids (Class IIa)
Consider magnesium 2 g IV (Class IIb)
Good response
Response sustained longer
than 60 minutes
Physical exam normal
FEV1 or PEFR > 70%
How is
the pa tient
responding?
Discharge to home
2-agonist MDIs (Class IIa)
Systemic corticosteroids (Class IIa)
Patient education (Class indeterminate)
Early outpatient follow-up
Consider inhaled steroids (Class
indeterminate)
Severe exacerbation?
Symptoms at rest, retractions,
accessory muscle use
No improvement
FEV1 or PEFR < 50% predicted/
personal best
No
Yes
Proceed
with RSI
Low tidal
volumes
ABG
Consider need for alternative therapies if continued deterioration or failure to improve (Class indeterminate)
Magnesium 2 g IV (Class IIb)
Intravenous -agonists (continuous drip) (Class indeterminate)
Heliox (Class indeterminate)
Inhalation anesthesia (Class indeterminate)
BiPAP if not intubated (Class indeterminate)
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2001 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited
copying privileges for educational distribution within your facility or program. Commercial distribution to
promote any product or service is strictly prohibited.
February 2001
15
Physiological objectives:
Pplat < 30 cmH2O (Class indeterminate)
Physiological
objectives achieved?
Yes
No
Yes
No
Unconventional therapies
Heliox, anesthetic agents
(Class indeterminate)
Yes
No
Continue aggressive
medical therapy
(Class IIa)
Consider buffer
therapy
(Class indeterminate)
LEGEND
FiO2 = fraction of inspired oxygen
VT = tidal volume
RR = respiratory rate
PEEP = positive end-expiratory pressure
Pplat = plateau airway pressure
SIMV = synchronized intermittent mandatory ventilation
NMB = neuromuscular blockade
Adapted from Figure 4 in: Jain S, Hanania NA, Guntupalli KK. Ventilation of patients with asthma and obstructive lung disease.
Crit Care Clin 1998;14:685-705.
The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2001 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited
copying privileges for educational distribution within your facility or program. Commercial distribution to
promote any product or service is strictly prohibited.
Emergency Medicine Practice
16
February 2001
face of notable tachypnea. Since they may be less dexterous than adults, be sure to prescribe a spacer or
valved holding chamber for use with MDIs. Smaller
children and infants will need a spacer with a mask.
These devices are a necessity for children, as well as
most adults. There are versions with holding chambers
(with or without face masks) for both infants and older
children alike. Even in very young children with acute
wheezing, RCTs show that the MDI plus spacer is at least
as effective as a nebulizer.80,190
In the child with asthma, consider inhaled steroids.
In one RCT, children who received 1.5 mg/kg of nebulized dexamethasone in the ED had fewer short-term
relapses than children treated with 2 mg/kg of oral
prednisone.191 Though a concern about the long-term
growth effects of inhaled steroids exists, their efficacy
usually outweighs the potential risk. In fact, poorly
Radiography
As in adults, chest radiographs rarely influence the
management of children with a history of asthma and
should not be routine.199 Overall, fewer than 14% of films
show significant findings (such as infiltrates, atelectasis,
pneumothorax, or pneumomediastinum).200 When a
wheezing child presents to the ED, a trial of inhaled agonists is appropriate before any imaging studies.
Children who improve during ED observation rarely
need a chest film.
Treatment
There are two basic categories of asthma medications. Long-term control medications are taken regularly (often
every day) to prevent or reduce inflammation in the airways. Using these medications makes the asthma sufferer
less likely to have an asthma attack. Quick-relief or rescue medications are designed to open the airways
rapidly and are taken when symptoms of an asthma attack are first noticed.
You can help prevent asthma attacks by taking the following steps: Take your asthma medication(s) exactly
as directed by your doctor. Use a peak-flow meterto monitor your breathingas often as instructed by your
doctor. Keep track of your condition and learn to recognize when your asthma symptoms are worsening. Know
how to respond when an asthma attack is beginning. A severe asthma attack is a medical emergency. Untreated,
it can be fatal.
Asthma episodes rarely occur without warning. Most people with asthma have warming signs (physical
changes) that occur hours before symptoms appear. Warning signs are not the same for everyone. You may have
different signs at different times. By knowing your warning signs and acting on them, you may be able to avoid
a serious episode of asthma.
February 2001
17
However, there is considerable controversy regarding the need for routine chest radiography in children
who present with a first-time episode of wheezing. Some
authors suggest chest films for all children who have no
prior history of bronchospasm in order to identify
important mimics such as foreign body, pneumonia, CHF,
or other cardiopulmonary disease. In one study of firsttime wheezing in children, the authors stated that they
were unable to identify any individual or combination of
clinical factors that could accurately predict a positive
chest film. They suggested routine use of chest radiography for the initial episode of childhood bronchospasm.201
In contrast, another group found several clinical
characteristics among children with first-time wheezing that
were associated with a positive chest x-ray. These included
elevated temperature (37.9C vs 37.5C; P = 0.04), absence of
family history of asthma (72.6% vs 27.4%; P < 0.01), and the
presence of localized wheezes (76.0% vs 24.0%; P = 0.02) or
localized rales (76.0% vs 24.0%; P < 0.01).202
Chest x-rays may be worthwhile in asthmatic children
with fever or those with persistent rales and rhonchi. The
following are indications for chest x-rays in children with
wheezing and a history of reactive airway disease:203
Toxicity
Significant respiratory distress
Persistent rales and rhonchi
Fever with no obvious viral source
Poor response to ED treatment
Suspicion of pneumothorax, pneumonia, foreign
Disposition
Numerous guidelines exist to help the emergency
physician form an educated decision with regards to
patient disposition. (See also the bottom part of the
clinical pathway Management Of Patients With An
Acute Asthma Exacerbation, which starts on page 14.)
Response assessment should be based on subjective
improvement of wheezing, air exchange, and dyspnea;
objective criteria such as improvement in FEV1 or PEFR;
and the patients risk for relapse and poor outcomes, in
part predicted by his or her past history.
Complete resolution of symptoms and a PEFR or FEV1
greater than 70% predicted signifies a good response to
treatment.204 When determining improvement, one group
suggests that a 12% (of predicted) improvement in PEFR
and a 2 cm improvement on a 10 cm dyspnea visual analog
scale may represent the minimum clinically significant
response.205 Individuals who demonstrate significant
improvement, as well as those with minimal symptoms,
may be safely discharged home. An five- to 10-day course
of oral corticosteroids and a 10-day regimen of intense
-agonist therapy remain the mainstay of outpatient
therapy. This seems to be true despite conflicting data on
relapse rates of discharged patients.60
Even with the most aggressive of therapies, some
asthmatics may fail to respond. Poor response to treat-
18
February 2001
February 2001
19
Discharge Medications
Education
Asthma education in the ED may decrease future
emergency visits. One successful education program
included topics such as prevention of asthma, decreasing
inflammation as a means of improving asthma control
(stressing inhaled corticosteroids), self-monitoring with a
peak flow meter, and demonstrating the correct inhalation technique with metered-dose inhalers and a spacer
device.216 In another study, ED asthma education using a
nurse educator led to reduced symptoms, improved lung
function, less time off work, and fewer consultations with
health professionals.217
Despite some evidence that self-management
programs with a written action plan reduce hospitalizations,218 only 28% of the adult patients hospitalized for
asthma had written action plans that defined how to
manage their asthma and control an exacerbation.219
Furthermore, Emond et al recently surveyed 77 emergency departments to assess the presence of formal
asthma education programs. Only 16% of the sites had
asthma education programs, and the majority of those
were at pediatric facilities.220 This is an arena in which
emergency physicians could play a greater role.
Simple handouts including an Asthma Action Plan
(see the sample on page 19) should be dispensed at discharge or at admission. Patients should be taught to monitor
their peak flows: A drop in peak flow below 80% of personal
best indicates need for added medications, while a drop
below 50% indicates a severe exacerbation. In addition,
provide handouts with written information about the
symptoms and treatment of asthma, as well as instructions
on the use of an MDI. (See Tool 1: Sample Discharge
Instructions For The Patient With Asthma on page 17 and
Tool 2: Your MDI: Guidelines To Proper Use on page 18.)
This last strategy of proper MDI use is deceptively
simple yet profoundly important. Only about 20% of
asthmatics use their MDI correctly.221 The physician or
respiratory therapist should critically observe the
patients technique before discharge. Many asthmatics
casually use their inhaler as if it were a breath freshener.
Observation Units
Observation units are an option for incomplete responders.
Recent studies indicate that as many as 59% of asthmatics
admitted to observation units where strict care protocols are
Smoking
Ask the parents of wheezing children if they or anyone
else smokes inside the house. Cigarette smoke in the
home is an important modifiable risk factor in reactive
airway disease among children.222,223 People who will not
Adapted from Table 4 in: Brenner B, Kohn MS. The acute asthmatic
patient in the ED: To admit or discharge. Am J Emerg Med 1998;16:69-75.
20
February 2001
Summary
Numerous myths and pitfalls of asthma management are
perpetuated despite modern medicine. Withholding agonist therapy in the ED because of recent use at home
is unwarranted, has no scientific basis, and is extremely
dangerous. Likewise, failing to start corticosteroids, lack
of effort toward patient education, and failure to arrange
prompt outpatient follow-up are also concerning. (For
suggestions on how to avoid these pitfalls, see the Ten
Excuses That Dont Work In Court on page 11.)
No established treatment regimen is completely
efficacious. Numerous drugs and drug combinations can
be used in the acute asthmatic to achieve optimal and
maximum bronchodilatory effect. Treatment should begin
with inhaled -agonists and, if the patient is hypoxic,
oxygen as well. Additional therapy may include anticholinergic agents and corticosteroids. Objective measures of
treatment responsiveness, such as pulmonary function
tests, vital signs, chest and heart exams, as well as the
patients subjective assessment of dyspnea, may guide
ED intervention.
On discharge, all patients requiring systemic steroids
in the ED should be prescribed steroid therapy equivalent to oral prednisone 40-60 mg in a non-tapering
burst.224 The steroids may be given by mouth, by inhalation, or by injection. The best duration of therapy remains
unclear; recommendations range from five to 10 days.
Long-acting intramuscular steroids offer the advantage of
foregoing outpatient oral steroids, thereby ensuring full
patient compliance.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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Class III:
Unacceptable
Not useful clinically
May be harmful
Level of Evidence:
No positive high-level data
Some studies suggest or
confirm harm
Indeterminate
Continuing area of research
No recommendations until
further research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent,
contradictory
Results not compelling
Adapted from: The Emergency
Cardiovascular Care Committees
of the American Heart Association
and representatives from the
resuscitation councils of ILCOR:
How to Develop Evidence-Based
Guidelines for Emergency Cardiac
Care: Quality of Evidence and
Classes of Recommendations; also:
Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee and
Subcommittees, American Heart
Association. Part IX. Ensuring
effectiveness of community-wide
emergency cardiac care. JAMA
1992;268(16):2289-2295.
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