Key Points

Introduction

In this section, recommendations are presented for the assessment and treatment of exacerbations in the home, ED, and hospital. See section 1, "Overall Methods Used To Develop This Report," for literature search strategy and tally of results for this EPR—3: Full Report 2007 section on "Managing Exacerbations of Asthma." Four Evidence Tables were prepared: 17, Increasing the Dose of Inhaled Corticosteroids; 18, IV Aminophylline; 19, Magnesium Sulfate; and 20, Heliox.

Asthma exacerbations are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness—or some combination of these symptoms.

Exacerbations are characterized by decreases in expiratory airflow that can be documented and quantified by simple measurement of lung function (spirometry or PEF). These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms. In general, milder exacerbations may be managed "at home" (i.e., outside the health care system), whereas more serious exacerbations may require an unscheduled ("urgent") office visit, an ED visit, or a hospital admission (see figure 5-1). The most severe exacerbations require admission to the intensive care unit (ICU) for optimal monitoring and treatment. Although assessment and treatment of young children pose unique challenges, the management of asthma exacerbations in older children and adults is fairly similar.

Figure 5-1

CLASSIFYING SEVERITY OF ASTHMA EXACERBATIONS IN THE URGENT OR EMERGENCY CARE SETTING

Individuals who have their asthma under control with ICSs will decrease the risk of exacerbations. Nonetheless, patients in good control can still be vulnerable to exacerbations, for example, when they have clinical respiratory infections (Reddel et al. 1999). Diurnal variability, a marker of poor control, may not change during an exacerbation; thus, clinicians may fail to detect important changes in lung function. The striking difference between PEF variations during exacerbations, as compared with during poor asthma control, suggests differences in beta₂-adrenoceptor function between these conditions. The decrease in responsiveness to SABA during some severe exacerbations may help to explain the benefit of ipratropium bromide and other "alternative" approaches to bronchodilation.

General Considerations

Based on the scientific literature and the opinion of the Expert Panel, the Panel recommends that clinicians consider the following general principles and goals for managing asthma exacerbations: early treatment, special attention to patients who are at high risk of asthma-related death, and special attention to infants (EPR—2 1997).

• ▪ Early treatment is the best strategy for management of asthma exacerbations. Important elements of early treatment include:

  • — A written asthma action plan (See "Component 2: Education for a Partnership in Asthma Care," figure 3–10) to guide patient self-management, especially for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations.
  • — Recognition of early indicators of an exacerbation, including worsening PEF. Patients are instructed to recognize early signs and symptoms of worsening asthma and to use quick-relief medications if symptoms occur or if PEF drops below 80 percent predicted or personal best. If PEF is 50–79 percent, the patient should carefully monitor the response to quick-relief medication and, based on the response, consider contacting a clinician. If PEF is below 50 percent, immediate medical care is usually required (See sample written asthma action plans, figures 3–10a, b, and c.). In the urgent or emergency care setting, different parameters are used to classify the severity of the exacerbation and determine the clinical course; see figure 5-1. The Panel chose cut points of 40 percent and 70 percent of predicted (or personal best) because 40 percent denotes an exacerbation severity below which several adjunct therapies are effective, and 70 percent is a posttreatment goal for discharge from the ED or hospital.
  • — Appropriate intensification of therapy, often including a short course of systemic corticosteroids.
  • — Removal of or withdrawal from allergens or precipitating irritants in the environment that may be contributing to the exacerbation.
  • — Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to SABA treatment, or decreased duration of effect.
• ▪ Patients who are at high risk for asthma-related death require special attention—particularly intensive education, monitoring, and care. Such patients should be counseled to seek medical care early during an exacerbation and instructed about the availability of ambulance services. Such patients include those who have identifiable risk factors (See figure 5-2a.).
• ▪ Infants require special attention, especially due to their greater risk for respiratory failure (See figure 5-2b.).

Figure 5-2a

RISK FACTORS FOR DEATH FROM ASTHMA Sources: Abramson et al. 2001; Greenberger et al. 1993; Hardie et al. 2002; Kallenbach et al. 1993; Kikuchi et al. 1994; O'Hollaren et al. 1991; Rodrigo and Rodrigo 1993; Strunk and Mrazek 1986; Suissa et al. 1994

Figure 5-2b

SPECIAL CONSIDERATIONS FOR INFANTS Source: EPR—2 1997.

Treatment Goals

The principal goals and Expert Panel recommendations for treating asthma exacerbations are:

• ▪ Correction of significant hypoxemia, in moderate or severe exacerbations, by administering supplemental oxygen. In rare instances, alveolar hypoventilation requires mechanically assisted ventilation (EPR—2 1997).
• ▪ Rapid reversal of airflow obstruction (Evidence A). This is best achieved by:

  • — Repetitive or continuous administration of a SABA (Camargo et al. 2003b; Karpel et al. 1997; McFadden 2003; Travers et al. 2001)
    AND
  • — Early in the course of treatment, administration of systemic corticosteroids to patients who have moderate or severe exacerbations or to patients who fail to respond promptly and completely to SABA treatment (McFadden 2003; Rachelefsky 2003; Rowe et al. 2004).
• ▪ Reduction of the likelihood of relapse of the exacerbation or future recurrence of severe airflow obstruction by intensifying therapy (Evidence A). Often, a short course of systemic corticosteroids is useful (Rachelefsky 2003; Rowe et al. 2004).
• ▪ Achieving these goals requires careful assessment and monitoring (Evidence B). The ability to predict care requirements, including the need for hospitalization, is based on repeated clinical assessments. In adults, repeated measurements of lung function are often helpful. The specific measurements chosen for monitoring will depend on the age of the patient and the available resources.

  • — Children. In children, no single assessment tool appears to be the best for assessing the severity of the exacerbation or for monitoring response to treatment and predicting hospital admission (Chey et al. 1999; Gorelick et al. 2004a,b; Keahey et al. 2002; Keogh et al. 2001; Smith et al. 2002; Sole et al. 1999; Wright et al. 1997).

    • ♦ Serial measurements of lung function. Lung function measures using either FEV₁ or PEF may be useful for many children 5 years of age or older. However, neither maneuver may be obtainable during an exacerbation. Gorelick and colleagues (2004a) found that only 65 percent of children 5–18 years of age could complete either measurement during an acute exacerbation, and for children less than 5 years old, the maneuvers were almost impossible.
    • ♦ Pulse oximetry. An initial pulse oximetry in infants and young children might be useful for assessing exacerbation severity but not for predicting the need for hospital admission (Keahey et al. 2002; Kelly et al. 2004; Keogh et al. 2001; Sole et al. 1999; Wright et al. 1997). However, a repeat pulse oximetry of <92–94 percent (sea level) at 1 hour was a better predictor of need for hospitalization, and it may be useful to move those infants and children into the hospital and out of the ED at that time (Kelly et al. 2004; Sole et al. 1999; Wright et al. 1997).
    • ♦ Signs and symptoms scores. Several severity assessment scores have been developed and tested in children to help predict the need for hospitalization early in the course of ED treatment (Gorelick et al. 2004b; Keogh et al. 2001; Rodrigo and Rodrigo 1998b; Smith et al. 2002). None is 100 percent predictive, but the assessments may help to determine who should be transferred from the ED to the hospital after an initial 1- to 2-hour period of treatment, leaving the ED resources for those who are more likely to be able to go home after extended ED treatment and observation. These assessment scores combine physician- or nurse-observed signs and symptoms—such as shortness of breath, chest tightness, ability to speak in sentences or phrases, emotional impact, and alertness—plus respiratory rate, use of intercostals muscles, timing and volume of wheezes as well as pulse oximetry and, if available and feasible, FEV₁ or PEF. One score (Gorelick et al. 2004b) has added a parental assessment of asthma control over the past several months and history of previous exacerbations requiring ED or hospital management. Others add the continuing need for hourly SABA 4 or more hours after the administration of oral systemic corticosteroids.
      A recent study suggests that most children who require hospitalization can be identified by a repeat assessment 1 hour after initial treatment (Kelly et al. 2004). After 1 hour, those children who continue to meet the criteria for a severe exacerbation have >86 percent chance of requiring hospitalization; those who meet the criteria for moderate exacerbation at 1 hour have an 84 percent chance of requiring hospitalization; and those whose assessment has remained the same or dropped to the mild level have only an 18 percent chance of requiring hospitalization. These severity assessment studies highlight the importance of regular, multifaceted assessments and close observation of children and adolescents who present to the office or ED with acute asthma exacerbations (See figures 5-1 and 5-3.).
  • — Adults

    • ♦ Serial measurements of lung function. FEV₁ or PEF appear to be more useful in adults for categorizing the severity of the exacerbation and the response to treatment and in predicting the need for hospitalization. Repeated measurements of PEF or FEV₁ in adults at 1 hour and beyond are useful as isolated assessments in determining who will require hospitalization and who is likely to have sufficient response to treatment to allow continued ED care. Indeed, repeated FEV₁ or PEF measures at presentation to the ED and 1 hour after treatment were the strongest single predictor of hospitalization among adults who present to the ED with an asthma exacerbation (Karras et al. 2000; Kelly et al. 2004; McCarren et al. 2000; Rodrigo et al. 2004; Weber et al. 2002).
      When FEV₁ is unavailable, PEF may be substituted. Although percentage of personal best PEF or FEV₁ would be ideal for patient management, individuals may report erroneous values (Diner et al. 2001). Interpretation of percentage of predicted values is complicated by differences between formulas in the literature (Radeos and Camargo 2004). Regardless of the calculation chosen, for severe exacerbations with obvious airway compromise and even cyanosis, the immediate testing of FEV₁ or PEF provides little additional information, and the maneuver can be very uncomfortable for acutely ill patients (Kelly et al. 2004).
    • ♦ Pulse oximetry is indicated for patients who are in severe distress, have FEV₁ or PEF <40 percent of predicted, or are unable to perform lung function measures.
    • ♦ Signs and symptoms scores. As in children, some multifaceted prediction models have been tested and shown to improve slightly on the accuracy of the FEV₁ or PEF alone (Chey et al. 1999; Kelly et al. 2002b and 2004; McFadden 2003; Weber et al. 2002). Kelly and colleagues (2004) used multiple signs and symptoms to determine the level of the severity of the exacerbation at 1 hour after the first ED treatment as well as the duration of symptoms (either <6 hours or ≥ 6 hours) before the patient's arrival at the ED (Kelly et al. 2002b) and found the additional measures improved the prediction rate by 5–10 percent. (See paragraph above related to the same model used in children.) For EDs that have limited resources, the presence of drowsiness in a patient is a useful predictor of impending respiratory failure and reason to consider immediate transfer of the patient to a facility equipped to deal with ventilatory support (Cham et al. 2002). As in the case with children, the ability to predict future care requirements is based on repeated clinical assessments, and, in adults, repeated measures of FEV₁ or PEF (See figure 5-3.).

Figure 5-3

FORMAL EVALUATION OF ASTHMA EXACERBATION SEVERITY IN THE URGENT OR EMERGENCY CARE SETTING Notes:

Home Management of Asthma Exacerbations

Beginning treatment at home avoids treatment delays, prevents exacerbations from becoming severe, and also adds to patients' sense of control over their asthma. The degree of care provided in the home depends on the patients' (or parents') abilities and experience and on the availability of emergency care. General guidelines for managing exacerbations at home are presented in figure 5-4.

Figure 5-4

MANAGEMENT OF ASTHMA EXACERBATIONS: HOME TREATMENT

The Expert Panel recommends preparing patients for home management of asthma exacerbations by taking the following actions (Also see "Component 1: Measures of Asthma Assessment and Monitoring," and "Component 2: Education for a Partnership in Asthma Care.").

• ▪ Teach all patients how to monitor signs and symptoms so they can recognize early signs of deterioration and take appropriate action (Evidence A) (See "Component 2: Education for a Partnership in Asthma Care."), particularly since many fatal asthma exacerbations occur out of hospital (Krishnan et al. 2006). Patients should be taught how to adjust their medications early in an exacerbation (Kelly et al. 2002b) and when to call for further help or seek medical care. Patients should seek medical help earlier if the exacerbation is severe; treatment does not give rapid, sustained improvement; or there is further deterioration.
• ▪ Consider teaching how to monitor lung function, by using PEF to facilitate early and accurate assessment of exacerbations and response to treatment, to patients and parents of children who have moderate or severe persistent asthma or a history of severe exacerbations (Evidence B) and patients who are poor perceivers of airflow obstruction (Evidence D). Signs and symptoms imperfectly mirror airflow obstruction; therefore, other tools may be required, especially in the group of people who are "poor perceivers" and have failed to recognize previous exacerbations or symptom deteriorations early (Hardie et al. 2002; Kikuchi et al. 1994). Exacerbations recognized and treated within 6 hours of onset may be less likely to result in hospitalizations (Kelly et al. 2002b). When using PEF expressed only as a percent of personal best, the impact of any irreversible airflow obstruction must be considered. For example, in a person whose personal best is only 160 L/min, a drop to 60 percent of personal best represents life-threatening airflow obstruction.
• ▪ Provide to all patients a written asthma action plan that includes daily management and recognizing and handling worsening asthma, including self-adjustment of medications in response to acute symptoms or changes in PEF measures in the event of an exacerbation. A written asthma action plan is particularly recommended for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations or poorly controlled asthma (Evidence B). A peak-flow-based plan may be particularly useful for patients who have difficulty perceiving airflow obstruction and worsening asthma (Evidence D). See component 2—Education for a Partnership in Asthma Care, figure 3–10 for a sample plan. Children should also receive a plan appropriate to the school setting (See "Component 2: Education for a Partnership in Asthma Care," figure 3–16.). The plan should direct the patient to adjust medications in response to particular signs, symptoms, and peak flow measurements and should state when to seek medical help. Review the plan with the patient and family. The clinician should tailor the plan to the needs of individual patients. Patients who are at risk for asthma death (See figure 5-2a.) require especially close monitoring.
• ▪ Advise patients who have moderate or severe persistent asthma or a history of severe exacerbations to have the medication (e.g., corticosteroid tablets or liquid) and equipment (e.g., peak flow meter, compressor-driven nebulizer for young children) for treating exacerbations at home (Evidence A).

The Expert Panel recommends the following pharmacologic therapy for home management of exacerbations:

• ▪ Increase the frequency of SABA treatment (Evidence A).
• ▪ Initiate oral systemic corticosteroid treatment under certain circumstances (Evidence A). Short courses or "bursts" of oral corticosteroids reduce the duration and may prevent hospitalizations and relapse following an acute exacerbation (McFadden 2003; Rachelefsky 2003; Rowe et al. 2004). The Expert Panel recommends that, unless working from a defined action plan, individuals contact their health care provider before instituting a course of oral systemic corticosteroids (Evidence D).
• ▪ Doubling the ICS dose is not sufficient (Evidence B) (See Evidence Table 17, Increasing the Dose of Inhaled Corticosteroids.). Doubling the dose of an ICS in those patients already receiving ICS therapy has not been effective at reducing the severity or preventing progression of exacerbations (FitzGerald et al. 2004; Garrett et al. 1998; Harrison et al. 2004; Rice-McDonald et al. 2005). However, higher doses of an ICS may be effective in the ED management of acute asthma exacerbations. For example, preliminary evidence indicates that quadrupling the dose of an ICS for 7 days, starting at the first appearance of worsening symptoms, may prevent exacerbations requiring oral systemic corticosteroids (Foresi et al. 2000). For patients who experience substantial adverse effects with oral systemic corticosteroids (e.g., mood changes, worsening diabetes), high-dose ICS may be an effective alternative for mild to moderate exacerbations.
• ▪ Continue more intensive treatment for several days (EPR—2 1997). Recovery from an exacerbation varies, with symptom relief in 1–2 days for moderate exacerbations but in 3 or more days for severe exacerbations (See figure 5-1.). For many persons, the improvement is quite gradual. Even when symptoms have resolved, evidence of inflammation in the airways may continue for up to 2–3 weeks (McFadden 1975). In managing an exacerbation at home, patients' greater use of SABA should be continued until symptoms and PEF are stable. That said, patients should seek medical care rather than rely on bronchodilator therapy in excessive doses or for prolonged periods (e.g., >12 puffs/day for more than 24 hours).

The Expert Panel does not recommend the following home management techniques, because no studies have demonstrated effectiveness, and it is the opinion of the Panel that these techniques may delay patients from obtaining necessary care (EPR—2 1997).

• ▪ Drinking large volumes of liquids or breathing warm, moist air (e.g., the mist from a hot shower).
• ▪ Using over-the-counter products such as antihistamines or cold remedies. Over-the-counter bronchodilators may provide transient bronchodilation, but their use should not delay seeking medical care.

The Expert Panel also notes that although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory distress, these methods do not bring about improvement in lung function.

Prehospital Management of Asthma Exacerbations

The Expert Panel recommends that emergency medical services (EMS) providers administer supplemental oxygen and SABA to patients who have signs or symptoms of an asthma exacerbation (Evidence A).

Prehospital administration of SABA reduces airflow obstruction and relieves symptoms (Fergusson et al. 1995; Markenson et al. 2004; Richmond et al. 2005). Ideally, all EMS providers would receive a standing order to allow them to provide albuterol to their patients who have asthma exacerbations. Such an order would be consistent with their legally authorized scope of practice and local medical direction (Camargo 2006). In such settings, EMS providers should have available a nebulizer and/or an inhaler plus spacer/holding chamber for SABA administration (see figure 5-5 for dosages). If these are not available, subcutaneous epinephrine or terbutaline should be given for severe exacerbations (See figure 5-5.) (Sly et al. 1977; Smith et al. 1977).

Figure 5-5

DOSAGES OF DRUGS FOR ASTHMA EXACERBATIONS Notes:

When initiating bronchodilatory use, EMS personnel should not delay transport of the patient to the appropriate medical facility. The treatment, however, may be repeated while transporting the patient. Prolonged transport times (e.g., in a rural setting or during transport on congested urban streets) may necessitate multiple inhaled SABA treatments before arrival at the medical facility (Crago et al. 1998). Patients should receive a maximum of three inhaled SABA treatments in the first hour, and then one per hour thereafter (consistent with practice in the ED setting; see figures 5-5 and 5-6). After each treatment, EMS personnel should reassess and record the patient's vital signs and lung sounds.

Figure 5-6

MANAGEMENT OF ASTHMA EXACERBATIONS: EMERGENCY DEPARTMENT AND HOSPITAL-BASED CARE

Ambulance services should develop prehospital protocols for the treatment of acute asthma in children and adults (Markenson et al. 2004; Stead and Whiteside 1999). With medical oversight, these protocols can allow for more frequent administration of several established acute asthma treatments, such as ipratropium bromide and oral systemic corticosteroids (Knapp and Wood 2003). The latter medication is particularly important during prolonged transport times. All prehospital providers should receive training in how to respond to the clinical signs and symptoms of severe airway obstruction and imminent respiratory failure (Camargo 2006).

Emergency Department and Hospital Management of Asthma Exacerbations

Severe exacerbations of asthma are potentially life threatening. Care must be prompt. Effective initial therapies (i.e., SABA and the means of giving it by aerosol and a source of supplemental oxygen) should be available in a physician's office. Serious exacerbations, however, require close observation for deterioration, frequent treatment, and repetitive measurement of lung function. Therefore, most severe exacerbations of asthma require prompt transfer to an ED for more complete therapy (McFadden 2003; Rowe et al. 2001). Despite appropriate therapy, approximately 10–25 percent of ED patients who have acute asthma will require hospitalization (Pollack et al. 2002; Weber et al. 2002). In the hospital, multidisciplinary (e.g., nursing and respiratory care) clinical pathways for asthma appear to be effective in reducing hospital length-of-stay and inpatient costs, but they have less clear impact on clinical outcomes (Banasiak and Meadows-Oliver 2004). An overview of the treatment strategies in EDs and hospitals is presented in figure 5-6 and detailed below.

PATIENT DISCHARGE

The Expert Panel recommends that clinicians, before patients' discharge from the ED or hospital, provide patients with necessary medications and education on how to use them, a referral for a followup appointment, and instruction in an ED asthma discharge plan for recognizing and managing relapse of the exacerbation or recurrence of airflow obstruction (Evidence B).

The Expert Panel recommends the following actions for discharging patients from the ED:

• ▪ Release of the patient from the ED depends on the patient's response to treatment (EPR 2 1997).

  • — In general, discharge is appropriate if FEV₁ or PEF has returned to ≥70 percent of predicted or personal best and symptoms are minimal or absent. Patients who have an incomplete response to therapy (FEV₁ or PEF 50–69 percent of predicted or personal best) and with mild symptoms should be assessed individually for their suitability for discharge home, with consideration given to factors listed in figure 5-2a (Evidence C).
  • — The Expert Panel's opinion is that patients who have a rapid response should be observed for 30–60 minutes after the most recent dose of bronchodilator to ensure their stability of response before discharge to home.
  • — Extended treatment and observation in a holding area, clinical decision unit, or overnight unit to determine the need for hospitalization may be appropriate, provided there is sufficient monitoring and nursing care (McCarren et al. 2000).
• ▪ Prescribe sufficient medications for the patient to continue treatment after discharge.

  • — Patients given systemic corticosteroids should continue oral systemic corticosteroids for 3–10 days (Evidence A). The need for further corticosteroid therapy should be assessed at a followup visit. For corticosteroid courses of less than 1 week, there is no need to taper the dose. For 10-day courses, there remains no need to taper if patients are concurrently taking ICSs (O'Driscoll et al. 1993).
  • — Consider initiating an ICS at discharge, in addition to oral systemic corticosteroids (Evidence B). A retrospective review of a large patient database found a significant reduction in the risk of subsequent ED visits among patients using ICS therapy after ED discharge (Sin and Man 2002). A clinical RCT comparing ED patients discharged with and without ICSs demonstrated that ICSs added to oral systemic corticosteroids halved patients' risk of relapse events (Rowe et al. 1999). A Cochrane review (Edmonds et al. 2000) noted that two other relapse trials did not report similar benefit, but the review found that the combined estimate of the three available trials had borderline statistical significance (odds ratio 0.68; 95 percent CI 0.46 to 1.02). The Expert Panel concludes that initiating ICS therapy (e.g., providing a 1–2 month supply) at discharge from ED should be considered, given the potential for ICSs is to reduce subsequent ED visits, the strong evidence that long-term-control ICS therapy reduces exacerbations in patients who have persistent asthma, and the opinion of the Expert Panel that the initiation (and continuation) of ICS therapy at ED discharge can be an important effort to bridge the gap between emergency and primary care for asthma. Patients already taking ICS therapy should continue it following discharge.
• ▪ Emphasize the need for continual, regular care in an outpatient setting, and refer the patient for a followup asthma care appointment (either primary care provider (PCP) or asthma specialist) within 1–4 weeks (Evidence B). If appropriate, consider referral to an asthma self-management education program (Evidence B). A visit to the ED is often an indication of inadequate long-term management of asthma or inadequate plans for handling exacerbations. Having fewer general practice contacts in the previous year has been independently associated with an increased risk of fatal asthma (Sturdy et al. 2005), and an observational study found that having followup appointments within 30 days of an asthma-related ED visit was associated with a reduced 90-day readmission rate (Sin et al. 2002). Likewise, referral of patients in the ED to an asthma specialist for consultation was associated with a reduced rate of subsequent ED visits (Zeiger et al. 1991). These results contrast, however, with two recent randomized trials that found that facilitated referral of ED patients to the PCP did not alter long-term asthma outcomes (Baren et al. 2006; Smith et al. 2004). Although the evidence from RCTs regarding optimal referral practice is limited (e.g., PCP or asthma specialist), the ED and hospital staff should notify the patient's health care professional (or provide a referral to one if the patient does not name a source of asthma care) and encourage the patient to contact his/her health care provider (e.g., by telephone) for asthma-related problems during the first 3–5 days after ED or hospital discharge. The ED and hospital staff should instruct the patient to seek a followup medical appointment within 1–4 weeks. Whenever possible, the ED should schedule such an appointment before the patient is discharged, because this action will increase the likelihood that the patient actually receives an appointment and attends the followup (Baren et al. 2006; Zorc et al. 2003). At the followup appointment, the health care provider should try to ascertain the cause of the exacerbation and institute appropriate, specific, preventative therapy if possible. The followup visit should also include a detailed review of the patient's medications, inhaler and peak flow meter technique, and development of a comprehensive written asthma action plan that will help prevent subsequent exacerbations and urgent or emergency care visits (See section 3, "Component 2: Education for a Partnership in Asthma Care," figures 3–10a, b, and c; 3–11; and 3–14.). If appropriate, consider referring the patient to an asthma self-management education program.
• ▪ Review discharge medications with the patient and provide patient education on correct use of an inhaler (Evidence B) (See section 3, "Component 2: Education for a Partnership in Asthma Care," figures 3–12 and 3–14.).
• ▪ Give the patient an ED asthma discharge plan with instruction for medications prescribed at discharge and for increasing medications or seeking medical care if asthma should worsen (Evidence B). Although evidence from RCTs is limited, for many patients, a thoughtful, asthma-oriented ED discharge plan will suffice. If local staff and resources permit, however, the provision of a more detailed plan may be appropriate, especially for patients who had severe exacerbations or who do not have regular asthma care. See figure 5-7 for a sample ED asthma discharge plan and "Component 2: Education for a Partnership in Asthma Care."
• ▪ Consider issuing a peak flow meter and giving appropriate education on how to measure and record PEF to patients who have difficulty perceiving airflow obstruction or symptoms of worsening asthma (Evidence D). Studies document that some patients are unable to perceive signs of deterioration that would indicate a need to increase medication (Hardie et al. 2002; Kikuchi et al. 1994). These "poor perceivers" may particularly benefit from action plans based on peak flow monitoring, because this tool may prevent delays in treating exacerbations. Although clinical trials have not yet evaluated issuing peak flow meters at discharge from ED, it is the opinion of the Expert Panel that this approach warrants consideration. See "Component 1: Measures of Asthma Assessment and Monitoring" and "Component 2: Education for a Partnership in Asthma Care" for discussions of the advantages and disadvantages of peak flow monitoring.

Figure 5-7

EMERGENCY DEPARTMENT – ASTHMA DISCHARGE PLAN Source: Camargo CA Jr, Emond SD, Boulet L, Gibson PG, Kolbe J, Wagner CW, Brenner BE. Emergency Department Asthma Action Plan. Developed at "Asthma Education in the Adult Emergency Department: A Multidisciplinary (more...)

The Expert Panel recommends the following actions for discharging patients from the hospital:

• ▪ Prior to discharge, adjust the patient's medication to an outpatient regimen (EPR—2 1997). During the first 24 hours after this medication adjustment, observe the patient for possible deterioration.
• ▪ Discharge medications should include a SABA and sufficient oral systemic corticosteroids to complete the course of therapy (Evidence A) and instructions to continue long-term control therapy until the followup appointment (Evidence B). Consider initiating ICS therapy for patients who did not use an ICS prior to the hospital admission (Evidence B). If the decision is made to start the patient on an ICS, the ICS should be started before the course of oral corticosteroids is completed, because their onset of action is gradual (Kraan et al. 1988). Starting the ICS therapy before discharge gives the patient additional time to learn and demonstrate appropriate technique.
• ▪ Provide patient education:

  • — Review patient understanding of the causes of asthma exacerbations, the purposes and correct uses of treatment (including inhaler technique), and the actions to be taken for worsening symptoms or peak flow measures (Evidence B) (See "Component 2: Education for a Partnership in Asthma Care."). An exacerbation severe enough to require hospitalization may reflect a failure of the patient's self-management, particularly in patients who have low levels of health literacy (Paasche-Orlow et al. 2005). Some studies report that 35 percent of adult patients presenting to the ED are current smokers (Silverman et al. 2003). It would be appropriate to query patients hospitalized for asthma about their smoking status and encourage smoking cessation along with their asthma discharge plan. Hospitalized patients may be particularly receptive to information and advice about their illness (See "Component 2: Education for a Partnership in Asthma Care.").
  • — Educate patients about their discharge medications and the importance of taking medications as prescribed and attending their followup visit (Evidence B). Low levels of adherence to asthma medications are common, even in patients recently hospitalized for severe asthma exacerbations (Krishnan et al. 2004).
  • — Referral to an asthma specialist should be considered for patients who have a history of life-threatening exacerbations or multiple hospitalizations (Evidence B) (Harish et al. 2001; Mahr and Evans 1993; Mayo et al. 1990; Sperber et al. 1995).
  • — Consider issuing a peak flow meter and giving appropriate education on peak flow monitoring to patients who are ≥5 years of age (and parents) who have a history of severe exacerbations or who have moderate or severe persistent asthma (Evidence B) and those who poorly perceive airflow obstruction or worsening asthma (Evidence D).
• ▪ Review or develop a written plan for managing either relapse of the exacerbation of recurrent symptoms or exacerbations (Evidence B). The plan should describe the signs, symptoms, and/or peak flow values that should prompt increases in self-medication, contact with a health care provider, or return for emergency care. The plan given at discharge from the ED may be quite simple (e.g., instructions for discharge medications and returning for care if asthma worsens; see figure 5-7b). The preparation for discharge from the hospital should be more complete (See figure 5-8.). A detailed written asthma action plan for comprehensive long-term management and handling of exacerbations should be developed by the regular provider at a followup visit (See figure 3–10a, b, and c; "Component 2: Education for a Partnership in Asthma Care.").

Figure 5-7b

EMERGENCY DEPARTMENT – ASTHMA DISCHARGE PLAN : HOW TO USE YOUR METERED - DOSE INHALER

Figure 5-8

CHECK LIST FOR HOSPITAL DISCHARGE OF PATIENTS WHO HAVE ASTHMA

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