Discharge considerations for adult asthmatic patients ...

Discharge considerations for adultasthmatic patients treated in

emergency departmentsANTON F GRUNFELD MD FRCPC, J MARK FITZGERALD MB FRCPC

Department of Emergency Medicine and University of British Columbia Respiratory Clinic,Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia

322 Can Respir J Vol 3 No 5 Sep tem ber/Oc to ber 1996

REVIEW

AF GRUN FELD, JM FITZGER ALD. Dis charge con sid era -tions for adult asth matic pa tients treated in emer gencyde part ments. Can Respir J 1996;3(5):322- 327.

OB JEC TIVE: To re view the medi cal lit era ture on out -come of treat ment of acute asthma in the emer gency de part -ment and is sue rec om men da tions re gard ing pa tientad mis sion or dis charge.DATA SOURCES: A MED LINE search was done for ar ti -cles in the Eng lish lan guage on acute asthma and treat mentin the emer gency de part ment for the years 1975 to 1993. Inad di tion, ref er ences in per ti nent re view ar ti cles were re -viewed.STUDY SE LEC TION: Stud ies ad dress ing treat ment ofacute asthma in emer gency de part ments were se lected bycon sen sus.DATA SYN THE SIS: Three ma jor ar eas have been shownto af fect out come and the de ci sion to ad mit or dis charge apa tient fol low ing treat ment in the emer gency de part ment:first, the se ver ity of the at tack and the re sponse to ther apy;sec ond, his tori cal risk fac tors; and third, care fol low ing dis -charge from the emer gency de part ment. This pa per re views the lit era ture on out come of acute asthma at tacks and is suesrec om men da tions re gard ing ob jec tive air flow meas ure -ments and co- existing risk fac tors to be as sessed be fore dis -charg ing pa tients. The role of anti- inflammatory ther apy inemer gency de part ment treat ment and in post dis chargetreat ment of these pa tients is also re viewed.

CON CLU SION: Evalua tion for dis charge fol low ing treat -ment of acute asthma should in te grate ob jec tive meas uresof air flow ob struc tion with his tori cal high risk fac tors. Theuse of sys temic cor ti cos ter oids in the emer gency de part -ment and fol low ing dis charge, with care ful follow- up, mayhelp con trol the at tack and re duce re lapse of asthma.Key Words: Acute asthma, Dis charge cri te ria, Out come, Ther -apy

Ques tions rela tives au congé des adul tes asth -ma tiques trai tés aux serv ices des ur gencesOB JEC TIF : Revoir la litté ra ture médi cale sur les résul tats dutraite ment de l’asthme aigu au serv ice des ur gences et émet tre desre com man da tions quant à l’hos pi tali sa tion ou la non- hospitalisation des pa tients.SOURCES DES DONNÉES : Dans MED LINE, on a re cher chéles ar ti cles de langue anglaise por tant sur l’asthme aigu et sontraite ment au serv ice des ur gences, de 1975 à 1993. De plus, on apassé en re vue les réfé rences dans les ar ti cles de syn thèse per ti nents.SÉ LEC TION DES ÉTUDES : Les études trai tant du traite mentde l’asthme aigu aux serv ices des ur gences ont été sé lec tionnéespar con sen sus.SYN THÈSE DES DONNÉES : On a démon tré que trois fac teurs prin ci paux af fec taient les résul tats de la dé ci sion vi sant à hos pi ta -liser ou à don ner congé à un pa tient suite à un traite ment au serv ice des ur gences. En pre mier, la gravité de la crise d’asthme et laréponse au traite ment; en sec ond, les anté cédents de fac teurs de

Correspondence: Dr Anton Grunfeld, Department of Emergency Medicine, Vancouver Hospital and Health Sciences Centre, 855 West12th Avenue, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-4995, fax 604-875-4872, e-mail [email protected]

voir page suivante

Al though the great ma jor ity of pa tients treated in emer -gency de part ments (ED) with acute asthma re cover and

are safely dis charged home, sig nifi cant mor bid ity and mor -tal ity are well- recognized (1-3). The im por tant out comes tobe pre vented are death or a near fa tal event, and re lapse witha fur ther epi sode of acute asthma. Be cause most asthmadeaths oc cur in the com mu nity and those deaths that oc cur inthe ED are usu ally in pa tients who ar rive mori bund (2), thisar ti cle fo cuses on the ED evalua tion of pa tients in whom ade ci sion re gard ing ad mis sion or dis charge needs to be made.In ad di tion, it will re view the im por tant role of anti- inflammatory ther apy in the follow- up care of these pa tients.

DISCHARGE CONSIDERATIONSBe cause of the com plex ity of medi cal and non medi cal

fac tors as so ci ated with the out come of an asth matic at tack(4), our abil ity to pre dict and al ter it is im per fect. The threema jor ar eas that have been shown to af fect out come and thusre quire evalua tion be fore dis charg ing the pa tient are as fol -lows:

• the se ver ity of the at tack and re sponse to ther apy;

• his tori cal high risk fac tors;

• care fol low ing dis charge.

SEVERITY OF THE ATTACK ANDRESPONSE TO THERAPY

The as sess ment of the se ver ity of an acute asthma at tack is based both on clini cal ex ami na tion and on the ob jec tiveevalua tion of air flow ob struc tion. Sev eral physi cal signshave been rec og nized as be ing as so ci ated with life- threatening asthma, such as tachy car dia, tachyp nea, use ofac ces sory mus cles, pul sus para doxus, dia pho re sis and an in -abil ity to com plete sen tences in one breath. More omi noussigns in clude a si lent chest, cya no sis, bra dy car dia and de -creased lev els of con scious ness. It must be noted that the ab -

sence of these signs can not be in ter preted as sig ni fy ing thatthe at tack is not life- threatening. In ad di tion, stud ies in bothadults and chil dren failed to show a good cor re la tion be tween the physi cal find ings and physio logi cal meas ure ments in theas sess ment of acute air way ob struc tion (5-7), un der lin ing the need for us ing ob jec tive air flow meas ure ments in ad di tion tothe clini cal ex ami na tion.

At tempts have been made to con struct and vali date se ver -ity scores for acute asthma to pre dict the need for hos pi tali za -tion and safety in dis charg ing pa tients. Fischl et al (8)de vel oped an in dex score based on heart rate over 120beats/min, res pi ra tory rate more than 30 breaths/min, pul suspara doxus 18 mmHg or greater, peak ex pi ra tory flow rate(PEFR) 120 L/min, mod er ate to se vere dysp nea, the use ofac ces sory mus cles and wheez ing. Each of the signs wasscored with one point. The authors found that a score of 4 ormore was 96% ac cu rate in pre dict ing the need for hos pi tali -za tion and 95% ac cu rate in pre dict ing re lapse. How ever,when this scale was tested pro spec tively in two other lo ca -tions, it failed to show any use ful pre dic tive value (4,9).

Sev eral authors have cor re lated the se ver ity of air way ob -struc tion on pres en ta tion and at dis charge from the ED withthe prob abil ity that the pa tient would suf fer a re lapse. In apro spec tive study, Kel sen et al (7) found no sig nifi cant dif -fer ence in the ini tial level of air flow ob struc tion be tween pa -tients who did and those who did not ex pe ri ence re lapsewithin the next 10 days (mean forced ex pi ra tory vol ume in1 s [FEV1] was 1.15 L for the group as a whole, P>0.05).How ever, pa tients with sig nifi cantly lower lev els of lungfunc tion and a smaller de gree of im prove ment in lung func -tion at the time of dis charge were shown to be more likely tosuf fer a sub se quent re lapse (Ta ble 1). Pa tients who showedan FEV1 in crease af ter treat ment of 400 mL had a 67% re -lapse rate, while those with an im prove ment of more than400 mL had a re lapse rate of only 29%.

Ban ner and co- workers (10), in a pro spec tive evalua tion

Can Respir J Vol 3 No 5 Sep tem ber/Oc to ber 1996 323

Dis charge con sid era tions in acute asthma

risque, et en troisième, les soins que le pa tient re cevra à sa sor tie duserv ice des ur gences. Le pré sent ar ti cle passe en re vue la litté ra turesur l’a boutisse ment des cri ses d’asthme ai guës et émet des re com -man da tions à pro pos de la me sure ob jec tive du dé bit aé rien et desfac teurs de risque con comi tants qui doivent être évalués avant dedon ner congé aux pa tients. Le rôle d’une thé ra pie anti- inflammatoire ad min is trée à ces pa tients au serv ice des ur gences, etsuite à leur congé, est aussi ex aminé.

CON CLU SION : La dé ci sion de don ner congé aux pa tientsaprès le traite ment d’une crise d’asthme ai guë doit tenir comptedes me sures ob jec tives de l’ob struc tion bron chique et des anté -cédents des fac teurs de risque. L’u tili sa tion de cor ti costé roïdespar voie gé né rale au serv ice des ur gences, et suite au congé, ac -com pagnée d’un suivi rig oureux, peut fa vo riser la maîtrise descri ses d’asthme et réduire la fréquence des re chutes.

TABLE 1Forced expiratory volume in 1 s (L) at presentation and discharge

Presentation Discharge

Ref er ence Admitted RelapsedSuccessfullydischarged Admitted Relapsed

Successfullydischarged

Kelsen et al (7) 1.51 1.51 1.56 1.88Nowak et al (11) 0.47 0.72 0.98 1.03 1.54 1.91Nowak et al (12) 0.65 0.82 1.16 1.04 1.65 2.24Nowak et al (13) 0.68 0.86 1.12 1.02 1.80 2.16

of 67 epi sodes of acute asthma, found that pa tients who weresuc cess fully dis charged had a me dian peak flow of 70% pre -dicted. In the seven epi sodes where the treat ment failed, nopa tients had peak flow greater than 42% pre dicted. In ad di -tion, pa tients with ini tial peak flows of less than 16% pre -dicted and less than 16% im prove ment af ter an ini tialin jec tion of adrena line were ad mit ted or had a re lapse (Ta -ble 2).

Fischl et al (8), in a pro spec tive evalua tion of 205 pa tientswith acute asthma, found that PEFR at pres en ta tion was sig -nifi cantly higher in pa tients who were suc cess fully dis -charged than in those who were ad mit ted or re lapsed (157L/min ver sus 94 L/min and 89 L/min, re spec tively). At dis -po si tion, PEFRs in suc cess fully dis charged pa tients were

sig nifi cantly bet ter than those in pa tients who ex pe ri enced are lapse, which were bet ter than those in ad mit ted pa tients(299 L/min, ver sus 191 L/min, ver sus 118 L/min, re spec -tively) (Ta ble 3).

Nowak et al (11), in a pro spec tive evalua tion of 85 epi -sodes of acute asthma, also found sig nifi cant dif fer ences inFEV1 among the three groups of pa tients, both at the time ofpres en ta tion and fol low ing treat ment (Ta ble 1). Thirty- fiveper cent of the pa tients stud ied had an ini tial FEV1 of 0.6 L orless and a post- treatment FEV1 of 1.6 L or less. Ninety percent of pa tients ei ther were ad mit ted or had a sub se quent re -lapse.

In two fur ther stud ies, Nowak et al (12,13) also found sig -nifi cant dif fer ences among val ues of air flow in ad mit ted pa -tients, pa tients who de vel oped prob lems fol low ing dis charge and pa tients who were dis charged with out re lapse (Ta bles1-3). In one of these stud ies (12), 92% of pa tients with a pre -treat ment PEFR of less than 100 L/min and a post- treatmentvalue of less than 300 L/min re quired ad mis sion or had anun suc cess ful out- patient course. Of pa tients with a pre treat -ment PEFR of less than 100 L/min and an im prove ment ofless than 60 L/min af ter ini tial ter bu ta line, 85% were ad mit -ted or had prob lems af ter dis charge.

Fanta et al (14), in a pro spec tive evalua tion of dif fer entthera peu tic com bi na tions, found that the rate and mag ni tudeof re sponse in the first hour de pended on the se ver ity of air -way ob struc tion at pres en ta tion. In this study it was foundthat pa tients with an ini tial FEV1 of less than 30% pre dictedand who did not im prove to an FEV1 of at least 40% pre -dicted at the end of 60 mins of in tense bron cho di la tor ther apy re quired pro longed ED treat ment and/or hos pi tal ad mis sion.

The data in these stud ies show con sis tency in cor re lat ingspi ro met ric meas ure ments and out come. This al lows for rec -om men da tions re gard ing dis charge of asth matic pa tientsfrom the ED, as sum ma rized in Ta ble 4. The ab so lute val ues


Grun feld and FitzGer ald

TABLE 2Percentage predicted values (forced expiratory volume in 1 s and peak expiratory flow rate) at presentation anddischarge


Ref er ence Admitted RelapsedSuccessfullydischarged Admitted Relapsed


Banner et al (10) <16% ≤42% 70%Nowak et al (12) 28% 28% 40% 42% 55% 75%Nowak et al (12) 19% 25% 34% 33% 49% 65%Nowak et al (13) 30% 29% 40% 43% 52% 72%Nowak et al (13) 20% 25% 33% 32% 50% 63%

TABLE 3Peak expiratory flow rate (L/min) at presentation and discharge


Ref er ences Admitted RelapsedSuccessfullydischarged Admitted Relapsed


Fischl et al (8) 94 89 157 118 191 299Nowak et al (12) 126 122 179 184 248 336Nowak et al (13) 134 128 176 187 217 323

TABLE 4Spirometric criteria for deciding to admit or dischargeadult patients with acute asthma

Spirometry to assess the likely need for hospital admission ordischarge should be done on arrival (if the patient tolerates theprocedure) and after bronchodilator therapy

Decision regarding discharge is usually made after 1 h or more oftherapy

PretreatmentFEV1 <1.0 L or PEFR <100 L/min or <25% predicted or best:

patient will usually require admissionPost-treatmentFEV1 <1.6 L or PEFR <200 L/min or <40% predicted or best:

admission is recommendedFEV1 1.6-2.1 L or PEFR 200 to 300 L/min, or between 40% and

60% predicted or best: discharge may be possible afterconsidering the risk factors and follow-up care

FEV1 >2.1 L or PEFR >300 L/min or >60% predicted or best:discharge is likely after considering the risk factors and follow-upcare

FEV1 Forced ex pi ra tory vol ume in 1 s; PEFR Peak ex pi ra tory flowrate

given are ap proxi ma tions for the ‘a ve rage adult’. Per cent agepre dicted or pre vi ous best are more help ful when avail able.The pre- and post- treatment FEV1 or PEFR are proba bly thebest guides to ther apy.

How ever, there are two points worth not ing: first, cor ti co -s ter oids were not rou tinely used as part of the pro to col inthese stud ies; and sec ond, the dis charge cri te ria sug gested inthese stud ies, based on air flow ob struc tion, have not beenpro spec tively vali dated.

Sev eral authors have showed that re li ance on FEV1 orPEFR as the only cri te rion to pre dict the need for hos pi tali za -tion or re lapse has limi ta tions. Ver beek and Chap man (15)ex am ined Nowak’s data and showed that us ing a pro posedPEFR above 300 L/min or an FEV1 greater than 2.1 L wouldlead to one- third of all rec om mended ad mis sions be ing un -nec es sary. Wor thing ton and Ahuja (16) found that us ing thecom bi na tion of FEV1 of at least 0.7 L at pres en ta tion andFEV1 of at least 2.1 L be fore dis charge had a low posi tivepre dic tive value (47%) for ad mis sion or re lapse. How ever, afi nal FEV1 of greater than 2.4 L had a high sen si tiv ity (90%)and nega tive pre dic tive value (94%) when used as a cri te riafor dis charge. Pa tients who at tained this value could be dis -charged with a high de gree of con fi dence. While in di cat ing asafe dis charge, this cut- off value was not use ful for de cid ingad mis sion be cause of the low speci fic ity of only 41%. In thisstudy, knowl edge of the FEV1 did not al ter the de ci sion to ad -mit or dis charge a pa tient in 97% of cases.

In spite of the above limi ta tions, be cause of the knownvaria tions in the abil ity of pa tients to es ti mate the se ver ity ofair flow ob struc tion (17- 20) the meas ure ments are im por tant,not only in gaug ing ob jec tively the re sponse to ther apy, butalso in in te grat ing these lev els into de ci sions re gard ing dis -po si tion, as out lined above.

HISTORICAL HIGH RISK FACTORSStud ies of asthma deaths have iden ti fied his tori cal fac tors

that in crease the risk of pa tients dy ing of their dis ease. Thesein clude a re cent hos pi tal ad mis sion, a re cent visit to the ED,poor medi cal man age ment and poor com pli ance (21- 28).

In a ret ro spec tive case con trol study of death from asthma, Rea et al (29) con firmed the sig nifi cance of these risk fac tors. In ad di tion, they showed that psy cho logi cal prob lems weremore com mon in cases than in con trols. These in cluded re -cent un em ploy ment, re cent be reave ment, de pres sion, per -son al ity dis or ders and al co hol abuse. They con cluded that the best way to iden tify asthma pa tients at risk of death is to iden -tify those who have had a re cent hos pi tal ad mis sion and, inpar ticu lar, those who have ever had a life- threatening at tackre quir ing me chani cal ven ti la tion.

The ex is tence of two groups of pa tients who are con sid -ered at risk of dy ing from asthma was noted at a re cent con -sen sus meet ing on asthma mor tal ity (30). The groups are:

• pa tients with a his tory of near fa tal epi sodes, re quir ingre sus ci ta tion, re gard less of the un der ly ing se ver ity of dis -ease or pres ence of any other risk fac tors

• pa tients with un der ly ing se vere dis ease, judged bychronic se vere symp toms, sys temic ster oid re quire ment,fre quent regu lar use of bron cho di la tors, fre quent ED vis -its or hos pi tali za tions. Pa tients in this group may also have one or more of the fol low ing prob lems: re cent dis chargefrom the hos pi tal for se vere asthma, poor self- care or non -com pli ance with medi ca tions, de pres sion or se vere emo -tional dis tur bance, sig nifi cant other psy cho logi cal fac tors, or short com ings in edu ca tion and su per vi sion.

The po ten tial role of in dis crimi nate use of beta- agonists as a risk fac tor for fa tal asthma has re ceived at ten tion re cently.A number of case con trol stud ies from New Zea land havesug gested that the use of fe noterol may be as so ci ated with anin creased risk of death from asthma (31,32). More re cently,Spit zer et al (33) matched 129 cases who had fa tal or near fa -tal asthma and com pared them with 655 con trols from theSas katche wan Health In sur ance da ta base. The use of both fe -noterol and al buterol was as so ci ated with in creased risk ofdeath (OR 2.6 per can is ter per month, CI 1.7 to 3.9) and ofdeath or near death from asthma con sid ered to gether (OR 1.9per can is ter per month). The ad verse ef fect of regu lar use ofbeta- agonist was also shown by Sears et al (34) in a cross over study that com pared on- demand ver sus regu lar use of fe -noterol. The regu lar use of fe noterol was as so ci ated with lessop ti mal asthma con trol than its use on de mand.

Molfino et al (35) ex am ined the char ac ter is tics of 10 pa -tients who ar rived at hos pi tal in res pi ra tory ar rest or in whomit de vel oped within 20 mins of ar ri val at the ED. These pa -tients were simi lar to those de scribed in the lit era ture with ahigh risk of death from asthma, in clud ing a long his tory ofasthma in young- to middle- aged pa tients, pre vi ous life- threatening at tacks or hos pi tali za tion, de lay in medi cal aidand sud den on set of a rap idly pro gres sive at tack. Ex tremehyper capnia and aci do sis were found be fore me chani cal ven -ti la tion was be gun, but no pa tient de vel oped se ri ous car diacar rhyth mias dur ing re sus ci ta tion. They sug gest that un der -treat ment, as shown by se vere as phyxia, rather than over -treat ment with po ten tial car dio tox ic ity, may be a ma jor fac tor in the in creased number of deaths from asthma.

Kal len bach et al (36) stud ied 81 pa tients with acute se vere asthma in whom me chani cal ven ti la tion was re quired. In thisgroup of pa tients they found no evi dence to sup port the con -



TABLE 5Historical high risk factors associated with asthmarelapse

Previous near fatal episodeSudden precipitous attacksAllergic or anaphylactic triggersRecent emergency department visitFrequent hospitalizationsDependence on systemic steroids or recent useRecent attack of prolonged durationPoor compliance or knowledge of asthmaReturning to the same environmental triggers

cept of car dio tox ic ity re lated to bron cho di la tors con trib ut ingsig nifi cantly to mor tal ity from asthma. On the con trary, there ap peared to have been se ri ous un der treat ment in many cases,par ticu larly as re gards cor ti cos ter oids. The in ves ti ga torsiden ti fied a group of pa tients with ‘h ype racute’ asthma inwhom the du ra tion of the at tack from on set to me chani calven ti la tion was less than 3 h. This group was as so ci ated withan in creased risk of near fa tal epi sodes (P<0.03), and hy per -acute at tacks were uni formly near fa tal.

The data in these stud ies show con sis tency and al low forrec om men da tions re gard ing the con sid era tion of his tori calrisk fac tors be fore dis charge of asth matic pa tients from theED. Pa tients with the char ac ter is tics listed in Ta ble 5 are atrisk of re lapse. How ever, it is worth not ing that these highrisk cri te ria have not been vali dated in pro spec tive stud ies.

FOLLOW-UP CAREIn re cent years the piv otal role that air way in flam ma tion

plays in the patho gene sis of asthma has been rec og nized(37). Jef frey et al (37), in an ul tra struc tural study of bi op siestaken from the air ways of pa tients with asthma and com pared with con trol sub jects, showed the pres ence of in flam ma torychanges in the pa tients with asthma that were not found in the con trols. They in par ticu lar found an in crease in lym pho cytes in the air way and pos tu lated that these cells play a promi nentrole in the in flam ma tory pro cess. It fol lows that pa tients pre -sent ing to the ED have a sig nifi cant amount of air way mu co -sal in flam ma tion and edema. These air way changes havebeen the ba sis for the many rec om men da tions to use anti- inflammatory ther apy, usu ally in the form of sys temic cor ti -cos ter oids (38). De spite this ra tion ale pa tients con tinue to bedis charged from the ED with out such ther apy (39), lead ing to un ac cepta bly high rates of re lapse as well as on go ing poorsymp tom con trol.

A re cent meta- analysis (40), as well as a pre limi nary re -port of our own (41), criti cally re viewed the cur rent lit era ture and made spe cific rec om men da tions as to dos age and routeof ad mini stra tion of cor ti cos ter oids in acute asthma. Roweand Ox man (40) re viewed over 700 ar ti cles and found 30rele vant ran dom ized con trolled tri als. They found that earlyuse of cor ti cos ter oids for ex ac er ba tions re duced hos pi tal ad -mis sions for adults (OR 0.47, 95% CI 0.27 to 0.79) and chil -dren (OR 0.06 to 0.42). In the out- patient set ting they alsofound that cor ti cos ter oids pre vented re lapses in pa tients withacute ex ac er ba tions (OR 0.15, 95% CI 0.05 to 0.44). The ma -jor ity of pa tients who come to the ED with acute asthma have dis ease of such se ver ity that sys temic cor ti cos ter oids are re -

quired. Largely based on one study the dose of cor ti co s ter -oids given has usu ally been 125 mg of meth yl predni so lonein tra ve nously (42). How ever, a number of stud ies haveshown that oral predni sone will suf fice, even in sub jects re -quir ing hos pi tal ad mis sion (43,44). Rowe also looked at theef fect size of oral ver sus in tra ve nous cor ti cos ter oids andfound no dif fer ence in the groups treated with ei ther route.

Tra di tion ally a dose of predni sone 40 mg has been rec om -mended for sub jects dis charged from the ED (45). Where this dose is used, and in the pres ence of the on go ing use of in -haled anti- inflammatory ster oids, rou tine ta per ing of cor ti co -s ter oids at the end of a 10- day course of sys temic medi ca tionis not re quired (46). O’Dris coll et al (46) evalu ated 35 pa -tients ad mit ted to hos pi tal with an acute ex ac er ba tion ofasthma, ran dom ized them to a 10- day course of predni so lone40 mg daily and then ran dom ized them to pla cebo or a tra di -tional ta per ing dose and found no dif fer ence be tween the two groups. The im por tance of main te nance anti- inflammatoryin haled cor ti cos ter oids can be gauged from the fact that, al -though there was a treat ment ef fect at the end of 10 days inthe study of Chap man et al (45), there was no such dif fer enceat 21 days, show ing that short term bene fit of sys temic cor ti -cos ter oids is rap idly lost in the ab sence of ap pro pri ate on go -ing care.

Al though the use of a dou bling dose of in haled cor ti co s -ter oids has been rec om mended in a number of asthma guide -lines (47), there are no pub lished data sup port ing this rec om -men da tion in pre vent ing the evo lu tion of de te rio rat ingasthma into a full- blown acute at tack. Al though in tui tively itmakes sense, the dos ing and du ra tion of such ther apy needsto be vali dated in a pro spec tive study.

Pa tients are usu ally re ferred to fam ily phy si cians forfollow- up within the fol low ing week to moni tor re sponse tother apy. There is evi dence, how ever, that fa cili tated re fer ralto a spe cial ist leads to im prove ment in on go ing asthma care(48) and likely leads to a bet ter tran si tion from acute care toap pro pri ate on go ing con trol of the un der ly ing asthma. Thein te gra tion of a pro gram of asthma edu ca tion and these thera -peu tic in ter ven tions will likely lead to bet ter re sults (49,50).These stud ies sup port the rec om men da tions listed in Ta ble 6.

CONCLUSIONSPa tients pre sent ing to the ED should have air flow ob struc -

tion evalu ated ob jec tively. These meas ure ments should bein te grated with his tori cal fea tures out lined above in com ingto a de ci sion on ad mis sion or dis charge. The use of sys temiccor ti cos ter oids and follow- up with topi cal in haled cor ti co s -ter oids will en sure good ini tial and on go ing con trol ofasthma and pre vent many ad mis sions to hos pi tal, re duce re -lapse rate and, over time, lead to lower asthma mor bid ity andlikely mor tal ity.

AC KNOW LEDGE MENTS: This pa per was pre pared in con junc -tion with the de vel op ment of Guide lines for Emer gency Man age -ment of Adult Asthma by the Asthma Work Group of the Ca na dianAs so cia tion of Emer gency Phy si cians. The authors also thank DrsNaser Awadh and Ken dall Ho for their re view of the manu script.


Grun feld and FitzGer ald

TABLE 6Recommendations for follow-up care

Majority of patients require systemic corticosteroids in theemergency department and following discharge

Patients need to be educated in the use of their medication andrecognition and treatment of relapse

Follow-up by the family doctor or a specialist, especially in highrisk cases, is required

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