Emergency Department Care of the Asthma Patient: Predicting “Bounce-Back” Patients

Abstract

Asthma is a major cause of morbidity and mortality in the United States, affecting approximately 14 million people.1Marano MA Current estimates from the National Health Interviewing Survey: United States, 1994. DHHS publication no. (PHS) 96-1521, Vital Health Statistic series; 10:193. National Center for Health Statistics, US Government Printing Office, Washington, DC1996Google ScholarAcute asthma exacerbations account for 1 to 2 million emergency department (ED) visits, 450,000 hospital admissions, and 5,000 deaths every year. Unfortunately, the mortality rate from asthma is on the rise, despite more effective medications and better understanding of the pathophysiology of the disease. Deaths from acute asthma, many of which occur outside the hospital, reflect therapeutic failures at two different levels: failure of prophylaxis and failure in managing the acute attack.In this issue of CHEST (see page 919), Emerman and coworkers report on 932 patients discharged from EDs following an exacerbation of asthma. Six hundred thirty-nine patients had follow-up data on the use of health-care resources in the following 2 weeks. Seventeen percent of these patients reported relapse within this period. Longer duration of symptoms, a history of numerous ED or urgent clinic visits in the last year, use of a home nebulizer, and the report of multiple triggers of the asthma were all weak predictors of recurrence. These investigators have previously reported that the lack of an identifiable primary care physician was also a predictor of recurrence and their analysis controlled for this factor, as well as for age, gender, and race.2Emerman CL Cydulka RK Factors associated with relapse after emergency department treatment of acute asthma.Ann Emerg Med. 1995; 26: 6-11Abstract Full Text Full Text PDF PubMed Scopus (62) Google ScholarThe patient population chosen for this study were those patients who were discharged from the ED. The initial peak expiratory flow of this group was relatively good, averaging 55% of predicted, and the final peak expiratory flow rate was approximately 80% of predicted. Because these patients were discharged with only mild airway obstruction, it should be no surprise that the peak expiratory flow rate was not predictive of relapse in this cohort.Of concern also is the choice of the outcome variable. As in their previous paper,2Emerman CL Cydulka RK Factors associated with relapse after emergency department treatment of acute asthma.Ann Emerg Med. 1995; 26: 6-11Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar the authors have chosen an unscheduled clinic visit or return to the ED for asthma treatment as an indication of treatment failure. Clearly, we would hope that patients and their physicians would not expect that ED care is definitive treatment for a chronic illness such as asthma. Furthermore, as the authors note in their discussion, how many relapses are too many? Should this paper really be condemning peak expiratory flow rate as inadequate for predicting a relapse or extolling the virtue of high-quality ED care in preventing admissions and maintaining the need for subsequent unscheduled visits to health-care providers at less than 20%?Assessment of the asthma patient in the ED may be a difficult undertaking. The patient's signs and symptoms may give a clue as to the degree of airway obstruction. However, objective measurements of pulmonary function have become the norm in assessment. Formal pulmonary function tests (eg, spirometry) are difficult for patients presenting with acute exacerbation of asthma, and the measurement of peak expiratory flow rate has become the standard for ongoing monitoring. The peak expiratory flow rate provides a simple, quantitative, and reproducible measure of the severity of airflow obstructions. Several clinical studies have found that peak expiratory flow monitoring used as a component of comprehensive asthma self-management improves health outcomes.3Woolcock AJ Yan K Salome CM Effect of therapy on bronchial hyperresponsiveness in the long-term management of asthma.Clin Allergy. 1988; 18: 165-176Crossref PubMed Scopus (114) Google Scholar4Ignacio-Garcia JM Gonzalez-Santos P Asthma self-management education program by home monitoring of peak expiratory flow.Am J Respir Crit Care Med. 1995; 151: 353-359Crossref PubMed Scopus (233) Google Scholar5Beasley R Cushley M Holgate ST A self-management plan in the treatment of adult asthma.Thorax. 1989; 44: 200-204Crossref PubMed Scopus (222) Google Scholar Although dependent on effort and technique, measurement of the peak expiratory flow rate is a simple procedure that it is easily implemented in the ED setting. In fact, the National Institutes of Health (National Heart, Lung, and Blood Institute) have published guidelines that recommend this technique for determining severity and guiding treatment decisions in the ED setting.6National Institutes of Health (NHLBI) Expert Panel Report Guidelines for the diagnosis and management of asthma. NIH publication No. 97-4051. National Institutes of Health, Bethesda, MD1997: 1-86Google ScholarPeak expiratory flow rate was a routine part of the management of patients in the study by Emerman and coworkers. Patients that were discharged from the ED had only mild airway obstruction at final determination and one must assume (as did Emerman and colleagues) that astute clinicians examining clinical findings were influenced by expiratory flow rates in making their disposition decisions.Was the failure of peak expiratory flow rate in predicting relapse an indictment of this prognostic index in ED management? Or was the failure in providing follow-up care? It is our belief that patients with acute exacerbations of chronic illnesses, such as asthma, requiring ED visits must have close follow-up after discharge from the ED. A simple scheduled follow-up within 48 h after discharge may be all that is needed to prevent unscheduled visits and “relapses” as defined in this paper. The authors do not report the frequency of scheduled visits in their paper, but a 48-h assessment of the patient's status would permit adjustment of medications and continued education. Given the increased relapse rate for patients without an identifiable primary care physician, should the ED management of asthma patients include a return visit to the ED if no other health-care provider can see the patient at 48 h?Are there any other ways to prevent the ED presentation of“ bounce-back” asthma patients and thus the “failure” of 17% who warrant alterations in ED management? These are questions that clearly need to be resolved. Clinical trials with cost-effectiveness assessment of post-ED asthma follow-up are warranted. Asthma is a major cause of morbidity and mortality in the United States, affecting approximately 14 million people.1Marano MA Current estimates from the National Health Interviewing Survey: United States, 1994. DHHS publication no. (PHS) 96-1521, Vital Health Statistic series; 10:193. National Center for Health Statistics, US Government Printing Office, Washington, DC1996Google ScholarAcute asthma exacerbations account for 1 to 2 million emergency department (ED) visits, 450,000 hospital admissions, and 5,000 deaths every year. Unfortunately, the mortality rate from asthma is on the rise, despite more effective medications and better understanding of the pathophysiology of the disease. Deaths from acute asthma, many of which occur outside the hospital, reflect therapeutic failures at two different levels: failure of prophylaxis and failure in managing the acute attack. In this issue of CHEST (see page 919), Emerman and coworkers report on 932 patients discharged from EDs following an exacerbation of asthma. Six hundred thirty-nine patients had follow-up data on the use of health-care resources in the following 2 weeks. Seventeen percent of these patients reported relapse within this period. Longer duration of symptoms, a history of numerous ED or urgent clinic visits in the last year, use of a home nebulizer, and the report of multiple triggers of the asthma were all weak predictors of recurrence. These investigators have previously reported that the lack of an identifiable primary care physician was also a predictor of recurrence and their analysis controlled for this factor, as well as for age, gender, and race.2Emerman CL Cydulka RK Factors associated with relapse after emergency department treatment of acute asthma.Ann Emerg Med. 1995; 26: 6-11Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar The patient population chosen for this study were those patients who were discharged from the ED. The initial peak expiratory flow of this group was relatively good, averaging 55% of predicted, and the final peak expiratory flow rate was approximately 80% of predicted. Because these patients were discharged with only mild airway obstruction, it should be no surprise that the peak expiratory flow rate was not predictive of relapse in this cohort. Of concern also is the choice of the outcome variable. As in their previous paper,2Emerman CL Cydulka RK Factors associated with relapse after emergency department treatment of acute asthma.Ann Emerg Med. 1995; 26: 6-11Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar the authors have chosen an unscheduled clinic visit or return to the ED for asthma treatment as an indication of treatment failure. Clearly, we would hope that patients and their physicians would not expect that ED care is definitive treatment for a chronic illness such as asthma. Furthermore, as the authors note in their discussion, how many relapses are too many? Should this paper really be condemning peak expiratory flow rate as inadequate for predicting a relapse or extolling the virtue of high-quality ED care in preventing admissions and maintaining the need for subsequent unscheduled visits to health-care providers at less than 20%? Assessment of the asthma patient in the ED may be a difficult undertaking. The patient's signs and symptoms may give a clue as to the degree of airway obstruction. However, objective measurements of pulmonary function have become the norm in assessment. Formal pulmonary function tests (eg, spirometry) are difficult for patients presenting with acute exacerbation of asthma, and the measurement of peak expiratory flow rate has become the standard for ongoing monitoring. The peak expiratory flow rate provides a simple, quantitative, and reproducible measure of the severity of airflow obstructions. Several clinical studies have found that peak expiratory flow monitoring used as a component of comprehensive asthma self-management improves health outcomes.3Woolcock AJ Yan K Salome CM Effect of therapy on bronchial hyperresponsiveness in the long-term management of asthma.Clin Allergy. 1988; 18: 165-176Crossref PubMed Scopus (114) Google Scholar4Ignacio-Garcia JM Gonzalez-Santos P Asthma self-management education program by home monitoring of peak expiratory flow.Am J Respir Crit Care Med. 1995; 151: 353-359Crossref PubMed Scopus (233) Google Scholar5Beasley R Cushley M Holgate ST A self-management plan in the treatment of adult asthma.Thorax. 1989; 44: 200-204Crossref PubMed Scopus (222) Google Scholar Although dependent on effort and technique, measurement of the peak expiratory flow rate is a simple procedure that it is easily implemented in the ED setting. In fact, the National Institutes of Health (National Heart, Lung, and Blood Institute) have published guidelines that recommend this technique for determining severity and guiding treatment decisions in the ED setting.6National Institutes of Health (NHLBI) Expert Panel Report Guidelines for the diagnosis and management of asthma. NIH publication No. 97-4051. National Institutes of Health, Bethesda, MD1997: 1-86Google Scholar Peak expiratory flow rate was a routine part of the management of patients in the study by Emerman and coworkers. Patients that were discharged from the ED had only mild airway obstruction at final determination and one must assume (as did Emerman and colleagues) that astute clinicians examining clinical findings were influenced by expiratory flow rates in making their disposition decisions. Was the failure of peak expiratory flow rate in predicting relapse an indictment of this prognostic index in ED management? Or was the failure in providing follow-up care? It is our belief that patients with acute exacerbations of chronic illnesses, such as asthma, requiring ED visits must have close follow-up after discharge from the ED. A simple scheduled follow-up within 48 h after discharge may be all that is needed to prevent unscheduled visits and “relapses” as defined in this paper. The authors do not report the frequency of scheduled visits in their paper, but a 48-h assessment of the patient's status would permit adjustment of medications and continued education. Given the increased relapse rate for patients without an identifiable primary care physician, should the ED management of asthma patients include a return visit to the ED if no other health-care provider can see the patient at 48 h? Are there any other ways to prevent the ED presentation of“ bounce-back” asthma patients and thus the “failure” of 17% who warrant alterations in ED management? These are questions that clearly need to be resolved. Clinical trials with cost-effectiveness assessment of post-ED asthma follow-up are warranted.