Management Of Acute Asthma Research Articles

Asthma care pathways in the emergency department

The purpose of this review is to describe recent evidence of the efficacy and effectiveness of clinical pathways for the assessment and management of severe acute asthma in children and adults in the emergency department (ED). The review will highlight examples of successful knowledge translation initiatives and their ability to support adherence to Best Practice Guidelines. Recent studies reveal that management of pediatric and adult asthma in the ED setting often differs from that which is recommended in clinical practice guidelines. Single and multicenter North American studies have consistently found care gaps. Barriers to adherence to evidence-based management guidelines are numerous. Care pathways are knowledge translation tools that provide a means of applying knowledge translation principles to overcome these barriers, integrate guidelines into practice and optimize patient outcomes. Evidence from a recent Ontario multicenter asthma clinical pathway initiative is highlighted, demonstrating increased adherence to certain aspects of ED care, improved patient recollection of teaching done in the ED and increased referral rates. These findings strengthen the evidence supporting the development and implementation of standardized evidence-based asthma clinical pathways. Gaps between current and best practices persist for the management of asthma in children and adults in North American EDs. There is robust evidence in support of ED asthma clinical pathways to optimize asthma care and outcomes in this setting.

Can an evidence-based guideline reminder card improve asthma management in the emergency department?

ObjectiveAsthma is the most common chronic disease in children. Previous studies described significant variations in acute asthma management in children. This study was conducted to examine whether asthma management in the pediatric emergency department (ED) was improved through the use of an evidence-based acute asthma care guideline reminder card.MethodsThe Pediatric Acute Asthma Management Guideline (PAMG) was introduced to the ED of a pediatric tertiary care hospital in Ontario, Canada. Medical charts of 278 retrospective ED visits (January–December 2002) and 154 prospective visits (July 2003–June 2004) were reviewed to assess changes in acute asthma management such as medication treatment, asthma education, and discharge planning. Logistic and linear regressions were used to determine the effect of PAMG on asthma management in the ED. The propensity score method was used to adjust for confounding.ResultsDuring the implementation of PAMG, patients who visited the ED were more likely to receive oral corticosteroids (Adjusted Odds Ratio [AOR] = 2.26, 95% CI: 1.63–3.14, p < 0.0001) and oxygen saturation reassessment before ED discharge (AOR = 2.02, 95% CI: 1.45–2.82, p < 0.0001). They also received 0.23 (95% CI: 0.03–0.44, p = 0.0283) more doses of bronchodilator in the first hour of ED stay. Improvements in asthma education and discharge planning were noted, but the changes were not statistically significant.ConclusionsAfter the implementation of an evidence-based guideline reminder card, medication treatment for acute asthma in the ED was significantly improved; however, asthma education and discharge planning remained unchanged. Future efforts on promoting guideline-based practice in the ED should focus on these components.

Why take a peak flow in asthma – a review

Current asthma protocols advocate the measurement of peak flow expiratory rate (PEFR) by staff in pre-hospital care in their assessment and management of acute asthma. Yet in practice many, if not most, omit to do this. The limited amount of recent research available – which has been conducted by doctors and accident and emergency staff and concerns patients admitted to accident and emergency departments – shows that PEFR is one of the best, if not the best, predictive assessment tool available to ambulance staff. Pulse oximetry and PEFR do not measure the same things and cannot replace each other. Not taking a pre- and post-treatment PEFR is potentially detrimental to patient care and does not comply with Joint Royal Colleges Service Liaison Committee and British Thoracic Society standards. Paramedic-led research on assessment and management of acute asthma in pre-hospital settings is lacking.

Usefulness and early detection of acute exacerbation by peak expiratory flow rate in the management of asthma

The monitoring of peak expiratory flow (PEF) and maintenance of a symptom diary have been proposed as means to monitor asthma severity. This study assessed via longitudinal analysis, the usefulness and limitation of daily PEF monitoring (amplitude percent mean) as an index for asthma severity, and the usefulness of recording daily intake of beta-agonists as a measure of symptom severity. Nine subjects with moderate to severe asthma were treated with inhaled beclomethasone dipropionate (BDP). Sustained-release theophylline and oral corticosteroids supplemented inhaled BDP according to both individual symptom prevalence and PEF measurements. The patients kept records four times daily of their PEF and asthmatic symptoms (cough, sputum and number of attacks), from the beginning to the end of treatment. They also recorded the daily frequency of beta-agonist inhalation (as needed for symptomatic relief). Minimum daily PEF (expressed as percent best) correlated significantly with symptom scores: cough (r = -0.69), sputum (r = -0.69) and attack (r = -0.69). Minimum PEF correlated strongly with the daily frequency of beta agonist inhalation (r = 0.76). Each symptom score and the daily frequency of beta-agonist inhalation was zero when the minimum PEF was approximately 80%. We evaluated the correlation between minimum PEF and daily PEF variability in all data (r = -0.72): for a minimum PEF > or = 20% (r = -0.72), a minimum PEF > or = 30% (r = -0.77), a minimum PEF > or = 40% (r = -0.82) and a minimum PEF > or = 50% (r = -0.80). We determined the correlation between minimum PEFs of > or = 35 to 45% in 1% increments and daily PEF variability in relation to the severity of asthma. With a minimum PEF > or = 40%, the strongest correlation was demonstrated between minimum PEF and daily PEF variability. Daily PEF variability was a reliable indicator for the management of asthma when the PEF > or = 40%. When the minimum PEF was 80%, daily PEF variability was approximately 10%. When the minimum PEF was 40%, daily PEF variability was 46%, and the daily frequency of beta-agonist inhalation was 2.6. We concluded that, 1) The target values of minimum PEF and daily PEF variability are 80% and 10% respectively in the treatment of asthmatic patients, 2) The daily frequency of beta-agonist inhalation is recommended as an indicator for the severity of asthmatic symptoms, and 3) Daily PEF variability in combination with the daily frequency of beta-agonist inhalation is very useful in the management and early detection of acute asthma.

Preparation and standardization of a herbal agent for the therapeutic management of asthma

This study aims to develop a suitable single tablet dosage form containing a mixture of hot water stem back extracts of Anogeissus leiocarpus and Prosopis africana (AA1), suitable for use in the therapeutic management of asthma. The compaction characteristics of the oven-dried hot water extract (HWE) were studied using the Heckel equation. The mechanical properties as well as disintegration and dissolution profile of the compacts were also assessed. The results showed that AA1 exhibited high densification due to dye filling while the subsequent rearrangement of the granules did not contribute, significantly, to their densification. The granules had enhanced plasticity as shown by the low yield point, Py. The tablets produced from the extract had good mechanical properties, with hardness increasing with compression pressure while the friability decreased. Of the four disintegrants tested, tablets containing Explotab had the shortest disintegration time of 11 min while tablets containing Prosolv had the longest disintegration time of 40 min. The order of disintegrant property is Explotab > Cellactose > Emcocel > Maize starch > Prosolv. Dissolution results (t90%) show that tablets containing Explotab released 100% of the drug in 20 min proving to be the most suitable in acute asthma attack. The order of dissolution is Explotab > Cellactose > Maize starch > Prosolv > Emcocel. It is concluded that incorporation of Explotab (10%w/w) as a disintegrant in AA1 preparation produced tablets of suitable compressional properties and ensured adequate drug release for the management of acute asthma.

Clinical Audit: Management of Acute Severe Asthma in West Glasgow

The U.K. has 75,000 hospital admissions and over 1500 deaths from asthma annually. The British Thoracic Society (BTS) guidelines represent the recognised standard for acute asthma management. We assessed the degree of conformity with these guidelines in an acute medical unit. Data from consecutive admissions were collected prospectively. Practice was audited in October December 2005 and October 2006 - January 2007. Between cycles an educational programme was instigated, Fifty-eight patients were included. Clinical parameters were well recorded in both cycles. Peak expiratory flow was consistently under-recorded (72% at admission; 67% in monitoring). in monitoring). Severity assessment was documented at 55% and 66% in cycle one and two respectively. Of these, the assessment was incorrect in 33% in cycle one and 21% in cycle two. All misclassifications of severity were underestimates. All life-threatening attacks were not identified. No improvement occurred between cycles. Overall, 60% of patients were inappropriately treated according to BTS guidelines, 40% due to under-treatment. Under-treatment occurred more frequently in cycle two compared with cycle one (57% vs. 24%, p = 0.007), predominantly due to inadequate treatment of life-threatening asthma. Management of acute asthma in a large, urban teaching hospital is suboptimal. Educational intervention failed to improve care; more comprehensive strategies are required.

Pulmonary function testing in the Emergency Department and medications prescribed at discharge: results of the Multinational Acute asthma Management, Burden, and Outcomes (MAMBO) study

To evaluate asthma care in the emergency department (ED), including use of pulmonary function testing (PFT) and how patients are treated when discharged. Internet-based surveys were completed by 298 healthcare practitioners in seven countries on 1078 patients 15-70 years old with an acute asthma exacerbation. Less than 60% of patients received guideline-recommended therapy with a bronchodilator, corticosteroid, and supplemental oxygen. Patients undergoing PFT had significantly more courses of asthma therapy (2.3 vs 1.7; p < 0.001), and received more medications (5.7 vs 3.9; p < 0.001). At discharge, 17.9% of patients did not receive a prescription asthma medication and 12.8% did not receive a physician referral. Men (p<0.022), patients with more severe disease (p<0.0001), and those seen by a pulmonologist (p<0.0001), were more likely to be treated. Management of patients with acute asthma exacerbations diverged from guideline recommendations. Enhanced adherence to guidelines could lead to improved outcomes.

Comparing the efficacy and safety of two regimens of sequential systemic corticosteroids in the treatment of acute exacerbation of bronchial asthma.

Background:Corticosteroids are commonly used in the management of acute asthma. However, studies comparing various steroids in the management of acute asthma are lacking.Objective:To compare the efficacy and safety of two treatment regimens – intravenous (IV) methylprednisolone (MP) followed by oral MP and IV hydrocortisone (HC) followed by oral prednisolone in acute bronchial asthma patients.Materials and Methods:This was a randomized, prospective study performed in the emergency department (ED) of a tertiary care hospital in North India. A total of 94 patients with acute asthma were randomly allocated to either of the two treatment groups: Group A (n = 49) or Group B (n = 45). Patients in Group A were administered HC 200 mg IV 6-hourly until discharge from the ED, followed by oral prednisolone 0.75 mg/kg daily for 2 weeks. Patients in Group B were administered MP 125 mg IV bolus, followed by 40 mg MP IV 6-hourly until discharge, and then oral MP 0.6 mg/kg daily for 2 weeks. All clinical variables, peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) were assessed at baseline, at 1, 3 and 6 h and at every 6 h thereafter until discharge from the ED. The patients were followed-up after 2 weeks of discharge. The response to treatment was assessed by clinical and spirometric evaluation. Independent t-tests and chi-square tests were used to compare the two treatment regimens.Results:The baseline characteristics were comparable in the two groups. There was a significant improvement in PEF and FEV1 within the groups at 2 weeks of treatment when compared to the baseline. At 2 weeks of follow-up, Group B showed significant improvement over Group A in PEF (P < 0.0001), FEV1 (P < 0.0001) and asthma score (P = 0.034). There was a significant increase in the blood sugar value at 2 weeks in both the groups. However, the increase was greater in Group A as compared to Group B (P < 0.0001).Conclusion:This study suggests that in acute asthma patients, IV MP followed by oral MP is a more efficacious and safer treatment regimen than IV HC followed by oral prednisolone.

Race/Ethnicity Differences in the Inpatient Management of Acute Asthma in the United States

Race/Ethnicity Differences in the Inpatient Management of Acute Asthma in the United States

Management of acute asthma in adults in the emergency department: assisted ventilation

Jordan, a 32-year-old man with chronic, poorly controlled asthma, has been in the emergency department for 1 hour with only partial response to aggressive bronchodilator therapy and a single intravenous dose of corticosteroids. He is considered to be at high risk for potentially fatal asthma because

Management of acute asthma in adults in the emergency department: nonventilatory management.

Peter, a 26-year-old man with chronic, poorly controlled asthma, presents to a walk-in clinic reporting increasing asthma symptoms over a period of one week. He has been needing up to 20 puffs of salbutamol per day. An acute exacerbation of asthma is diagnosed, and the patient is immediately

Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments

Background: A recent meta-analysis showed that intravenous and nebulised magnesium sulphate have similar levels of evidence to support their use in the treatment of acute asthma in adults. This consisted...

IMPACT OF ASTHMA EDUCATION ON KNOWLEDGE OF MANAGEMENT OF ACUTE SEVERE ASTHMA AMONGST PRACTICING NURSES IN OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITAL COMPLEX ILE-IFE NIGERIA

PURPOSE: The upsurge in the incidence of acute severe asthma in the face of slow institutional response to the management of asthma, has heightened public concern in Nigeria. It is against this background that this study investigated the impact of asthma education on knowledge of management of acute severe asthma amongst practicing nurses vis-α-vis signs and symptoms of the disease as well as its therapy.

Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations

This article summarizes the recommendations regarding the management of asthma exacerbations presented in the Expert Panel Report 3 (EPR3). The evidence supporting these recommendations can be found in the report itself. All of the recommendations in this article are strong recommendations, unless indicated by the term conditional. Asthma exacerbations consist of acute or subacute episodes of progressively worsening shortness of breath, coughing, wheezing, and chest tightness or any combination thereof. These episodes differ from poor asthma control in that diurnal variability in airflow, a key marker of poor asthma control, might not change during an exacerbation. An important advance in the new National Asthma Education and Prevention Program (NAEPP) EPR3 guidelines is the creation of a chapter devoted to the management of asthma exacerbations. Moreover, the new EPR3 guidelines present different spirometry cut points for assessing the severity of acute asthma (exacerbations) versus chronic asthma. These and other changes underscore the distinction between acute and chronic asthma management. Two patient populations at particular risk during an asthma exacerbation include patients with 1 or more risk factors for asthma-related death (Table I) and infants, who are at greater risk

Variations and Gaps in Management of Acute Asthma in Ontario Emergency Departments: Lougheed MD, Garvey N, Chapman KR, et al. Chest 2009;135:724–36

Variations and Gaps in Management of Acute Asthma in Ontario Emergency Departments: Lougheed MD, Garvey N, Chapman KR, et al. Chest 2009;135:724–36

Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations

This article summarizes the recommendations regarding the management of asthma exacerbations presented in the Expert Panel Report 3 (EPR3). The evidence supporting these recommendations can be found in the report itself. All of the recommendations in this article are strong recommendations, unless indicated by the term conditional. Asthma exacerbations consist of acute or subacute episodes of progressively worsening shortness of breath, coughing, wheezing, and chest tightness or any combination thereof. These episodes differ from poor asthma control in that diurnal variability in airflow, a key marker of poor asthma control, might not change during an exacerbation. An important advance in the new National Asthma Education and Prevention Program (NAEPP) EPR3 guidelines is the creation of a chapter devoted to the management of asthma exacerbations. Moreover, the new EPR3 guidelines present different spirometry cut points for assessing the severity of acute asthma (exacerbations) versus chronic asthma. These and other changes underscore the distinction between acute and chronic asthma management. Two patient populations at particular risk during an asthma exacerbation include patients with 1 or more risk factors for asthma-related death (Table I) and infants, who are at greater risk

Evaluation of high-dose continuous nebulized levalbuterol

In this issue of The Journal, Andrews et al from the University of Pennsylvania compared high-dose continuous levalbuterol to high-dose continuous racemic albuterol using equipotent doses in 81 children attending the emergency department with acute exacerbations of asthma. The adverse effects and the outcomes were similar in the two groups. Both groups were weaned from continuous bronchodilator therapy in 16-18 hours but no advantage was demonstrated for levalbuterol. It is notable that there was pharmaceutical company support for this study, although in the end the results did not benefit the company. These findings are discussed in an accompanying editorial by Kercsmar, who reviews the current management of acute asthma in the emergency room with regards to the use of short acting β-agonists and continuous aerosol therapy. Although Kercsmar expresses some reservations concerning the study design, the results certainly do not support the use of levalbuterol in the emergency room, especially as it is significantly more expensive than the racemic mixture. Kercsmar goes on to discuss the question of whether there are some asthmatics for whom no form of albuterol is effective; recent trials have suggested that certain polymorphisms of the beta receptor respond poorly to albuterol. Future studies should clarify this issue. Article page 205▸ Editorial page 162▸

Acute asthma management by a pediatric after-hours call center.

To describe an asthma management protocol used in a nurse-staffed pediatric After-Hours Call Center (AHCC) that incorporates severity-based home treatment recommendations and follow-up call assessments. Call records for asthma advice from January 1, 2004 to June 30, 2004 were identified retrospectively and reviewed. Descriptive statistics were used to report patient demographics, frequencies of symptom severity zones (Red, Yellow, or Green) at initial calls, frequencies of call dispositions designating care advice provided (including home treatment recommendations and seeking emergency department [ED] care), and changes in severity zones between initial calls and follow-up calls when nurses reassessed patients after recommended home treatment. During the study period, 3,632 asthma calls (2,439 initial; 1,193 follow-up) were managed by AHCC nurses. Initial calls were classified mostly as Red (28%) or Yellow (42%) severity zones; 27% were Green zone and 3% could not be categorized. Fifty-two percent of initial calls with Red or Yellow severity zones involved home treatment recommendations; 50% of those Red zone and 63% of those Yellow zone calls had improved severity zones at follow-up call assessments. Twenty-eight percent of patients with home treatment recommendations were referred to the ED at the time of follow-up call nurse reassessment. This telephone-based nurse-staffed pediatric acute asthma management protocol includes provision of severity-based home treatment recommendations and follow-up assessments, and improved symptoms for many children with acute exacerbations. This protocol may also be successful in other locations and may improve outcomes, such as reduction in ED visits.

Race/Ethnicity Differences in the Inpatient Management of Acute Asthma in the United States

The only published US study on racial/ethnic disparities in inpatient asthma management was performed in 1989-1990 at a single center. The authors reported that black and Hispanic children were provided substandard care at hospital discharge compared to white children. The purpose of the present analysis was to reexamine this important issue in a large multicenter study. A cohort study of 1,232 children and adults hospitalized with a physician diagnosis of acute asthma at 30 hospitals in 22 US states was used. The cohort included 562 children (age range, 2 to 17 years; 39% white; 42% black; and 19% Hispanic) and 670 adults (age range, 18 to 54 years; 44% white; 44% black; and 12% Hispanic). There were no significant racial/ethnic differences in the choice of inpatient medications or length of stay among either children or adults. At hospital discharge, Hispanic children were less likely to receive an asthma action plan (37%) compared to white children (60%) or black children (63%; p < 0.001). Multivariate adjustment for eight variables (including socioeconomic status, hospital admissions for asthma in the past year, medication use prior to presentation, physical examination findings, and hospital admission location) attenuated the statistical significance of this association (odds ratio, 0.5; 95% confidence interval, 0.1 to 2.5). We did not identify racial/ethnic disparities in the inpatient treatment and outcomes for children or adults with acute asthma. At hospital discharge, Hispanic children were less likely to receive an asthma action plan compared to white or black children, possibly due to language or socioeconomic differences.

Variations and Gaps in Management of Acute Asthma in Ontario Emergency Departments

Variation in hospitalization rates for acute asthma in Ontario may reflect gaps between evidence and current emergency department (ED) management. We investigated ED management of asthma and differences in practice patterns for pediatric (< 20 years old) and adult (> or = 20 years old) patients in Ontario EDs. Patient characteristics and ED management during a 1-year period were assessed by questionnaire and chart abstractions in a stratified sample of 16 Ontario hospitals. Variation between sites was assessed by one-way analysis of variance, Kruskal-Wallis test, or chi(2) test. Reported results are based on the first of 2,671 pediatric (42.0% female) and 2,078 adult (66.7% female) visits with a corresponding questionnaire. Asthma severity, comorbidities, access to care, and prehospital management varied significantly among sites (all p < 0.001). Documentation of peak expiratory flow (27.2% of pediatric [age > or = 7] and 44.3% of adult charts), use of systemic steroids in ED (35.2% pediatric and 33.0% adult charts) and on discharge (31.7% pediatric and 33.2% adult charts), and referrals to asthma services (2.8% pediatric and 2.7% adult charts) varied among sites (all p < 0.001). Admission (%) was directly related to time to receive systemic steroids in ED in adults (r = 0.76; p = 0.004). Repeat ED visits (%) were inversely related to new inhaled steroid prescription on discharge in adults (r = -0.64; p = 0.02). Knowledge translation initiatives are warranted to increase adherence with best practices in emergency management of asthma (such as objective assessment of airflow rates, use of systemic steroids, and referrals) in order to reduce variations in care and improve outcomes of severe acute asthma.