Management Of Acute Asthma Research Articles

Abstracts

Abstracts

Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital

Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital. This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information. Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent. Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

Management of childhood asthma: physicians' perspective in Turkey.

Many attempts have been made to decrease asthma-related mortality and morbidity, including preparation and distribution of guidelines. However, several studies from different regions of the world have reported low asthma control among children as well as adults. A questionnaire-based study was performed involving a number of Turkish physicians taking care of pediatric asthmatics, and aimed to document asthma-related knowledge. Of 219 physicians, 126 (57%) completed the questionnaire. The majority were pediatricians (92%), with an average of 253 +/- 14.1 outpatients per week, and an asthmatic ratio of 15.8%. According to the self-reported knowledge, management of acute asthma received the highest (3.42 +/- 0.05) and chronic asthma the lowest scores (3.18 +/- 0.06). The study group further credited inhaled and oral steroids similarly for the treatment of exacerbations and reported infrequent usage of spirometry and oxygen saturation than physical finding to estimate attack severity. Although with regard to most subjects, physicians' opinions appeared to be in agreement with the guidelines, there were certain differences implying need for future educational training. Chronic management, reported as the least understood part of the guidelines, suggests requirement of new models for estimating chronic disease severity.

A specialist nurse led liaison model of care reduced unscheduled care for acute asthma in a deprived multiethnic area

Griffiths C, Foster G, Barnes N, et al . Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high...

Delivering oxygen during nebulization to infants and toddlers

Two hypotheses have been postulated for the continued trickle of asthma deaths [1]. Firstly due to cardiac arrhythmia, which is more common in adults. Secondly, a far more likely hypothesis is that these deaths occur as a result of progressively worsening hypoxemia due to ventilation-perfusion mismatch and alveolar hypoventilation. Management of acute asthma by various authorities recommend oxygen as the first line of treatment and simultaneous treatment with inhaled s2-agonists to relieve bronchospasm [2, 3] with repeated doses from metered dose inhalers (MDI) since they are considered equivalent to or better than nebulizers driven by compressed air, which are available in most of our service hospitals [4]. However, most children under 5 years cannot perform the respiratory gymnastics needed to use a MDI and when used with a spacer, many young children might refuse it due to anxiety or are too sick to generate enough respiratory pressure to open the one-way valve on these spacers. In such children, nebulizers are used and these should ideally be oxygen driven since nebulization of s2-agonists without oxygen can cause or worsen hypoxemia [1, 5]. The mechanism of this is well documented. s2-agonist when nebulized, results in vasodilation by inhibiting hypoxia induced pulmonary vasoconstriction resulting in increased intrapulmonary shunting i.e. increasing perfusion to poorly ventilated lung units and hence ventilation-perfusion mismatch which leads to worsening of hypoxemia. Studies have also documented a significant fall in arterial oxygen saturation in about 50% of the asthmatic children who were treated with salbutamol nebulized with compressed air [5, 6]. Oxygen therapy is often delayed during nebulization for 10-15 minutes, hence giving air driven high doses of nebulized salbutamol to children may transiently increase ventilation-perfusion mismatch sufficiently to cause a further critical desaturation, which may result in death.

Comparison of effectiveness between nebulized budesonide plus albuterol versus albuterol alone in children with moderate acute asthma

Rationale Acute asthma is a common cause of Emergency Department consultation in pediatric population. Beta 2 agonist and systemic corticosteroids have shown to be effective for standard therapy. Inhaled corticosteroids have become accepted as cornerstone of chronic preventive asthma therapy because of their efficacy and lack of systemic effects but they have also emerged has a new therapy with an unclear role in acute asthma management. Methods Randomized, double blind, clinical trial with two parallel groups of patients from 7 to 17 years of age with moderate acute asthma. We compared inhaled treatment with budesonide 500 μg plus albuterol 0.15 mg/kg/dose (Group 1) versus albuterol (Group 2) alone in order evaluate the clinical usefulness of both treatments. The difference between groups was assessed by analysis of variance. Results Group 1; 40 patients (19 female, 21 male, mean age 10.04 +/- 2.31). Group 2; 46 patients (20 female, 26 male, mean age 10.71 +/- 2.06). Symptoms and peak flow before and after treatment were measured. Percent of improvement after treatment of the peak flow in group 1 was 11.6 (SD 9.47 EM 1.49) and in group 2, 9.8 (SD 8.59 EM 1.26). There was not significance between both groups. Conclusions The effectiveness of inhaled corticosteroids in acute asthma is far from clear compared with standard therapy with bronchodilators. There was not a significant difference between groups. Although there was significant difference inside each group.

Estudio comparativo de la eficacia del deflazacort frente a prednisolona en el tratamiento de la crisis asmática moderada

To assess the efficacy and tolerability of oral deflazacort versus oral prednisolone in acute moderate asthma in children. We performed a prospective, randomized, parallel group trial of children aged 6 to 14 years old with a diagnosis of asthma who presented to the pediatric emergency department for moderate asthma exacerbation. All patients were administered short-acting beta2-adrenergic agonists. The intervention groups received either oral deflazacort (1.5 mg/kg) or prednisolone (1 mg/kg) for 7 days. The primary outcome measure was forced expiratory volume in 1 second (FEV1) and secondary outcome measures were pulmonary symptom score index, peak expiratory flow rate (PEFR), hospitalization rate and the use of rescue beta2-agonists. Patients were evaluated at the start of treatment (visit 1), on day 2 (visit 2) and on day 7 (visit 3). Of the 54 children enrolled, two were hospitalized on visit 2 (one from each group). Baseline clinical data were similar in both groups: FEV1: 53 and 51 %; bronchodilator test: 119 and 121 %; PEFR: 169 and 165 L/min; symptom score: 6 and 6.5 for the deflazacort and prednisolone groups, respectively. On visit 2, all measures improved: FEV1: 122.2 and 126.5 % (p < 0.05); PEFR: 164 and 149 L/min (p < 0.05); symptom score: -4.4 and -3.8 (p < 0.05), without significant differences between groups. On visit 3 all variables continued to show improvement: FEV1: 133.2 and 132.5 % (p < 0.05); PEFR: 1115.7 and 187.6 L/min (p < 0.05); symptom score: -5.4 and -5.9 (p < 0.05), without significant differences between groups. No adverse effects were reported. Deflazacort and prednisolone show similar efficacy in improving pulmonary function and in producing clinical improvement in the management of acute moderate asthma in children.

Comparison of racemic albuterol and levalbuterol for treatment of acute asthma

Objective To determine whether levalbuterol resulted in fewer hospital admissions than racemic albuterol when used for treatment of acute asthma. Study design A randomized, double-blind, controlled trial was conducted in the emergency department (ED) and inpatient asthma care unit of an urban tertiary children's hospital. Children age 1 to 18 years (n = 482) provided a total of 547 enrollments. Patients received a nebulized solution of either 2.5 mg racemic albuterol or 1.25 mg levalbuterol every 20 minutes (maximum six doses). Patients admitted to the asthma care unit were treated in a standardized fashion by using the same blinded drug assigned in the ED. Hospitalization rate was the primary outcome. Results Hospitalization rate was significantly lower in the levalbuterol group (36%) than in the racemic albuterol group (45 %, P = .02). The adjusted relative risk of admission in the racemic group compared with the levalbuterol group was 1.25 (95% confidence interval, 1.01-1.57). Hospital length of stay was not significantly shorter in the levalbuterol group (levalbuterol, 44.9 hours; racemic albuterol, 50.3 hours; P = .63). No significant adverse events occurred in either group. Conclusions Substituting levalbuterol for racemic albuterol in the ED management of acute asthma significantly reduced the number of hospitalizations.

A Randomized Controlled Trial of Inhaled Flunisolide in the Management of Acute Asthma in Children

Inhaled corticosteroids (ICS) may provide benefit in the therapy of acute asthma. The purpose of this study was to test the hypothesis that ICS are as effective as oral corticosteroids (OCS) in the management of acute childhood asthma. A randomized, masked, placebo-controlled study was conducted in children aged 6 to 16 years seeking emergent care for an acute exacerbation of asthma. Patients were randomized into one of two groups: group 1 (OCS), oral prednisone, 2 mg/kg (maximum of 60 mg/d) for 7 days, and placebo pressurized metered-dose inhaler with valved holding chamber, four inhalations bid; and group 2 (ICS), flunisolide, four inhalations (1 mg) bid for 7 days, and daily placebo tablets. Spirometry (FEV(1)) was performed at baseline, day 3, and day 7 of the study. A symptom diary and twice-daily peak expiratory flow were recorded. A total of 58 subjects receiving ICS (n = 27) or OCS (n = 28) were enrolled. Baseline asthma severity, race, gender, and age were balanced between the two groups. chi(2) showed no significant difference in symptom severity between the two groups at any time during the study. FEV(1) percentage of predicted was lower in the ICS group on day 3 (65% vs 78%, p = 0.03) and on day 7 (77% vs 95%, p = 0.002). ICS were found to be useful in the management of acute asthma in children; however, spirometry data suggested a more rapid resolution of asthma with OCS.

The administration of beta2-agonists for paediatric asthma and its adverse reaction in Australian and New Zealand emergency departments: a cross-sectional survey.

To determine the current use of beta2-agonists, in particular salbutamol, for the management of acute asthma in children in emergency departments throughout Australia and New Zealand. A cross-sectional survey using a questionnaire that sought to determine the current use of salbutamol and any adverse drug reactions in paediatric emergency departments. Out of 37 hospitals eligible as paediatric emergency departments, 33 (89.1%) responded to the survey, 54.5% having guidelines for the management of acute asthma. Of the paediatric emergency departments surveyed, 45.5% used metered-dose inhaler spacer combination in the treatment of mild to moderate asthma. All paediatric emergency departments used nebulized salbutamol for acute severe asthma. In addition, 85% of paediatric emergency departments used continuous-infusion intravenous salbutamol in unresponsive patients, 63.6% administering a single-dose intravenous salbutamol bolus before commencing the infusion. District paediatric emergency departments were more likely to treat with continuous-infusion intravenous salbutamol outside of the intensive care unit. Clinical unresponsiveness to inhaled salbutamol and clinical improvement were the reported criteria in all paediatric emergency departments for the use and cessation of intravenous salbutamol. Adverse drug reactions were common: tremor (90%), hypokalaemia (45.5%) and supraventricular tachycardia (21%), particularly if continuous-infusion intravenous salbutamol administered. Eight deaths from asthma were reported, none being related to adverse drug reactions. We report a wide variation of salbutamol use in paediatric emergency departments and a high prevalence of type A adverse drug reactions when continuous-infusion intravenous salbutamol therapy was administered. More evidence is needed on the clinical significance of the adverse effects reported in this study and optimal doses for the safe use of continuous-infusion intravenous salbutamol therapy in paediatric emergency departments.

Early use of inhaled corticosteroids in the emergency department treatment of acute asthma.

Systemic corticosteroid therapy is central to the management of acute asthma The use of inhaled corticosteroids may also be beneficial in this setting. To determine the benefit of inhaled corticosteroids for the treatment of patients with acute asthma managed in the emergency department (ED). Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews, and texts also were searched. The search is considered updated to February of 2003. Only RCTs or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma to the ED or its equivalent, and were treated with inhaled corticosteroids or placebo, in addition to standard therapy. Two reviewers independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two reviewers. Data were extracted independently by two reviewers if the authors were unable to verify the validity of extracted information. Missing data were obtained from the authors or calculated from other data presented in the paper. Eight trials were selected for inclusion, but data were not available for one of them. In the seven usable trials, (4 adult, 3 paediatric), a total of 376 patients were studied (191 with inhaled corticosteroids, 185 without). Patients treated with inhaled corticosteroids were less likely to be admitted to hospital (OR: 0.30; 95% CI: 0.16, 0.57). This benefit was evident in the subgroup of patients not receiving concomitant systemic steroids (OR 0.21; 95% CI: 0.08, 0.53). Patients receiving concomitant systemic steroids showed a similar, but non-significant, trend towards reduced admissions compared to placebo treatment (OR 0.45; 95% CI: 0.18, 1.12). Patients receiving inhaled corticosteroids also demonstrated small, significant improvements in peak expiratory flows (PEFR WMD: 8%; 95% CI: 3, 13 %) and forced expiratory volumes (FEV1 WMD: 5%; 95% CI: 0.4, 10 %). The treatment was well tolerated, with few reported adverse side effects. A secondary analysis compared inhaled corticosteroids alone vs systemic steroids alone; in the four trials included, there was significant heterogeneity between the study results for admission rates which precluded meaningful pooling of the study results. Inhaled steroids reduced admission rates in patients with acute asthma, but it is unclear if there is a benefit of inhaled corticosteroids when used in addition to systemic corticosteroids. There is insufficient evidence that inhaled corticosteroids result in clinically important changes in pulmonary function or clinical scores when used in acute asthma. Similarly, there is insufficient evidence that inhaled corticosteroids alone are as effective as systemic steroids. Further research is needed to clarify if there is a benefit of inhaled corticosteroids when used in addition to systemic steroids.

Facilitation of professional development in the management of acute asthma in primary care: a randomised controlled trial

Background:Professional development requires practitioners to identify sub-optimal practice, and develop plans to improve care. The General Practice Airways Group (GPIAG) acute asthma development programme aims to facilitate this process.Method:We invited 59 GP practices, in Grampian, Scotland, to participate. We randomised consenting practices to intervention and control groups. Data about practice organisation and the management at baseline of all the acute attacks occurring over 3 months (excluding children <5yrs) were collected retrospectively from the records. Audit results were fed back to intervention practices, who attended a workshop and were encouraged to formulate a development plan. Progress was assessed by a follow up audit at 6mResults:23 practices were randomised: 11 to intervention. Baseline demography and organisation were similar. The intervention group recorded 54 acute attacks at baseline (B) and 62 at 6 months (6m). After the workshop, intervention practices identified availability of peak flow (PF) meters and provision of self management plans as key areas for development At 6m more GPs in the intervention group had a PF meter (B: 17/39 (44%) vs 6m: 33/38 (87%) p=<0.001) and more attacks had a PF assessment (B: 26/54 48% vs 6m: 49/62 79% p=<0.001) Post exacerbation arrangements improved, including follow up advice given to more patients (B: 22/54 41% vs 6m: 47/62 76% p=<0.001) and more patients were given a Self Management Plan (B: 6/54 11% vs 6m: 17/62 27% p=0.028). No significant improvements occurred in the control groupConclusion:In line with their stated intentions for development the intervention practices improved the objective assessment of attacks and improved follow up arrangements over the 6 months of the programme.

Acute exacerbation of asthma in adults

Acute asthma remains an important cause of morbidity adults. The recognition, assessment and appropriate management of acute asthma are essential to avoid unnecessary morbidity and also mortality, which unfortunately still occurs. This article will present an overview of the hospital management of acute asthma exacerbations in adults. The British Thoracic Society(BTS) conjunction with the Scottish Intercollegiate Guidelines Network(SIGN) published the latest British Guidelines on all aspects of asthma management in February of this year .1 This article is a précis of these latest British guidelines as they relate to acute asthma in adults.

The management of acute severe asthma in adults

Asthma is a common condition, which can develop into a severe, life-threatening form in any sufferer. Generally, those at risk of an acute attack are women from minority ethnic groups, who have a poor compliance history. Most patients that die of asthma do so in the community. Those who attend the emergency room generally respond to conventional treatments and hospital admission. However, a small proportion of patients will require ITU admission and mechanical ventilation, and, if the admission is not secondary to cardiorespiratory arrest, generally survive. Ventilation techniques that prevent dynamic hyperinflation and the consequent complications of hypotension and barotrauma, are now generally adopted. This includes a pressure-limited mode of ventilation associated with low tidal volumes, high flows and low respiratory rate. Follow up of these patients is essential as they form a very poor prognostic group. Detailed self-management planning, PEFR monitoring and physician review should be therefore encouraged.

A pilot study to assess the feasibility and acceptability of undertaking acute asthma professional development in three different UK primary care settings.

The General Practice Airways Group's Professional Development programme promotes the evidence-based management of acute asthma in line with current guidelines. 4 GP practices, 2 Out-of-Hours services and 2 nurse-run Walk-In Centres were recruited to this pilot study. Participants provided organisational data and undertook a critical event analysis of acute attacks. Results were fed back prior to attendance at the GPIAG/NRTC Congress. The audit was repeated after six months. Feasibility and acceptability were assessed with evaluation questionnaires. Baseline data from 7 centres (160 attacks) suggested that management guidelines are not being fully adhered to. For practical reasons only four of the organisations attended the Congress. Organisations successfully formulated their own development plans: one introduced a standard proforma, one commissioned in-service training and two acquired a supply of steroids. Follow-up data was submitted by 5 organisations. (98 attacks) Programme evaluations were generally positive: the audit protocol was practical in all three settings, the feedback was appreciated and the educational intervention was well received by those able to attend. This pilot study has provided useful information on which to base the future development of the GPIAG acute asthma professional development programme. The initiative has been well received and innovation has been facilitated. Future projects should consider more flexible, local provision of workshops.

Controversies in the pharmacological management of acute asthma in children

To present a review of controversial issues related to the pharmacological management of the treatment of acute asthma in children. Articles published in national and international scientific journals. Data were selected from Lilacs and Medline databases. The article was organized into topics, presenting aspects on which there is consensus regarding the pharmacological treatment of asthma in children. Issues related to the use of metered dose inhaler versus nebulizers, the role of beta2-adrenergic drugs administered intravenously as well as the role of methylxanthine and magnesium sulfate are approached critically. Inhaled beta2-agonist drugs combined with corticosteroids remain the treatment of choice for acute episodes of asthma in children. Either nebulizers or metered dose inhalers connected to spacers are efficient for the relief of acute symptoms. Patients who are refractory to conventional treatment and develop severe acute asthma should receive beta2-agonist drugs intravenously, provided they are properly monitored. Methylxanthine and magnesium sulfate should be considered a second choice for selected patients.

Management of acute pediatric asthma.

Pediatric asthma prevalence, morbidity, and severity are increasing. Direct costs associated with providing emergency department and inpatient care account for more than 40% of overall dollars spent for this disease in the United States. Physicians in many health care settings may be required to treat a child in severe respiratory distress caused by acute asthma. This article reviews the pathophysiology, evaluation, and treatment of severe asthma exacerbations, or status asthmaticus.

The management of acute severe asthma 1,2

Asthma is a common cause of morbidity and mortality in the United States, with over two million Emergency Department (ED) visits each year. Airway inflammation is recognized as a major component in the pathophysiology of asthma. The classic presentation of asthma is that of wheezing, cough, and dyspnea, however, the severity of airflow limitation correlates poorly with clinical signs. Forced exhaled volume in 1 s (FEV 1) and the peak expiratory flow rate (PEFR) are direct reflections of the severity of airflow obstruction and are the standard measures used in the ED to assess the severity of airflow obstruction and the response to therapy. β2-adrenergic bronchodilators, ipratropium bromide, and corticosteroids form the cornerstone of therapy. Inhaled corticosteroids, leukotriene modifying drugs, and noninvasive positive pressure ventilation should be considered in patients with severe disease and in those who have responded poorly to standard therapy. Mechanical ventilation is usually well tolerated and may be lifesaving in patients with refractory asthma. Precautions are required to prevent dynamic hyperinflation during assisted ventilation.

The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: A meta-analysis

Study objective: Inhaled corticosteroids (ICSs) are of proven benefit in the treatment of chronic asthma; however, their role in the management of acute asthma is unclear. Methods: We performed a systematic review of randomized controlled trials involving children or adults treated in the emergency department for acute asthma with or without the addition of ICSs. Outcome measures included hospital admission, pulmonary function tests, and side effects. Results: Seven trials were selected for inclusion in the primary analyses. ICSs versus placebo were compared; data were not available on 1 of these trials. In the remaining 6 trials, a total of 352 patients were studied (179 ICS-treated and 173 non-ICS-treated patients). Two trials compared ICSs plus systemic corticosteroids versus placebo plus systemic corticosteroids; 4 trials compared ICSs versus placebo. Patients treated with ICSs were less likely to be admitted to the hospital (odds ratio 0.30; 95% confidence interval [CI] 0.16 to 0.57) and showed small improvements in peak expiratory flows (weighted mean difference 8%; 95% CI 3% to 13%) Overall, the treatment was well tolerated, with few reports of adverse side effects. A secondary analysis compared ICSs alone versus systemic corticosteroids alone; in the 4 included trials, significant heterogeneity between the study results for admission rates precluded meaningful pooling of admission data. Conclusion: There is evidence of decreased admission rates for patients with acute asthma treated with ICSs. However, there is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function when used in acute asthma, and there is insufficient evidence that ICSs alone are as effective as systemic corticosteroids. [Edmonds ML, Camargo CA Jr, Pollack CV Jr, Rowe BH. The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis. Ann Emerg Med. August 2002;40:145-154.]

Doctors' use of clinical guidelines: Two applications of the Theory of Planned Behaviour

This paper reports three studies looking at guideline use by hospital doctors. The first study involved unstructured interviews with a randomly selected group of doctors to find out what factors they believe influence their use of clinical guidelines. The second study used a questionnaire based on the Theory of Planned Behaviour and incorporated the factors elicited during the initial interviews to explain and predict the intentions of junior doctors to use a guideline for the management of acute asthma in Accident and Emergency departments in England and Wales. The third study extended the second study by using a sample of more senior doctors and a guideline for the use of antibiotics. Factors thought by interviewees to be most influential in their decision to use a clinical guideline were whether the guideline was: (A) 'useful', (b) based on strong 'evidence', but (c) did not deny the 'individuality' of the patient. Subjective norm was the strongest predictor of intention to use the asthma guideline; attitude was the strongest predictor of intention to use the antibiotic guideline. Further research is needed to clarify whether these findings reflect differences between the guidelines or the status of the doctors included in each study.