Asthma is one of the most common diseases in developing countries and has a worldwide prevalence of 7 to 10%. It is also a common cause of urgent care and emergency department visits. From 2001 through 2003 in the United States, asthma accounted for an average 4210 deaths annually and a total of approximately 504,000 hospitalizations and 1.8 million emergency department visits.
• How should inhaled short-acting (beta)2-adrenergic agonists be administered to a patient with a severe asthma exacerbation?
Most guidelines recommend the use of nebulizers for patients with severe exacerbations; metered-dose inhalers with holding chambers can be used for patients with mild-to-moderate exacerbations. There is some evidence that continuous rather than intermittent administration of albuterol results in greater improvement in PEF and FEV1 and a greater reduction in the need for admission, particularly in patients with severe asthma. The recommended dose of nebulized albuterol is 2.5-5 mg every 20 min over the first hr; then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hr continuously.
• What corticosteroid regimen is recommended for patients with a severe asthma exacerbation?
In most patients with exacerbations that necessitate treatment in the emergency department, systemic corticosteroids are warranted. Because comparisons of oral prednisone and intravenous corticosteroids have not shown differences in the rate of improvement of lung function or in the length of hospital stay, the oral route is preferred for patients with normal mental status and without conditions expected to interfere with gastrointestinal absorption. The most recent National Asthma Education and Prevention Program Expert Panel Report 3 recommends the use of 40 to 80 mg per day in one dose or two divided doses.
Morning Report Questions
Q: What criteria can be used to determine suitability for admission to the hospital?
A: After treatment in the emergency department for 1 to 3 hours, patients who have an incomplete or poor response, defined as an FEV1 or PEF of less than 70% of the personal best or predicted value, should be evaluated for admission to the hospital. Patients who have an FEV1 of less than 40%, continuing moderate-to-severe symptoms, drowsiness, confusion, or a partial pressure of arterial carbon dioxide of 42 mm Hg or greater should be admitted.
Q: What features can be used to determine readiness for discharge?
A: According to the authors, patients may be discharged if the FEV1 or PEF after treatment is 70% or more of the personal best or predicted value and the lung function and improvement of symptoms are sustained for at least 60 minutes. After discharge, patients should continue to use inhaled short-acting (beta)2-adrenergic agonists as needed and should be prescribed oral corticosteroids for 3 to 10 days.
Table 1. Medications for Treatment of Asthma Exacerbation in the Emergency Department.