Vol. 10 •Issue 8 • Page 58
Emergency Care for Asthma
An Ounce of Prevention
By Joseph J. Zorc, MD
The best asthma teachers are the patients and families we care for. The following actual patient case and treatment course illustrates typical issues seen in the emergency department. Many of the concerns identified are preventable, and proper management would help improve care and decrease serious exacerbations.
FIRST IMPRESSIONS
Maria (not her real name) is a 7-year-old girl sent by the school nurse to an urban emergency department. She arrives by ambulance with a 12-hour history of wheezing, fatigue and difficulty breathing. She has no fever, but she has a cough. Her mother expresses concern that her daughter has been sick for the past five years with her breathing.
Physical examination reveals the child is in moderate respiratory distress with a respiratory rate of 28 breaths per minute, tripod body position and intercostal retractions. Her breath sounds are diminished bilaterally, and no wheezing is heard.
The intern walks in to find the nurse placing the child on a pulse oximeter, attempting to get a room air saturation.
The lack of wheezing in light of Maria’s obvious distress is an ominous sign. It may, however, give the inexperienced practitioner a false impression that this isn’t an asthma exacerbation at all.
The initial treatment obviously is oxygen regardless of the room air oxygen saturation. A common misconception is that it’s necessary to document a presenting oxygen saturation. Although this has been shown to be a predictor of admission for asthmatic children,1 it shouldn’t delay the administration of oxygen for a child in respiratory distress. Unlike an adult with chronic obstructive pulmonary disease whose respiratory drive may be dependent on his baseline hypoxia, one cannot do harm to a child in respiratory distress by administering oxygen, regardless of room air saturation.
PROMOTING UNDERSTANDING
The respiratory therapist assigned to the emergency department astutely suggests a beta-agonists nebulizer, in spite of resistance from the intern. The intern says, “She isn’t even wheezing, but OK.” A combination ipratroprium bromide and albuterol nebulizer is administered.
The intern asks the mother what medications Maria takes for her asthma. The mother says she uses a pink inhaler and a yellow inhaler. She has been out of the yellow one for two days. “I have been giving her the pink one every two hours at home,” the mother says. “I don’t understand why it isn’t working.” She denies any other medications. “It seems every time she visits her dad, she comes back wheezing.”
The mother’s frustration at her daughter’s chronic illness stems from a poor understanding of asthma. Many parents are great resources to health care providers because they know the child and her disease the best. Some parents, however, were never educated about asthma, did not hear what they were taught, or are in denial.
Maria’s mother looks surprised when asked, “Do you understand that Maria may have this disease for the rest of her life?” Follow up by discussing that with appropriate care, Maria’s disease can be controlled and that she will not always be this severe. Stress that Maria is not “delicate” and her activities should be mainstreamed with other children. The goal is to help Maria and her family manage her asthma so that their lives can have as few disruptions as possible.
The mother’s confusion about why the pink inhaler isn’t working for an acute exacerbation obviously indicates that she doesn’t know which inhaler is a prevention inhaler and which is a rescue medication. The yellow inhaler, of course, is albuterol. The rescue medication would be more beneficial at this point in Maria’s care than the pink inhaler, an inhaled steroid. This information should alert the emergency department pro viders that this patient doesn’t understand the medications and is in need of more aggressive education.
From an emergency department standpoint, patients like this aren’t uncommon. Whether it’s poor planning on the part of the primary providers by not giving sufficient refills of medications or on the part of the family by not anticipating when the child will run out of medications is unimportant. What is critical is that the patient and family truly understand the difference in medications and their roles in asthma management.
If time allows, this would be a good opportunity to instruct the parents on how to determine the amount of medication left in the inhaler. One such method would be floating the inhaler canister in water. If it sinks, it’s full, and if it floats on its side, it’s empty. The flotation level between these two extremes can allow the patient to estimate how much medication remains. Shaking the inhaler isn’t an accurate method of estimation.
The intern or a clinician in-volved in this child’s care also should ask about triggers Maria may be in contact with. One clue is that certain situations seem to exacerbate her asthma, such as when she visits her dad. Are there smokers in his home? Do they use a fireplace or wood-burning stove? What furry animals are around? Awareness of these triggers is a necessary aspect of asthma care, especially if environmental modification is to occur.
PLANNING AHEAD
Maria receives two subsequent albuterol nebulizers and is discharged home with a refill of her inhalers. Her mother asks for a note for the school nurse, and the intern instructs the child in the use of peak flow meters, metered dose inhalers and spacers. Luckily, the attending physician realizes Maria could benefit from other medications and stops the family just before they walk out of the emergency department.
The child who presents in moderate to severe respiratory distress and improves after aggressive respiratory treatments would benefit from a short course of oral steroids. A three- to four-day burst of 1 mg/kg to 2 mg/kg of prednisone or similar steroid is indicated. This is the medication the attending physician added to the child’s regimen as she was discharged.
Oral or parental steroids begin taking effect on inflammation six to eight hours after the first dose. If Maria had been given steroids upon presentation to the emergency department, this would be one to two fewer hours until they would start helping her. To institute maximal therapy as early as possible, order the first dose of systemic steroids at the same time as the first nebulizer.
Maria also would benefit from an emergency plan that guides the caregiver when to start extra medications, such as parental steroids, and when to give her beta-agonists more frequently at home. School personnel should have a similar emergency plan in place. However, a recent survey of school nurses reported that only 50 percent of students have an emergency asthma management plan, and only half of the school nurses are involved in the plans that do exist.2
The study also reported that only 16 percent of schools had oxygen, nearly 10 percent did not have a dedicated telephone, and most do not have beta-agonist nebulizers or inhalers available. The effect of having these medications available in schools hasn’t been studied, but intuitively it would seem beneficial. The medications and their administration are straightforward, especially for school nurses.
RAISING AWARENESS
Just like with injury prevention and other diseases, education of the asthmatic patient and the family is essential. Of course, with the limited resource of time in a busy emergency department, taking advantage of this opportunity may be easily overlooked. If each provider–the respiratory therapist, the nurse, the physician–who comes in contact with the child and her caregivers offers a bit of information, the task may be more easily accomplished.
Health care provider education also is highlighted in this case. Unfortunately, this initiative may be somewhat more difficult to accomplish. Many providers are unaware of the National Institutes of Health Asthma Guidelines.3 Raising their awareness is the first step for comprehensive care of the child with asthma in the emergency department.
REFERENCES
1. Gorelick MH, Scribano PV, Stevens MW, Schultz RT, Shults J. Predicting need for hospitalization in acute pediatric asthma. Acad Emerg Med. 2001;8(5):416-7.
2. Sapien RE, Allen A. School preparation for the asthmatic student. J Asthma. 2000;37(8): 719-24.
3. GlaxoSmithKline. Web-based survey results. 1999. Accessed via the Web at www.asthmainamerica.com.
Dr. Sapien is associate professor, emergency medicine and pediatrics, and medical director, pediatric emergency medicine, University of New Mexico Health Sciences Center, Albuquerque.
Emergency visits are important stops along the complex journey of asthma care. Symptoms have reached a crisis point, and follow-up discussions about preventive care clearly are needed.
Unfortunately, research has shown that intervention by a primary care provider (PCP) often does not occur, particularly in inner-city populations where asthma morbidity is the highest. For example, the National Cooperative Inner-City Asthma Study (NCICAS) found that only half of 344 children saw a PCP during the weeks after an emergency department asthma visit.1 Follow-up rates in adults are lower than in children, although few studies have looked comprehensively at this issue.2
Why do patients fail to see a PCP after an emergency department visit? The reasons are multiple, but surveys and focus groups with patients reveal common themes.3,4
The most common reason parents in the NCICAS study gave for lack of follow-up was that an appointment was not needed because the child’s acute condition had improved. What the parents fail to realize is that while the child feels better for the moment, little may have been done to control chronic symptoms and prevent future exacerbations.
Many patients are unaware of the safety and effectiveness of preventive therapy. Asthma treatment has progressed rapidly in recent years, and patients’ symptoms can be well controlled without significant adverse effects. Multiple studies have described reductions in emergency visits, hospitalizations and deaths due to the use of anti-inflammatory medications such as inhaled steroids.5-7
Secondly, although most patients (particularly children) have access to primary care, there are often barriers and delays in reaching that care. Office phone lines are busy, appointment schedules are full, and patients or their parents must take off from work or school because offices are not open during evening hours. Faced with these obstacles, many do not make the extra effort to see a PCP.
SIMPLE INTERVENTIONS
Although low PCP follow-up rates appear discouraging, recent research suggests that with simple interventions, significant improvements in follow-up care can be achieved.
Researchers at the Hospital of the University of Pennsylvania studied an intervention that included a course of prednisone, a reminder phone call and a cab voucher that the patient could use to make a follow-up visit.2 Adults who received this intervention were significantly more likely to see a PCP after the emergency department visit (46 percent vs. 29 percent). These findings are currently being replicated in a large multi-center study, which also is assessing whether the improvement in PCP follow-up has an effect on future health out-comes and quality of life.
An even simpler intervention was studied at the Children’s Hospital of Philadel phia, where re-searchers made sure that a follow-up appointment had been scheduled either from the emergency department or by phone contact with the patient soon after the visit.8 For the 272 subjects studied in this randomized trial, the rate of PCP follow-up increased significantly from 40 percent to 65 percent with this intervention alone.
Improving primary care follow-up is only one small piece of the complex puzzle that must be solved to improve asthma care in the United States. Good outcomes also depend upon PCPs prescribing appropriately and patients being able to afford and willing to follow these prescriptions.
Experts have gathered the available evidence on asthma therapy and developed straightforward recommendations such as the National Asthma Education and Prevention Program Guidelines sponsored by the National Heart, Lung, and Blood Institute.9 Despite these efforts, preventive therapy has not reached its potential. Research studies in a variety of populations have found low adherence to recommended therapies.10,11
For example, in the Children’s Hospital study, although the PCP follow-up rate improved significantly with the intervention, there was no improvement in the use of anti-inflammatory medications at one month after the emergency department visit. On a large population level, the most effective way to improve asthma outcomes may involve comprehensive interventions such as case management programs.
REINFORCING CARE
However, on an individual level, an emergency visit should be viewed as an opportunity to reinforce primary care for asthma. Providers should ask patients about their relationship with their PCPs and whether they have made follow-up visits in the past. If not, what were the reasons and what can be done to overcome these barriers? Review the benefits of continuity of care and, if possible, help to schedule an appointment while the patient is in the emergency department.
While reviewing medications, make sure that the patient is aware of the dif-ference between controller anti-inflammatory medications and rescue agents. If the patient is not using an anti-inflammatory, ask for the reasons and address any concerns that the patient may have.
Ideally, every patient should go home from the emergency department with a clear plan for follow-up and the tools to manage future symptoms. A moment spent on this issue during an emergency visit may be one of the most important therapies to offer.
REFERENCES
1. Leickly FE, Wade SL, Crain E, et al. Self-reported adherence, management behavior, and barriers to care after an emergency department visit by inner city children with asthma. Pediatrics. 1998;101(5). Available at www.pediatrics.org/cgi/content/full/101/5/e8.
2. Baren JM, Shofer FS, Ivey B, et al. A randomized controlled trial of a simple ED intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations [abstract]. Ann Emerg Med. 2001;38:115-22.
3. Crain EF, Kercsmar C, Weiss K, Mitchell H, Lynn H. Reported difficulties in access to quality care for children with asthma in the inner city. Arch Pediatr Adolesc Med. 1998;152:333-9.
4. Mansour ME, Lanphear BP, DeWitt TG. Barriers to asthma care in urban children: Parent perspectives. Pediatrics. 2000;106:512-9.
5. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277: 887-91.
6. Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000;343:332-6.
7. The Childhood Asthma Management Program Research Group: Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med. 2000;344:564-72.
8. Zorc JJ, Hong TH, Grunstein L, Harmelin M, Scarfone RJ. Scheduled follow-up after a pediatric emergency department visit for asthma: A randomized trial [abstract]. Acad Emerg Med. 2001;8:418.
9. National Asthma Education and Prevention Program. Expert panel report: Guidelines for the Diagnosis and Management of Asthma. NIH pub # 98-4051. Bethesda, MD, 1997. Accessed via the Web at www.nhlbi.nih.gov/nhlbi/lung/asthma/prof/asthgdln.htm.
10. Warman KL, Silver EJ, McCourt MP et al. How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI Guideline recommendations? Pediatrics. 1999;103:442-27.
11. Diette GB, Skinner EA, Markson LE, et al. Consistency of care with national guidelines for children with asthma in managed care. J Pediatr. 2001;138:59-64.
Dr. Zorc is assistant professor of pediatrics, University of Pennsylvania, Philadelphia, and attending physician in the division of emergency medicine at the Children’s Hospital of Philadelphia.
