Improving Asthma Care in the Emergency Room

Improving Asthma Care in the Emergency Room

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Improving Asthma Care in the Emergency Room

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To Circumvent Exacerbation, Use Prevention

Though the United States is considered one of the most advanced countries in the health care arena, a large number of asthma patients still rely on the emergency room and its staff as their primary care providers. The National Institutes of Health estimates that 1.8 million ER visits are attributable to asthma, making it one of the most common ER admission diagnoses.

Most experts agree that better management of asthma would not only provide better quality patient care, but also reduce costs. In 1994, the U.S. spent 1 percent of total annual health care costs, or $5.2 billion, on asthma. Indirect costs attributed to asthma totaled another $2.6 billion that year.

McFadden et al., in Cleveland,1 found an aggressive approach using sympathomemetics and careful monitoring can build an effective treatment program and result in significant savings. By using protocols to treat severe exacerbations, 77 percent of patients resolved their symptoms in about two hours, according to the study. Algorithms helped them to identify the patients who required hospitalization.

However, the study also noted that this approach is not the norm. There is a lack of standardized care for treating asthma in ERs across the nation. Currently, no single definitive set of guidelines exists that tells ER physicians how to deal with a severe asthma attack. The treatment patients receive varies significantly from region to region and even from hospital to hospital. The choice of medication, frequency of treatment and dosage vary widely too. There can even be a difference in how a patient is treated by the same physician on different admissions.

NHLBI Recommendations
The National Heart, Lung and Blood Institute’s (NHLBI) guidelines may be useful in resolving the question of setting up protocols for treating asthma in an ER. The goal of any treatment program should be the relief of bronchoconstriction and the restoration of normal airflow and lung function. To accomplish this and determine the most appropriate treatment, clinicians should first conduct a thorough assessment of the patient’s status. This assessment has three components:

  • The current history of the patient, including the perceived severity of symptoms, the time of onset, the medications taken and the activities or possible triggers the patient has been exposed to. Patients presenting in the ER may not have a clue at all as to what started their attacks, so a little detective work might be necessary.
  • A physical examination of the patient, including the usual vital signs and subjective observations made by the practitioner and also a determination of severity. The NHLBI defines severity as mild, moderate or severe.
  • A functional assessment includes a measure of the patient’s peak flow, an arterial blood gas, a chest X-ray if other cardiopulmonary complications are suspected and lab work as deemed necessary by the physician. The crucial assessment tool most frequently overlooked is the peak flow, which should be taken prior to initiating any treatment.

    The NHLBI recommends the use of inhaled, short acting beta2-agonists, given three times at an interval of 20 minutes. The patient is reassessed at the one-hour interval. The use of systemic corticosteroids is also recommended in some cases.

    If patients are having moderate attacks and showing improvement, treatment is continued. Beta2-agonists are given every hour up to three hours if they show improvement. If the attack resolves, the patients may be sent home. If patients have some relief, but not a significant response, they should be admitted to the hospital. Patients with little or no response to therapy within one hour should be considered for admission to an ICU.

    When setting up a protocol, patient supervision in the ER also should be addressed. Monitor those with a peak flow less than 40 percent of predicted continuously if they don’t respond to therapy or are in a state of impending respiratory arrest. Continuous supervision should be maintained until the patient is out of eminent danger of respiratory failure. A peak flow greater than 70 percent of predicted is a good indicator, as is a decrease in the frequency of a beta-agonist to every four hours and a patient’s subjective feelings of comfort.

    Follow-Up Care
    Patients should always be kept in the ER for at least one hour after the last dose of beta-adrenergics has been administered to ensure the resolution of their bronchospasm. During discharge, caregivers should write out the patient’s follow-up care arrangements, including the type of inhalers or other medications prescribed, the frequency of their use and, if possible, appointments with their usual health care providers.

    It’s also a good idea to include the patient’s family in the discharge planning, especially because the patient may not be in a position to explain to someone what is needed for help if an acute exacerbation should return.

    Patients who respond well to therapy in the ER and are discharged should be advised to check in with their regular physicians within 24 hours. They should also be counseled to monitor their peak flows closely and be alert to the possibility of a recurrence of bronchoconstriction.

    Follow-up care and prevention are critical. Asthmatics can never be over-educated about their condition. In a perfect world, all asthma patients would be referred to specialists who are trained, ready and waiting to help them, but this is not the case.

    For this reason, many ERs are developing asthma education and outreach programs.

    Patients presenting with an exacerbation are referred to educational programs that assist them in better understanding and managing their condition. These programs can be hospital- or community-based. One such program, the Chicago Asthma Consortium, has teamed up with the Chicago school system and several emergency departments in a working group to develop the optimum protocols for taking care of asthmatics.

    Another initiative, The Breathmobile™ program, originating in Los Angeles, is an asthma clinic on wheels that treats and educates asthmatics in their community. (For more information, see ADVANCE’s March issue.) Taking care to patients is being explored in several cities across the nation. These programs promote better patient self-management through education and a team approach to managing the asthmatic condition.

    RT’s Job
    As therapists, we have to realize not every primary care practitioner is an asthma expert, and not every patient has access to an asthma specialist. We need to educate our ER physicians and provide literature and support to our ER staff so patients have the resources they need. Finally, make sure the follow-up protocols are user-friendly and assist physicians.

    The United Kingdom currently uses very aggressive asthma protocols that are standardized across the nation. Caregivers have found this modality of care to be successful and cost-effective. Studies in the United States are now showing the use of protocols is beneficial to patients and corporate bottom lines.

    The NHLBI’s Global Strategy for Asthma was not specifically designed for the ER practitioner, but it does offers the tools needed to develop protocols. Many ERs are taking this initiative and paving the way. The result is better patient care, reduced workloads and health care dollars saved.


    1. McFadden ER Jr, elSanadi N, Strauss L, Galan G, Dixon L, McFadden CB, Shoemaker L, Gilbert L, Warren E, Hammonds T. The influence of parasympatholytics on the resolution of acute attacks of asthma. Am J Med. 1997;102(1):7-13.

    Varnell is a practitioner and freelance writer in Atlanta.