Characteristics of Acute Asthma Patients Attended Frequently Compared with Those Attended Only Occasionally in an Emergency Department

Asthma patients that depend on emergency department (ED) services are generally considered to have extremely poor disease control and prognosis. It is important to identify characteristics related to poor disease control and frequent visits to the ED to apply appropriate clinical management. This study comprised a cross-sectional survey of consecutive patients with asthma exacerbation (age ≥12 years) presenting at the adult ED of a large, tertiary care, university-affiliated hospital over a 2-month period. The frequent visitors (FV) were defined by ≥3 visits to the ED in the preceding year, and the occasional visitors (OV) by ≤2 visits. Eighty-six patients (61 females and 25 males) were included in the study (mean age 38 ± 18 years). Of these patients, 51.2% were FV and 48.8% were OV. Sixty-nine percent had annual income lower than A$3000 and 66.3% had ≤8 years of the formal education. Only 18.6% had used inhaled corticosteroids, 79.1% identified the asthma attack severity, 70.9% increased or initiated inhaled β-agonist, 20.9% increased or initiated steroid therapy, and 55.8% had an asthma action plan for attack. The number of hospital admissions in past year (OR 4.3, P = .02), use of home nebulizer (OR 3.6, P = .05) and the lack of a written asthma action plan (OR 3.3, P = .03) were independently associated with frequent visits to the ED. We conclude that a substantial proportion of the patients that visit the ED are FV. These patients are more likely to have hospital admission in the past year, to use a home nebulizer, and to lack a written asthma action plan. They should be considered the most important target for asthma education.     

Relapse Following Treatment of Acute Asthma in the Emergency Department

Most patients presenting to the emergency department (ED) with acute asthma will have some, if not significant, relief of respiratory distress following treatment. The majority of patients are discharged to home; however, a significant portion of patients relapse and require urgent medical treatment. Many patients have continued respiratory symptoms and impairment in activities of daily living after ED treatment. In a large multicenter trial, we found that 1 7% of patients relapse within 2 weeks, requiring urgent medical treatment. The factors associated with asthma relapse were a history of numerous ED visits over the previous year, a history of urgent clinic visits over the previous year, use of a home nebulizer, multiple asthma triggers, and duration of symptoms between 1 and 7 days. In other studies, we found that many patients relapse before they can see their primary care physician, and that the lack of an identifiable primary care physician is associated with a higher incidence of relapse. Two interventions have been shown in studies to decrease the rate of relapse. The first, the administration of corticosteroids, has been adopted into general medical practice. Despite the routine use of corticosteroids following ED treatment, however, relapse remains a substantial problem. The second intervention involves focused long term management by an asthma specialist. Several projects have demonstrated the efficacy of this approach in decreasing ED visits. Although it is time- and resource-intensive, this approach may be necessary for those patients who have frequent ED visits. Whether this approach is generalizable has yet to be demonstrated. In this article, we review the previous work on asthma relapse and suggest areas for further study.     

Predicting Emergency Department Utilization in Adults with Asthma: A Cohort Study

A consecutive sample of 378 adults with asthma were assessed at a university asthma program and then interviewed 1 year later regarding their need for emergency department (E.D.) asthma treatment. The purpose of this prospective cohort study was to determine whether any of their initial features could predict their subsequent need for E.D. asthma treatment. At one year, a total of 73 of the subjects had attended emergency departments for asthma. On entry, the 73 subjects had demonstrated more self-reported lifestyle restriction from asthma and more hospital admissions E.D. visits for asthma as well as poorer asthma control or than had the 305 subjects who had not required E.D. asthma treatment since entry to the cohort. This study suggests that special attention should be paid to subjects with asthma that interferes with their lifestyle and to those who have needed hospital admission for asthma.     

An Umbrella Review: Corticosteroid Therapy for Adults with Acute Asthma

The objective of this “umbrella” review is to synthesize the evidence and provide clinicians a single report that summarizes the state of knowledge regarding the use of corticosteroids in adults with acute asthma. Systematic reviews in the Cochrane Library and additional clinical trials published in English from 1966 to 2007 in MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL, and references from bibliographies of pertinent articles were reviewed. Results indicate that the evidence base is frequently limited to small, single-center studies. Findings suggest that therapy with systemic corticosteroids accelerates the resolution of acute asthma and reduces the risk of relapse. There is no evidence that corticosteroid doses greater than standard doses (prednisone 50-100 mg equivalent) are beneficial. Oral and intravenous corticosteroids, as well as intramuscular and oral corticosteroid regimens, seem to be similarly effective. A nontapered 5- to 10-day course of corticosteroid therapy seems to be sufficient for most discharged patients. Combinations of oral and inhaled corticosteroids on emergency department/hospital discharge might minimize the risk of relapse.     

Characteristics and Correlates of Asthma Knowledge Among Emergency Department Users in Harlem

We constructed a questionnaire to assess asthma knowledge, assessed its psychometric properties, and examined its association with demographic characteristics, psychosocial factors, and disease severity and management in 375 adults following an asthma-related emergency department visit. Overall knowledge was poor but varied widely among respondents. Better knowledge was related to younger age, higher education, and less severe disease. Chance-orientated health locus of control and low self-esteem were associated with lower asthma knowledge. Better knowledge was associated with better disease management. We conclude that asthma education can lead to improved disease outcomes, and psychosocial factors need to be considered when designing interventions for asthma education.     

Characteristics and Correlates of Asthma Knowledge Among Emergency Department Users in Harlem

We constructed a questionnaire to assess asthma knowledge, assessed its psychometric properties, and examined its association with demographic characteristics, psychosocial factors, and disease severity and management in 375 adults following an asthma-related emergency department visit. Overall knowledge was poor but varied widely among respondents. Better knowledge was related to younger age, higher education, and less severe disease. Chance-orientated health locus of control and low self-esteem were associated with lower asthma knowledge. Better knowledge was associated with better disease management. We conclude that asthma education can lead to improved disease outcomes, and psychosocial factors need to be considered when designing interventions for asthma education.     

Relapse Following Treatment of Acute Asthma in the Emergency Department

In this analysis, we sought to determine factors that predicted the level of asthma knowledge in a sample of adolescents with asthma and their parents. Eighty-five young people aged 10–24 years attending tertiary care asthma clinics and 46 of their parents answered validated respiratory and asthma knowledge questionnaires. Older adolescents were more knowledgeable about asthma than were younger adolescents (r=0.36, p=0.001). Young people with severe asthma (p=0.015) scored higher on the asthma knowledge questionnaire than those with mild/moderate asthma. Asthma knowledge among young people was related to that of their mothers (r=0.47, p=0.014), however, only age and the asthma knowledge of fathers significantly predicted adolescent asthma knowledge. Adolescents develop increasing autonomy for asthma self-management as they mature, but parents remain an important source of information about asthma for young people.     

Predictors of Treatment Adherence Among Asthma Patients in the Emergency Department

This study examined predictors of treatment adherence among 120 adult patients with asthma at two emergency departments (EDs). Structured medical chart reviews were performed for characteristics hypothesized to be associated with treatment adherence difficulties. Sixty percent of subjects had evidence of nonadherence with asthma treatment. Several variables were associated with nonadherence including younger age, more utilization of ED services (more ED visits, using the ED for medication refills), certain treatment characteristics (receiving more medications in the ED, not being prescribed prednisone at discharge), and not keeping post-discharge follow-up appointments. Further research should be directed at enhancing self-management skills and decreasing inappropriate ED use among nonadherent patients.     

Predictors of Treatment Adherence Among Asthma Patients in the Emergency Department

This study examined predictors of treatment adherence among 120 adult patients with asthma at two emergency departments (EDs). Structured medical chart reviews were performed for characteristics hypothesized to be associated with treatment adherence difficulties. Sixty percent of subjects had evidence of nonadherence with asthma treatment. Several variables were associated with nonadherence including younger age, more utilization of ED services (more ED visits, using the ED for medication refills), certain treatment characteristics (receiving more medications in the ED, not being prescribed prednisone at discharge), and not keeping post-discharge follow-up appointments. Further research should be directed at enhancing self-management skills and decreasing inappropriate ED use among nonadherent patients.     

A Prospective Multicenter Study of Written Action Plans among Emergency Department Patients with Acute Asthma

Background. The prevalence of written “action plans” (APs) among emergency department (ED) patients with acute asthma is unknown. Objective. To determine the prevalence of APs among ED patients, to describe the demographic and clinical profile of patients with and without APs, and to examine the appropriateness of response to an asthma exacerbation scenario. Methods. Using a standard protocol, 49 North American EDs performed a prospective cohort study involving interviews of 1,756 patients, ages 2–54, with acute asthma. Among children only, a random sample was contacted two years after the index ED visit to assess current AP status and parents' self-management knowledge. Results. The overall prevalence of APs was 32% (95% confidence interval [CI], 30%–34%), and was higher among children than adults (34% vs. 26%, respectively; p = 0.001). Patients with APs had worse measures of chronic asthma severity (p < 0.05) and were more likely to be hospitalized (multivariate odds ratio, 1.5; 95%CI, 1.1–2.1). After 2 years, most children with an AP at the index ED visit still had one but only 20% of those without an AP had obtained one; moreover, many of the APs appeared inadequate. Parents of children with a current AP performed slightly better on the asthma scenario, but both groups overestimated their asthma knowledge. Conclusion. The prevalence of APs among ED patients with acute asthma is unacceptably low, and many of these APs appear inadequate. “Confounding by severity” will complicate any non-randomized analysis of the potential impact of APs on asthma outcomes in ED patients.     

Symptomatic Improvement Following Emergency Department Management of Asthma: A Pilot Study of Intramuscular Dexamethasone Versus Oral Prednisone

Systemic corticosteroid therapy is an established adjunct to beta-adrenergic medications in acute exacerbations of asthma. To date, no study has defined the role of long-acting intramuscular preparations of corticosteroids in pediatric patients with asthma. A pilot study was conducted to prospectively compare symptomatic improvement following a single injection of intramuscular dexamethasone (IMD) to a 3-day regimen of oral prednisone (OP) for children with mild to moderate wheezing episodes that are responsive to nebulized medications in the Pediatric Emergency Department (PED). The following children presenting with acute exacerbations of asthma to the PED were eligible for enrollment: age 3-16 years; more than two prior wheezing episodes; mild to moderate wheezing; and oxygen saturation 95% or more in room air. The study patients were randomly assigned to receive either IMD (n = 21) or OP (n = 21) in addition to a standardized treatment regimen of nebulized albuterol. All of the children were clinically rated for wheezing severity by the Pulmonary Index (PI) score at regular intervals during the study. Discharge home was based on clinical improvement during treatment in the PED; patients who were admitted to the hospital were removed from the study. Follow-up was conducted the fifth day after discharge from the ED either by clinic visit or by telephone. Patients were assessed for symptomatic improvement and relapse or clinical deterioration during the study period by a clinician blinded to group assignment. Forty-two children participated in this pilot study. There were no significant differences between the IMD and OP groups for gender or age. Mean ages were: 82 months (SD 46 months), IMD group; 63 months (SD 36 months), OP group. Clinical progress (based on PI) with treatment in the PED was the same in both groups: pretreatment median, PI = 6; PED discharge median, PI = 2. None of the study patients were hospitalized during the follow-up period, and all reported symptomatic improvement since initial treatment. The data of this pilot study suggest that IMD may be a feasible alternative to OP for treatment of acute wheezing episodes in children with asthma. IMD provides sufficient treatment to prevent clinical deterioration within 5 days after initial therapy for mild to moderate pediatric exacerbations of asthma that are responsive to nebulized medications.     

Symptomatic Improvement Following Emergency Department Management of Asthma: A Pilot Study of Intramuscular Dexamethasone Versus Oral Prednisone

Systemic corticosteroid therapy is an established adjunct to beta-adrenergic medications in acute exacerbations of asthma. To date, no study has defined the role of long-acting intramuscular preparations of corticosteroids in pediatric patients with asthma. A pilot study was conducted to prospectively compare symptomatic improvement following a single injection of intramuscular dexamethasone (IMD) to a 3-day regimen of oral prednisone (OP) for children with mild to moderate wheezing episodes that are responsive to nebulized medications in the Pediatric Emergency Department (PED). The following children presenting with acute exacerbations of asthma to the PED were eligible for enrollment: age 3-16 years; more than two prior wheezing episodes; mild to moderate wheezing; and oxygen saturation 95% or more in room air. The study patients were randomly assigned to receive either IMD (n = 21) or OP (n = 21) in addition to a standardized treatment regimen of nebulized albuterol. All of the children were clinically rated for wheezing severity by the Pulmonary Index (PI) score at regular intervals during the study. Discharge home was based on clinical improvement during treatment in the PED; patients who were admitted to the hospital were removed from the study. Follow-up was conducted the fifth day after discharge from the ED either by clinic visit or by telephone. Patients were assessed for symptomatic improvement and relapse or clinical deterioration during the study period by a clinician blinded to group assignment. Forty-two children participated in this pilot study. There were no significant differences between the IMD and OP groups for gender or age. Mean ages were: 82 months (SD 46 months), IMD group; 63 months (SD 36 months), OP group. Clinical progress (based on PI) with treatment in the PED was the same in both groups: pretreatment median, PI = 6; PED discharge median, PI = 2. None of the study patients were hospitalized during the follow-up period, and all reported symptomatic improvement since initial treatment. The data of this pilot study suggest that IMD may be a feasible alternative to OP for treatment of acute wheezing episodes in children with asthma. IMD provides sufficient treatment to prevent clinical deterioration within 5 days after initial therapy for mild to moderate pediatric exacerbations of asthma that are responsive to nebulized medications.     

急诊绿色通道在抢救急性心肌梗死患者中的作用

目的:探讨急诊绿色通道在抢救急性心肌梗死(AMI)患者中的价值。方法:回顾性分析自2003年设施急诊绿色通道以来,我科对124例AMI的诊断与治疗情况,观察其是否在有效的时间窗内得到治疗。结果:124例患者在发病后2h内得到及时治疗者29例,2～6h得到及时治疗者75例,6～12h得到及时治疗者16例,>12h者4例,死亡7例。结论:AMI患者在急诊绿色通道实施救治可减少心肌梗死患者在诊断、治疗过程中时间的浪费,使之得到及时有效的救治。     

Utility of Portable Spirometry in a Pediatric Emergency Department in Children with Acute Exacerbation of Asthma

Objectives. The primary purpose of this study was to determine if portable spirometers can be successfully used in an emergency department (ED) in children with an acute exacerbation of asthma. The secondary purpose of this study was to determine if a validated clinical asthma score (CAS) correlates with the spirometry results in children with an acute exacerbation of asthma. Methods. Children between the ages of 6 and 17 years who presented to an urban free-standing children's hospital ED with an acute exacerbation of asthma were enrolled in our study. On arrival, the CAS was recorded and then portable spirometry was performed. Attempts were continued until acceptable and reproducible flow loop measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with the CAS. Results. A total of 101 patients were enrolled in this study. Of those patients, only 35 (35%) were able to successfully perform portable spirometry. Successful spirometry attempts were associated with older age (10.4 vs. 8.9, p = .01), lower respiratory rates (24.8 vs. 30.2, p = .001), lower heart rates (110 vs. 124, p = .004), and lower CASs (8.4 vs. 9.7, p = .001). Increasing asthma severity correlated with a decreased likelihood of successfully obtaining a useful forced expiratory volume in 1 second (FEV₁) measurement (p = .013). Compared with cases of mild asthma, a patient with moderate asthma is 33% less likely to be able to perform spirometry, and a patient with severe asthma 93% less likely to perform spirometry. The CAS correlated poorly with the more objective measure of FEV₁% predicted in those with mild asthma. Conclusion. Many children are incapable of using portable spirometry for the evaluation of acute exacerbations of asthma in the ED. The clinical asthma scoring system demonstrated poor correlation with portable spirometry measurements in terms of severity classification.     

Corticosteroid Timing and Length of Stay for Children with Asthma in the Emergency Department

Objective. The aim of this study was to evaluate the relationship between time of corticosteroid administration to children with asthma exacerbations in the Emergency Department (ED) and length of stay (LOS). We hypothesized administration within 60 minutes would be associated with a 10- minute or greater decrease in mean LOS. Methods. A retrospective chart review of 882 patients was conducted. Children between the ages of 2 and 18 years presented to the Connecticut Children’s Medical Center’s (CCMC’s) ED with an acute asthma exacerbation were included. Children were excluded if they did not receive oral corticosteroids in the ED, had significant co-morbidities, were currently taking corticosteroids, or had taken them within the past 7 days. Children receiving corticosteroids within 60 minutes of triage were compared with children receiving corticosteroids for 61 minutes or later. The primary outcome was mean LOS. Results. Children treated with corticosteroids within 60 and 61 minutes or later had similar age, gender, insurance, and disposition. Children treated with corticosteroids within 60 minutes had a 25-minute decrease in LOS compared with children treated for 61-minute or later (95% CI: 15–35), p < .0001. Conclusions. Administering corticosteroids to pediatric asthma patients in the ED within an hour of triage is associated with a 25-minute mean decrease in LOS. With large numbers of asthma visits, a 25-minute decrease in LOS for each child could have a significant impact on patient throughput in the ED.     

Emergency Department Use of Ketamine in Pediatric Status Asthmaticus*

The objective of this study was to evaluate the effects of adding ketamine to standard emergency department (ED) therapy for patients with status asthmaticus. This was a prospective observational study. Ten patients with an acute exacerbation of asthma who were unresponsive to standard therapy were enrolled in the ED. Upon enrollment, children received ketamine at a loading dose of 1 mg/kg intravenously (i.v.), followed by a continuous infusion of 0.75 mg/kg/hr (12.5 μg/kg/min) for 1 hr. Clinical asthma score (CAS), vital signs, and peak expiratory flow (PEF) measurements were obtained prior to ketamine administration, within 10 min after ketamine administration was completed, and 1 hr after infusion. Median CAS on ED arrival was 15 (range 7–23) and did not significantly change immediately prior to infusion of ketamine (median 14, range 8–21). Median CAS decreased to 10.5 immediately after infusion and to 9.51 hr post ketamine infusion (37% reduction, p < 0.05 by ANOVA vs. preketamine CAS). Median respiratory rate (RR) also decreased from 39 prior to ketamine to 30 immediately following ketamine administration (25% decrease vs. preketamine; p < 0.05). Oxygen saturation significantly improved after ketamine infusion, although 5 patients remained on oxygen. Median PEF improved after infusion, but was not statistically significant. Four patients experienced mild side effects including mild hallucinations, diffuse flushing, and moderate hypertension. Side effects resolved with benzodiazepines or with discontinuation of the infusion. Addition of ketamine to standard therapy was associated with improved indices of acute asthma severity. Side effects were transitory and comparable to previous studies. However, a double-blinded randomized controlled trial needs to be conducted to determine if improvement is attributable to the addition of ketamine to standard asthma therapy.