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Imj_469.kelly.fmInternal Medicine Journal 2003; 33: 406–413 Snapshot of acute asthma: treatment and outcome of patients with acute asthma treated in Australian emergency departmentsA.-M. KELLY,*1,2,5 C. POWELL*3,4,5 and D. KERR*1 1Joseph Epstein Centre for Emergency Medicine Research and 2Department of Emergency Medicine, Western Hospital, Departments of 3Emergency Medicine and 4General Paediatrics, Royal Children’s Hospital and 5The University of Melbourne, Melbourne, Victoria, Australia *For the Snapshot of Asthma Study Group 2000 and 2001.
tered included: (i) salbutamol to 90%, (ii) ipratropium Aims: To characterize presentations due to acute asthma bromide to 59% and (iii) corticosteroids to 71%. Only at Australian emergency departments (ED), including six patients received aminophylline. Spacer use for sal- their severity, treatment and disposition.
butamol was rare (1%) in adults and only moderate Methods: This prospective, observational study involved (43%) in children. Sixty-five percent of patients were 38 departments of emergency medicine throughout discharged home from the ED. Less than 1% of patients Australia participating in the Snapshot of Asthma Study required ventilatory assistance, of which half was pro- Group project 2000 and 2001. Data were collected vided non-invasively. One percent of patients were for patients presenting with acute asthma between admitted to the intensive-care unit or high-dependency 21 August 2000 and 3 September 2000, and 20 August 2001 and 2 September 2001 and included demograph- Conclusion: Overall adherence to treatment guidelines ics, severity classification, treatment and disposition.
was good. There appears to be underuse of spacers and Results: There were 1340 acute asthma presentations in corticosteroids in some groups and overuse of ipra- the study periods. Of these presentations, 67% were for tropium bromide. The majority of patients are treated children aged <15 years. Asthma severity (according to and discharged from the ED. (Intern Med J 2003; 33: the Australian National Asthma Guidelines classifi- cation) was ‘mild’ in 49% of cases; ‘moderate’ in 45% ofcases; and ‘severe’ in 6% of cases. Treatment adminis- Key words: asthma, management, outcome, guidelines.
patients, their families and health professionals withinformation to improve the standard of asthma care. As Asthma is common in Australia and can be life- part of this process, The National Asthma Campaign has threatening. The National Asthma Campaign facilitated the development of asthma management (Australia) has been working for some years to provide guidelines.1 This document covers all aspects of asthma Correspondence to: A-M Kelly, Joseph Epstein Centre for Emergency Hospital, Qld); Dr. R. Day (Hornsby and Ku-Ring-Gai Hospital, Medicine Research, Department of Emergency Medicine, Western Hospital, NSW); Dr. D. Cruse (Joondalup Hospital, WA); Dr. E. Merfield Footscray, 3011 Vic., Australia. Email: Anne-Maree.Kelly@wh.org.au. (Launceston Hospital, TAS); Dr. C. Gavaghan (Lismore Hospital, Received 16 September 2002; accepted 16 January 2003. NSW); Dr. D. Lewis-Driver (Logan Hospital, Qld); Dr. B.Sadlier (Mackay Base Hospital, Qld); Dr. A. Rosengarten (Maroondah Hospital, Funding: 2001 data collection was supported by a grant from Vic.); Dr. R. Pitt (Mater Hospital, Qld); Dr. P. Rosengarten (Monash Commonwealth Department of Health and Ageing. Medical Centre, Vic.); Dr. J. Roberts (Port Macquarie Hospital, NSW); Dr. H. Hunt (Rockhampton Base Hospital, Qld); Dr. C. Powell (The * The Asthma Snapshot Study Group comprised: Dr. P. Love (Albury Royal Children’s Hospital and Sunshine Hospital, Vic.); Dr. R. Clark Base Hospital, NSW); Dr. G. McInerney (Auburn Hospital, NSW); Dr. (Royal Children’s Hospital, Qld); Dr. D. Palmer (Royal Darwin G. Campaign (Ballarat Base Hospital, Vic.); Dr. L. Dann (Bankstown Hospital, NT); Dr. G. Fulde (St. Vincent’s Hospital, NSW); Dr. N. Hospital, NSW); Dr. L. Pouw (Box Hill Hospital, Vic.); Dr. S. Andrew- Small (Townsville Base Hospital); Assoc. Prof. D. Taylor (The Royal Starkey (Caboolture Hospital, Qld); Dr. S. Brazenor (Calvary Hospital, Melbourne Hospital, Vic.); Dr. J. Raftos (Sutherland Hospital, NSW); ACT); Dr. M. Chu (Canterbury Hospital, NSW); Dr. A. Tankel (Coffs A/ Prof D. Richardson (The Canberra Hospital, ACT); Dr. S. Curran Harbour, NSW); Dr. J. Wenzel (Dandenong Hospital, Vic.); Dr. A. (Wagga Wagga Base Hospital, NSW); Prof. A. Kelly (Western Hospital, Yuen (Epworth Hospital, Vic.); Dr. T Elisizo (Flinders Medical Centre, Vic.); Dr. A. Bezzina (Wollongong Hospital, NSW); Dr. J. Raftos SA); Dr. J. Hodge (Fremantle Hospital, WA); Dr. D. Green (Gold Coast (Women’s and Children’s Hospital, SA). Snapshot of acute asthma in Australia management, including the assessment and management participating hospitals volunteered and data were col- of acute attacks. In particular, it sets down guidelines for lected locally. This project was considered an audit by the management of patients presenting to emergency most centres and was hence exempted from the require- departments (ED), stratified according to the severity of ment for ethics committee approval. Ethics committee the episode. Evidence from the United Kingdom2,3 and approval was obtained for those centres where it was a small, single-centre Australian study4 suggest that compliance with asthma management guidelines is The subjects included patients aged 1–60 years (in the 2000 study) and 1–55 years (in the 2001 study) with a The primary aim of the present study was to compare physician-confirmed diagnosis of acute asthma. Patients reported actual patient management with that recom- aged >55 years (2001) and >60 years (2000) were mended by the National Asthma Guidelines (NAG). A excluded to minimize overlap with chronic obstructive secondary aim was to characterize presentations due to airways disease. Patients aged <1 year were excluded to acute asthma to Australian ED with respect to demo- minimize overlap with bronchiolitis.
graphics, severity, disposition and outcome. This is the Data collected included: (i) demographic information, first multicentre study of its type conducted in Australia.
(ii) duration of attack, (iii) classification of the severityof the attack according to medical officer assessment (iv) treatment, (v) disposition (home; ward; intensive- This prospective, observational study was conducted care unit (ICU)/high-dependency unit; transfer) and in 38 Australian ED between 21 August 2000 and 3 September 2000, and 20 August 2001 and 2 Sep- Actual treatment and disposition was compared to the tember 2001 (not all hospitals participated in both data- recommendations in NAG (Tables 3 and 4).
collection periods). All ED accredited for training by the Data were collected by clinical staff at each hospital, Australasian College for Emergency Medicine were entered onto a specifically designed form and analysed contacted by mail and invited to participate. The 38 using descriptive statistics. Quality checks on the data Initial assessment of severity of acute asthma in children† †Adapted from the Asthma Management Handbook (page 12).1 ‡% predicted.
Initial assessment of severity of acute asthma in adults† †Adapted from the Asthma Management Handbook (page 12).1 ‡% predicted.
Internal Medicine Journal 2003; 33: 406–413 e IV when no response to aerosol salbutamol Oral prednisolone (1 mg/kg per dose daily) Initial management of acute asthma in children Internal Medicine Journal 2003; 33: 406–413 Snapshot of acute asthma in Australia e IV if no response to aerosol (i.e.
ere asthma and those not responding.
tainty exists regarding the benefits of this Initial management of acute asthma in adults Internal Medicine Journal 2003; 33: 406–413 collected were not performed. Descriptive analysis was Treatment given to adults is summarized in Table 6.
Ipratropium bromide was again commonly administeredin all severity groups. There is some underuse of corti- costeroids in the moderate group. Four patients receivedaminophylline (1%) and four patients received paren- There were 1340 acute asthma presentations recorded teral adrenaline (1%). Nine patients required ventilatory for the 38 participating ED during the study period.
support (2%). For five of these, non-invasive ventilatory Sixty-seven percent of patients were aged ≤15 years. The age distribution is shown in Fig. 1. The severity distribu- Overall, 62% of children and 70% of adults were tion was different between the adult and child groups, with the adult group having higher severity distribution(P = 0.0015).
Treatment given to children is summarized in Table 5. Of note, nebulisers are used much more NAG1 provide recommendations for the assessment and commonly than spacers for the delivery of aerosol treatment of acute asthma in Australia. This is the first β-agonists. Ipratropium bromide (IB) was commonly study to examine how well these guidelines are followed used in all severity groups, despite the guideline recommendation that it is not needed in mild and Overall adherence to the guidelines with respect to moderate severity groups. There is underuse of cortico- steroids, particularly for the severe group. Two patients Corticosteroids have been shown to reduce admission received aminophylline (0.2%) and only one child rates, relapse rates and the need for additional β-2 required ventilatory support (0.1%).
agonists.5–7 In the present study there was someunderuse of corticosteroids in both adults and childrenwho were classified as having moderate or severe asthma.
The reason for this is unclear. Possible explanationsinclude documentation errors (i.e. steroids were givenbut not recorded), and an under-classification of severitycompared with the NAG by the treating doctor.
Oxygen also appears to be under-administered in the severe group for both adults and children. This is,however, very likely to be a documentation effect. Thevast majority of these patients received inhaled β-agonists by nebuliser, which is commonly oxygen- Age distribution of the study sample.
Treatment given to children (<16 years of age) stratified by National Asthma Guidelines (NAG) severity classification combined for 2000 and 2001 for all presentations (892 presentations, 52 missing NAG severity data) Internal Medicine Journal 2003; 33: 406–413 Snapshot of acute asthma in Australia NAG recommend IB administration be reserved for push for change to spacer use recently. Published patients with severe asthma for both adults and children.
evidence suggests that delivery via this method is as Studies in children and adolescents with severe asthma effective as delivery by nebuliser.13 In paediatrics, many (forced expiratory volume in 1 second (FEV ) or peak centres have already changed over to the use of spacers expiratory flow (PEFR) <50%), suggest that multiple for acute asthma.14,15 There are data suggesting that doses, administered in the first hour of treatment along treatment with spacers has less side-effects,16,17 a with β-2 agonists, may have an influence on admission shorter period of time in ED,17 quicker response to rate.8 They may also have an impact on cost.9 There is treatment,18 a reduced hospital-admission rate and good evidence that ipratropium does not have a role in possible reduced morbidity.19,20 There are concerns mild to moderate asthma when sufficient β-2 agonists about cost and this has yet to be addressed in an are used.10 Further, a meta-analysis of four trials Australian population, however some data suggest that spacers are cheaper.19,20 In adults, the case for spacers concludes that there appears to be a modest, statistically is less compelling. The study of Cates and Rowe significant benefit with the use of IB, but raises doubts suggests that the choice of delivery method should about whether the effect size found is clinically signifi- reflect patient preference, practice situations and formal cant.11 This is supported by a recent randomized controlled trial (RCT) involving 180 people with severe The low rate of aminophylline use is concordant with acute asthma (FEV <50%) which demonstrated that the guidelines and current evidence in adult studies.21 In ipratropium significantly improved lung function and paediatrics, some doubt about the role of aminophylline that, after 3 h, subjects were more likely to be discharged persists. One RCT, including 163 children with severe home (20% vs. 39%; P < 0.01).12 Given the evidence asthma, demonstrated that, in asthma that was unre- and the cost of routine use of IB, the NAG position is sponsive to initial treatment, aminophylline may still justifiable. Our data confirm unnecessary use of ipratro- have a role in reducing the intubation rate.22 pium. Given the unit cost of IB of approximately $A18 The use of therapies not included in the current guide- per dose, elimination of its use in the mild and moderate lines – in particular intravenous (IV) adrenaline and groups could translate into considerable drug-cost non-invasive ventilation (NIV) – is interesting. There is savings per year. Unfortunately this study’s methodology no published evidence supporting the use of IV adrena- does not allow us to estimate the potential cost savings.
line rather than IV salbutamol. That said, adrenaline has The finding of a low rate of spacers to deliver the potential advantage of bronchial vasoconstriction as β-agonist was somewhat surprising; particularly in the well as bronchodilation and potentially greater efficacy treatment of children, where there has been a significant in sudden onset (anaphylactoid) asthma. This is an area Treatment given to adults (>15 years of age) stratified by National Asthma Guidelines (NAG) severity classification classification combined for 2000 and 2001 for all presentations (448 presentations, 27 missing NAG severity data, complete data-set 421 adults) ICU, intensive care unit; IV, intravenous; HDU, high-dependency unit; CPAP, non-invasive ventilation using continuous positive airway pressure.
Internal Medicine Journal 2003; 33: 406–413 requiring further study. With respect to NIV, there is some evidence that it results in rapid correction ofgas exchange abnormalities,23 and assists inspiratory Although most cases presenting to EDs are moderate, muscles.24 Although there are case reports/small series 6% of patients have severe asthma. The overall reporting its successful use,25,26 there is currently no compliance with the treatment guidelines was good.
conclusive evidence that it reduces the requirement for There appears to be underuse of spacers and cortico- steroids and overuse of IB. The majority of patients An important finding of the present study was that are treated and discharged from the ED.
severity classification based on initial assessment was nota good predictor of the need for hospital admission. The NAG state that patients with moderate asthma ‘willprobably need admission’ and that ‘ICU should be 1 National Asthma Campaign. Asthma Management Handbook considered’ for those in the severe group. This study 1998. Melbourne: National Asthma Campaign Ltd; 1998.
found that 60% of adults and 44% of children in the 2 Lipworth BJ, Jackson CM, Ziyaie D, Winter JH, Dhillon PD, Clark RA. An audit of acute asthma admissions to a respiratory moderate severity classification and 26% of adults and unit. Health Bull (Edinb) 1992; 50: 389–98.
18% of children in the severe classification could be 3 Hart SR, Davidson AC. Acute adult asthma – assessment of discharged home after a period of treatment in the ED.
severity and management and comparison with British Thoracic Data were not, however, collected on whether any of Society Guidelines. Respir Med 1999; 93: 8–10.
these patients represented requiring admission as part of 4 Gibson PG, Talbot PI, Hancock J, Hensley MJ. A prospective the same asthma episode. Given that the NAG recom- audit of asthma management following emergency asthma mendations provide a potential avenue for litigation if treatment at a teaching hospital. Med J Aust 1993; 158: 775–8.
they are not followed, this finding may lead to a reconsid- 5 Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy eration of the strength of the recommendation regarding in acute exacerbations of asthma: a meta-analysis. Am J Emerg disposition of this group of patients. It is possible that the 6 Edmonds ML, Camargo CA Jr, Pollack CV Jr, Rowe BH. Early NAG guideline recommendations were based on old or use of inhaled corticosteroids in the emergency department incomplete information about ED asthma management treatment of acute asthma. Cochrane Database Syst Rev 2001; or that asthma management in ED has improved since this section of the guidelines was written.
7 Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. The present study has some limitations that should be Early emergency department treatment of acute asthma with considered when interpreting the results. The ED that systemic corticosteroids. Cochrane Database Syst Rev 2001; 1: participated did so voluntarily. They may represent ED with a particular interest in asthma management and 8 Plotnick LH, Ducharme FM. Combined inhaled anticholinergics generalisability to the broader range of ED might and beta2-agonists for initial treatment of acute asthma in therefore be questioned. Patients were identified children. Cochrane Database Syst Rev 2000; 4: CD000060.
9 Lord J, Ducharme F, Stamp RJ, Littlejohns P, Churchill R. Cost prospectively, however some data were collected retro- effectiveness of inhaled anticholinergics for acute childhood and spectively and are therefore subject to documentation adolescent asthma. Br Med J 1999; 319: 1470–71.
weakness. Although every attempt was made to include 10 Ducharme F, Davies GM. Randomised controlled trial of all eligible patients, some may have been missed. The ipratropium bromide and frequent low doses of salbutamol in the diagnosis of asthma was based on physician judgement management of mild and moderate acute pediatric asthma. rather than objective measures of lung function, thus some of the patients included may not have been 11 Rodrigo G, Rodrigo C, Burschtin O. Ipratropium bromide in suffering from asthma. The sample does, however, acute adult severe asthma: a meta analysis of randomized represent a ‘real world’ sample and thus we consider the controlled trials. Am J Med 1999; 107: 363–70.
treatment patterns found to be valid. The sample has an 12 Rodrigo GJ, Rodrigo C. First line therapy for adult patients with acute asthma receiving multiple dose protocol of ipratropium over-representation of children. This is partly explained bromide plus albuterol in the emergency department. Am J Resp by the prevalence of the condition among children and Crit Care Med 2000; 161: 1862–8. Also available from URL: the participation of several children’s hospitals. There http://www.nationalasthma.org.au/publications/amh/amhcont.htm may also be an element of parental behaviour in seeking 13 Cates CJ, Rowe BH. Holding chambers versus nebulisers for asthma care. This is supported by the higher severity beta-agonist treatment of acute asthma. Cochrane Database Syst classification distribution in the adult group.
Future directions for this research include: 14 Powell CVE, Maskell G, Marks MK, South M, Robertson CF. (i) exploring whether there are different phenotypes of Successful implementation of spacer treatment guideline for acute acute asthma with different patterns of response to treat- asthma. Arch Dis Child 2001; 84: 142–6.
ment, (ii) evaluating whether an assessment after 1 h of 15 Gazarian M, Henry RL, Wales SR, Micallef BE, Rood EM, O’Meara MW et al. Evaluating the effectiveness of evidence-based treatment is a better indicator of need for admission than guidelines for the use of spacer devices in children with acute initial assessment, (iii) determining the characteristics of asthma. Med J Aust 2001; 174: 394–7.
patients who re-present to the ED and how this might be 16 Robertson CF, Norden MA, Fitzgerald DA, Connor FL, avoided and (iv) evaluating whether participation in this Van Asperen PP, Cooper PJ et al. Treatment of acute asthma: study process affects asthma management in the study salbutamol via jet nebuliser vs spacer and metered dose inhaler. J Paediatr Child Health 1998; 34: 142–6.
Internal Medicine Journal 2003; 33: 406–413 Snapshot of acute asthma in Australia 17 Chou KJ, Cunningham SJ, Crain EF. Metered dose inhalers with 22 Yung M, South M. Randomised controlled trial of aminophylline spacers vs nebulizers for pediatric asthma. Arch Pediatr Adolesc for severe acute asthma. Arch Dis Child 1998; 79: 405–10.
23 Meduri GU, Cook TR, Turner RE, Cohen M, Leeper KV. 18 Rubilar L, Castro-Rodriguez JA, Girardi G. Randomized trial of Noninvasive positive pressure ventilation in status asthmaticus. salbutamol via metered–dose inhaler with spacer versus nebulizer for acute asthma in children less than 2 years of age. Pediatr 24 Shivaram U, Donath J, Khan FA, Juliano J. Effects of continuous positive airway pressure in acute asthma. Respiration 1987; 52: 19 Dewar AL, Stewart A, Cogswell JJ, Connett GJ. A randomised controlled trial to assess the relative benefits of large Volume 25 Mansel JK, Stogner SW, Norman JR. Face-mask CPAP and spacers and nebulisers to treat acute asthma in hospital. Arch Dis sodium bicarbonate infusion in acute severe asthma and metabolic 20 Leversha AM, Campanella SG, Aickin RP, Asher MI. Costs and 26 Vilianis G, Piazza L, Bobo D, Hellmann F, Coaloa M, Bracco G. effectiveness of spacer versus nebulizer in young children with CPAP with face mask in severe asthma. Description of a clinical moderate and severe acute asthma. J Pediatr 2000; 136: 497–502.
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21 Parameswaran K, Belda J, Rowe BH. Addition of intravenous aminophylline to beta2-agonists in adults with acute asthma. Cochrane Database Syst Rev 2000; 3: CD002742.
Internal Medicine Journal 2003; 33: 406–413
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