Internal 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. Abstract
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
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2 Lipworth BJ, Jackson CM, Ziyaie D, Winter JH, Dhillon PD,
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4 Gibson PG, Talbot PI, Hancock J, Hensley MJ. A prospective
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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
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8 Plotnick LH, Ducharme FM. Combined inhaled anticholinergics
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11 Rodrigo G, Rodrigo C, Burschtin O. Ipratropium bromide in
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