Annals of Emergency Medicine
Volume 45, Issue 3 , Pages 295-298, March 2005

A Call for Expanding the Role of the Emergency Physician in the Care of Patients With Asthma

From the Department of Emergency Medicine, Stony Brook University, Stony Brook, NY (Singer); the Department of Emergency Medicine, Massachusetts General Hosital, Boston, MA (Camargo); the Department of Emergency Medicine, University of Rochester School of Medicine, Pittsford, NY (Lampell); the Department of Emergency Medicine, Washington University, St. Louis, MO (Lewis); the Department of Emergency Medicine, Case Western Reserve University, Grosse Pointe Park, MI (Nowak); the Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (Schafermeyer); and the Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI (O'Neil)

published online 06 January 2005.

See Editorial, P. 299.

Article Outline

 

Asthma is a common illness responsible for a large number of emergency department (ED) visits and hospital admissions.1, 2, 3, 4, 5, 6, 7 Recognition of the importance of chronic inflammation in the pathogenesis of asthma has led to evidence-based recommendations for increased use of controller medications, such as inhaled corticosteroids.1, 8, 9, 10, 11, 12

Despite the dissemination of evidence-based guidelines supporting the role of anti-inflammatory agents in the management of chronic asthma, few emergency physicians prescribe these agents at the time of discharge and instead rely on the patient's primary care physician to address those patient needs.13 However, many patients with asthma do not see their primary care physician in a timely manner, and even when presenting to a primary care physician, many eligible patients do not receive inhaled corticosteroids.13 Thus, the emergency physician should strongly consider initiating inhaled corticosteroids at the time of discharge to break the vicious cycle of recurrent ED visits for asthma exacerbation. A brief educational effort aimed at stressing the chronicity of the disease and the need for inhaled corticosteroids, as well as instructions for the proper use of inhalers, should also be made while in the ED.14 These efforts may be especially effective in the ED setting because the patients' receptivity and compliance may be enhanced during the acute event, which presents a unique and often missed “teachable moment.”

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Evidence supporting the role of oral and inhaled corticosteroids in controlling asthma 

There is good evidence that a brief course of oral corticosteroids is effective in improving pulmonary function, reducing the need for hospitalization, reducing mortality, reducing the recurrence rate of asthmatic attacks, and reducing the need for β2-agonist therapy.15, 16 Also, the earlier corticosteroids are given in the acute attack the better the outcome.15, 16 Although the use of oral corticosteroids has been widely adopted by emergency physicians, prescription of inhaled corticosteroids is less widespread.17 Even among ED patients with a primary care physician, inhaled corticosteroids appear to be underused.13

Patients with poorly controlled asthma should be considered for initiation of inhaled corticosteroids, in addition to a brief course of oral corticosteroids, to reduce the frequency and severity of future exacerbations.1, 8 From a practical standpoint, the emergency physician can use the “rules of two” to determine whether the patient's asthma is well controlled or not: use of quick-relief inhalers more than 2 times per week, awakening at night with an asthma attack 2 times per month, or use of more than 2 quick-relief inhalers per year all suggest poor control.18

There is a large body of evidence demonstrating that use of inhaled corticosteroids improves outcomes in patients with asthma.19 Randomized controlled trials have demonstrated that inhaled corticosteroids increase lung function,20 decrease airway hyperresponsiveness,21 reduce the need for rescue bronchodilators, 22 and improve asthma symptoms compared with treatment with a placebo.19, 20, 21, 22 A large, Canadian, population-based cohort involving more than 30,000 individuals with asthma found that regular use of inhaled corticosteroids was associated with a decreased risk of asthma death (adjusted rate ratio 0.79; 95% confidence interval [CI] 0.65 to 0.97).23 In addition to its beneficial effects in chronic asthma, inhaled corticosteroids may also be beneficial for the subacute management of asthma exacerbations. A randomized controlled trial comparing oral steroids with or without inhaled corticosteroids in ED patients with mild intermittent asthma found that patients discharged from the ED after treatment for acute asthma benefit from added treatment with high-dose inhaled budesonide for 21 days compared with oral corticosteroids alone.24 Another study concluded that inhaled corticosteroids after ED discharge reduced the relapse rate by 45% (95% CI 31% to 56%).25 In contrast, a systematic review concluded that there was insufficient evidence that inhaled corticosteroids therapy alone is as effective as oral corticosteroids when used in patients with mild asthma upon discharge.26 Finally, a recent systematic review concluded that inhaled corticosteroids are the single most effective therapy for adults with asthma.27

The evidence supporting the use of controller medications other than inhaled corticosteroids is less compelling. For example, 2 recent meta-analyses comparing the efficacy of inhaled corticosteroids and leukotriene modifiers concluded that patients treated with inhaled corticosteroids had fewer asthma-related hospitalizations and ED visits and lower total asthma-related health care costs than patients treated with leukotriene modifiers.28, 29 One study even concluded that patients switched from inhaled corticosteroids to leukotriene modifiers were at 7 times greater risk for an asthma-related hospitalization compared with patients who continued to receive inhaled corticosteroids.30

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Evidence supporting educational interventions in the ED 

Although the evidence supporting educational efforts in the ED is less compelling than the evidence in favor of initiation of inhaled corticosteroids, the risk-benefit ratio for educational efforts in the ED is favorable. Although time consuming, there is little potential harm in educating ED patients with asthma. Additionally, several studies suggest that asthma education in the ED may decrease future ED visits.31, 32 One such program included topics such as prevention, self-monitoring, and demonstration of correct inhaler technique.31 A program using an ED nurse educator led to reduced symptoms, improved lung function, less time off work, and fewer consultations with health professionals.32 An earlier study also demonstrated that verbal education in the ED by a nurse with a personal history of asthma was effective in reducing subsequent ED visits.33

Despite some evidence that a written action plan reduces asthma hospitalizations,34 most adult patients hospitalized for asthma do not receive such action plans.35 Additionally, studies have shown that even with education, noncompliance and poor inhaler technique are common.36

Although the National Institutes of Health guidelines stress the importance of reinforcing asthma teaching at every asthma encounter (including ED visits), few EDs provide such teaching.37 Many barriers exist that make it difficult to provide effective education in the ED. Major challenges include the allocation of adequate staff time for patient education, adjustment of content to meet individual patients' needs, and the assessment of learners' comprehension. An important constraint is the lack of reimbursement for patient education.38, 39 However, efforts to obtain reimbursement for asthma education are ongoing.40

In general, most asthma education programs rely on respiratory therapists and nursing staff to teach patients. Most sites use demonstrations and written materials in their educational sessions. Multimedia instructional programs can complement one-on-one education by health professionals, and the Internet constitutes an affordable instructional medium that can help overcome some of the barriers to delivering effective patient education.37, 38, 39, 41 A recent study shows that supplementing traditional verbal and asthma printed education with an interactive multimedia asthma educational program can result in increased asthma knowledge, reduced asthma morbidity, and reduced ED costs.38 The program was implemented during typical waiting periods in a pediatric clinical setting and demonstrated that the multimedia instructional program can be incorporated into the visit without disruption of patient flow. Several multimedia instructional programs designed as games for pediatric asthma have been tested. All 4 programs reported an increase in asthma-related knowledge, and 2 studies showed a reduction in ED visits.42, 43, 44, 45, 46

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Why ME? Why in the ED? The case for initiating inhaled corticosteroids in the ED 

With the continued increase in the prevalence of asthma and the difficulty many of these patients have in accessing primary care and obtaining additional health education, it is important that emergency physicians help to address these important patient needs. Some emergency physicians are reluctant to prescribe medications for chronic illnesses. The reasons for this are multiple, not the least of which is the concern for adverse events and lack of adequate follow-up. For example, initiation of medications for the treatment of hyperglycemia or hypertension without adequate follow-up could potentially result in reductions in the glucose and blood pressure levels. Asthma is unique among chronic illnesses in that initiation of inhaled corticosteroids is safe and associated with very few potential adverse outcomes. Even if patients fail to follow up with their primary care physician, it is unlikely that inhaled corticosteroids will be harmful. On the other hand, early initiation of inhaled corticosteroids at the time of ED discharge ensures that the patient is prescribed an effective controller medication.

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Bridging the gap between emergency physicians, community physicians, and asthma specialists 

National Institutes of Health guidelines recommend considering referral to an asthma specialist for consultation for all patients discharged from the ED.1 This is based on studies that reported reduced rates of subsequent ED visits after referral to a specialist or an asthma clinic.46, 47 Patients with moderate to severe persistent asthma, as well as those with hard to control symptoms (especially in the presence of comorbidities), should be considered for referral to an asthma specialist. Physicians at many academic and nonacademic institutions have partnered to form asthma management coalitions that help bridge the gap between emergency physicians, primary care physicians, and asthma specialists. These partnerships can help define common practice guidelines, including indications for referral, on the basis of national guidelines.1, 8

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Summary and recommendations 

Most patients with asthma presenting to the ED have poorly controlled asthma. Because inhaled corticosteroids are effective, simple, and safe, and because most patients with asthma do not see their primary care physician in a timely manner, emergency physicians should strongly consider initiating this therapy on ED discharge for patients with poorly controlled asthma. ED visits provide an ideal opportunity for asthma patient education. Patients with particularly problematic or recalcitrant disease should be referred to an asthma specialist.

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We thank the following individuals who participated in manuscript preparation and review: Rita Cydulka, MD, MS; David McClellan, MD; Regan Schwartz, MD; Thomas Terndrup, MD; and Michael Wainscott, MD.

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References 

  1. Second Expert Panel on the Management of Asthma. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1997;NIH Publication No. 97-4051
  2. Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma—United States, 1980-1999. MMWR Surveill Summ. 2002;51(1):1–13
  3. Hartert TV, Peebles RS. Epidemiology of asthma: the year in review. Curr Opin Pulm Med. 2000;6:4–9
  4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Advance data from vital and health statistics; No. 335. Hyattsville, MD: National Center for Health Statistics; 2003;
  5. Weber EJ, Silverman RA, Callaham ML, et al. A prospective multicenter study of factors associated with hospital admission among adults with acute asthma. Am J Med. 2002;113:371–378
  6. Emerman CL, Cydulka RK, Crain EF, et al. Prospective multicenter study of relapse following treatment for acute asthma among children presenting to the emergency department. J Pediatrics. 2001;138:318–324
  7. Pollack CV, Pollack ES, Baren JM, et al. A prospective multicenter study of patient factors associated with hospital admission from the emergency department among children with acute asthma. Arch Pediatr Adolesc Med. 2002;156:934–940
  8. Executive Summary of the NAEPP Expert Panel Report. Guidelines for the diagnosis and management of asthma—update on selected topics 2002. Bethesda, MD: National Institutes of Health; 2002;NIH Publication No. 02-5075
  9. National Asthma Council . Asthma Management Handbook. 5th ed.. Melbourne, Victoria, Australia: National Asthma Campaign; 2002;
  10. Anonymous . British guidelines on the management of asthma. Thorax. 2003;58(Suppl):i1–i94
  11. Boulet LP, Becker A, Berube D, et al. Canadian asthma consensus report, 1999. CMAJ. 1999;161(11 Suppl):S1–S72
  12. Global Initiative for Asthma . Global Strategy for Asthma Management and Prevention. Bethesda, MD: National Heart, Lung and Blood Institute; 2002;NIH Publication No. 02–3659
  13. Singh AK, Woodruff PG, Ritz RH, et al. Inhaled corticosteroids for asthma: are ED visits a missed opportunity for prevention?. Am J Emerg Med. 1999;17:144–147
  14. Wei HG, Camargo CA. Patient education in the emergency department. Acad Emerg Med. 2000;7:710–717
  15. Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. (Cochrane Review) In: The Cochrane Library, Issue 2. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
  16. Rowe BH, Spooner C, Ducharme FM, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma. (Cochrane Review) In: The Cochrane Library, Issue 2. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
  17. Camargo CA, Clark S. Emergency department management of acute asthma between 1996-2001: potential impact of the 1997 NAEPP guidelines. [abstract] J Allergy Clin Immunol. 2002;109(Suppl):S156
  18. National Heart, Lung, and Blood Institute . Executive Summary of Expert Panel Report 2: guidelines for the diagnosis and management of asthma—update on selected topics 2002. Bethesda, MD: National Institutes of Health; 2002;NIH Publication No. 02-5075
  19. Barnes PJ. Inhaled corticosteroids for asthma. N Engl J Med. 1995;332:868–875
  20. Dahl R, Lunback E, Malo JL, et al. A dose-ranging study of fluticasone propionate in adult patients with moderate asthma. Chest. 1993;104:1352–1358
  21. Kertstjens HA, Brand PL, Hughes MD, et al. A comparison of bronchodilator therapy with or without inhaled corticosteroid therapy for obstructive airways disease: Dutch Chronic Non-Specific Lung Disease Study Group. N Engl J Med. 1992;327:1413–1419
  22. Lorentzson S, Boe J, Eriksson G, et al. Use of inhaled corticosteroids in patients with mild asthma. Thorax. 1990;45:733–735
  23. Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the long term prevention of death from asthma. N Engl J Med. 2000;343:332–336
  24. Rowe BH, Bota GW, Fabris L, et al. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department. JAMA. 1999;281:2119–2126
  25. Sin DD, Man P. Low-dose inhaled corticosteroid therapy and risk of emergency department visits for asthma. Arch Intern Med. 2002;162:1591–1595
  26. Edmonds ML, Camargo CA, Brenner BE, et al. Inhaled steroids for acute asthma following emergency department discharge. (Cochrane Review) In: The Cochrane Library, Issue 3. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
  27. Sin DD, Man J, Sharpe H, et al. Pharmacological management to reduce exacerbations in adults with asthma: a systematic review and meta-analysis. JAMA. 2004;292:367–376
  28. Halpern MT, Khan ZM, Stanford RH, et al. Asthma: resource use and costs for inhaled corticosteroids vs. leukotriene modifier treatment—a meta-analysis. J Fam Pract. 2003;52:382–389
  29. Ng D, Di Salvio F, Hicks G. Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. (Cochrane Review) In: The Cochrane Library, Issue 3. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
  30. Stempel DA, Pinto L, Stanford RH. The risk of hospitalization in patients with asthma switched from an inhaled corticosteroid to a leukotriene receptor antagonist. J Allergy Clin Immunol. 2002;110:39–41
  31. Kelso TM, Self TH, Rumbak MJ, et al. Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics. Am J Emerg Med. 1995;13:632–637
  32. Levy ML, Robb M, Allen J, et al. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respir Med. 2000;94:900–908
  33. Maiman LA, Green LW, Gibson G, et al. Education for self-treatment by adult asthmatics. JAMA. 1979;241:1919–1922
  34. Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma. In: The Cochrane Library, Issue 3. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
  35. Hartert TV, Windom HH, Peebles RS, et al. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100:386–394
  36. Shrestha RI, Du Toit D, Jordaan E, et al. Metered-dose inhaler technique of patients in an urban ED: prevalence of incorrect technique and attempt at education. Am J Emerg Med. 1996;14:380–384
  37. Edmond S, Reed C, Graff LG, et al. Asthma education in the emergency department. Ann Emerg Med. 2000;36:204–211
  38. Krishna S, Francisco B, Balas A, et al. Internet enabled interactive multimedia asthma education program: a randomized trial. Pediatrics. 2003;111:503–510
  39. Peterson M, Strommer I, Dayton C. Asthma patient education: current utilization in pulmonary training programs. J Asthma. 2001;38:261–267
  40. National Asthma Educator Certification Board. Available at: http://www.naecb.org/CBR/. Accessed August 26, 2004.
  41. Krishna S, Balas A, Spencer D, et al. Clinical trials of interactive computerized patient education: implications for family practice. J Fam Pract. 1997;45:25–33
  42. Yawn BP, Algatt-Bergstrom PJ, Yawn RA, et al. An in-school CD-ROM asthma education program. J Sch Health. 2000;70:153–159
  43. Rubin D, Bauman L, Lauby J. The relationship between knowledge and reported behavior in childhood asthma. J Dev Behavioral Pediatrics. 1989;10:307–312
  44. Bartholomew LK, Gold RS, Parcel GS, et al. Watch, discover, think, and act: evolution of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns. 2000;39:269–280
  45. Homer C, Susskind O, Alpert HR, et al. An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Pediatrics. 2000;106:210–215
  46. Zeiger RS, Heller S, Mellon MH, et al. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol. 1991;87:1160–1168
  47. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med. 1990;112:864–867

 Funding and support: All of the authors have received honoraria from the GSK Respiratory Institute (Research Triangle Park, NC) for their participation in a National Advisory Board on the ED Care of Asthma. Dr. Camargo has received honoraria from Merck & Co., Inc. (Whitehouse Station, NJ), AstraZeneca LP (Wilmington, DE), Aventis (Bridgewater, NJ), Boehringer-Ingelheim Corporation (Ridgefield, CT), Dey LP (Napa, CA), Forest Inc. (St. Louis, MO), Genentech Inc. (San Francisco, CA), Novartis (Cambridge, MA), Schering-Plough (Kenilworth, NJ), and Sepracor Inc. (Marlborough, MA).Reprints not available from the authors.

PII: S0196-0644(04)01476-3

doi:10.1016/j.annemergmed.2004.09.024

Annals of Emergency Medicine
Volume 45, Issue 3 , Pages 295-298, March 2005

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