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Managing outpatient asthma exacerbations

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Abstract

Asthma is a chronic inflammatory disease that renders individuals prone to acute exacerbations. Several allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, prevention of relapses, and forestalling future episodes. A written asthma home-management plan is essential to minimize the severity of exacerbations. Short-acting β-agonists, oxygen, and corticosteroids are fundamental to early intervention in acute asthma exacerbation. Anticholinergics and magnesium sulfate can help nonresponders. Newer agents such as levalbuterol and long-acting β-agonists might be future additions to our armamentarium of drugs to treat acute exacerbations. Initiation or intensification of long-term controller therapy, treatment of co-morbid conditions, and avoidance of possible triggers along with prompt follow-up can help prevent relapses. Listening to patient preferences and concerns to enhance adherence and regular follow-up care can help prevent future episodes.

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References and Recommended Reading

  1. Mannino DM, Homa DM, Akinbami LJ, et al.: Surveillance for asthma-United States, 1980–1999. MMWR 2002, 51:1–14.

    Google Scholar 

  2. Scarfone RJ, Zorc JJ, Capraro GA: Patient self-management of acute asthma: adherence to National Guidelines a decade later. Pediatrics 2001, 108:1332–1338. A prospective questionnaire-based study of 433 children presenting to an emergency department with acute asthma identifying nonadherence to several aspects of the NHLBI guidelines for prevention and home management of asthma exacerbation. Inadequate daily-controller therapy use, peak flow meter use, and no written asthma action plan were some of the problem areas identified.

    Article  PubMed  CAS  Google Scholar 

  3. Warman KL, Silver EJ, McCourt MP, Stein REK: How does home management of asthma exacerbations by parents of innercity children differ from NHLBI guideline recommendations. Pediatrics 1999, 103:422–427.

    Article  PubMed  CAS  Google Scholar 

  4. Green RM, Custovic A, Sanderson G, et al.: Synergism between allergens and viruses and risk of hospital admission with asthma: case-control study. BMJ 2002, 324:1–5.

    Google Scholar 

  5. McFadden ER Jr, Hejal RB: The pathobiology of acute asthma. Clin Chest Med 2000, 21:213–224.

    Article  PubMed  Google Scholar 

  6. Milgrom H, Wood RP II, Ingram D: Respiratory conditions that mimic asthma. Immunol Allergy Clin North Am 1998, 18:113–132.

    Article  Google Scholar 

  7. National Heart, Lung and Blood Institute: National Asthma Education and Prevention Program, Expert Panel Report 2: guidelines for the diagnosis and management of asthma, 1997. NIH Publication No. 97-4051A:42-43.

  8. National Heart, Lung and Blood Institute: NHLBI/WHO workshop report: global strategy for asthma management and prevention. 1995, NIH Publication 96-3659. Revised 2002. p.134–135 Available at www.ginasthma.com.

  9. Idris AH, McDermott MF, Raucci JC, et al.: Emergency department treatment of severe asthma, metered dose inhaler is equivalent in effectiveness to nebulizer. Chest 1993, 103:665–672.

    PubMed  CAS  Google Scholar 

  10. Closa RM, Ceballos JM, Fomez-Papi A, et al.: Efficacy of bronchodilators administered by nebulizers versus spacer devices in infants with acute wheezing. Pediatr Pulmonol 1998, 26:344–348.

    Article  PubMed  CAS  Google Scholar 

  11. Cates CJ, Rowe BH, Bara A: Holding chambers versus nebulizers for beta-agonist treatment of acute asthma. In The Cochrane Database of Systematic Reviews. Issue 2:2002. A systematic review of 21 trials with a total of 880 children and 444 adults finding comparable efficacy of MDI with holding chamber and nebulizer for delivery of β-agonist in acute asthma for several outcomes including hospital admission rates, PEFR/FEV1 improvement, and length of emergency department stay.

  12. Beasley R, Crane J, Buress C: b-agonists: What is the evidence that their use increases the risk of asthma morbidity and mortality? J Allergy Clin Immunol 1999, 103:S18–30. A careful review of β agonists that focuses on the potential for harm from the regular use and overuse of β agonists and the factors involved in increased mortality related to high-dose fenoterol and isoproterenol use.

    Article  Google Scholar 

  13. Templeton AGB, Chapman I, Chilvers E, et al.: Effects of S-salbutamol on isolated human bronchus. Pulm Pharmacol Ther 1998, 11:1–6.

    Article  PubMed  CAS  Google Scholar 

  14. Baramki D, Koester J, Anderson AJ, Borish L: Modulation of T-cell function by (R)- and (S)-isomers of albuterol: anti-inflammatory influences of (R)-isomers are negated in the presence of the (S)-isomer. J Allergy Clin Immunol 2002, 109:449–454.

    Article  PubMed  CAS  Google Scholar 

  15. Cockcroft DW, Davis BE, Swystun VA, et al.: Tolerance to the bronchoprotective effect of _2-agonists: comparison of the enantiomers of salbutamol with racemic salbutamol and placebo. J Allergy Clin Immunol 1999, 103:1049–1053.

    Article  PubMed  CAS  Google Scholar 

  16. Lotvall J, Palmqvist M, Arvidsson P, et al.: The therapeutic ratio of R-albuterol is comparable with that of RS-albuterol in asthmatic patients. J Allergy Clin Immunol 2001, 108:726–731.

    Article  PubMed  CAS  Google Scholar 

  17. Ahrens R, Weinberger M: Levalbuterol and racemic albuterol: Are there therapeutic differences? J Allergy Clin Immunol 2001, 108:681–684. A systematic breakdown of various controversies surrounding Ralbuterol, S-albuterol and the racemic mixture of these two drugs. The authors do not find compelling data to support routine use of Ralbuterol, and they dismiss the potential significance of the accumulation of S-albuterol; however, they identify the need for studies to examine the potential adverse effects of repeated high dosing of racemic albuterol in acute care settings.

    Article  PubMed  CAS  Google Scholar 

  18. Milgrom H, Skoner DP, Bensch G, et al.: Low-dose levalbuterol in children with asthma: safety and efficacy in comparison with placebo and racemic albuterol. J Allergy Clin Immunol 2001, 108:938–945.

    Article  PubMed  CAS  Google Scholar 

  19. Nelson HS, Bensch G, Pleskow WW, et al.: Improved bronchodilation with levalbuterol compared to racemic albuterol in patients with asthma. J Allergy Clin Immunol 1998, 102:943–952.

    Article  PubMed  CAS  Google Scholar 

  20. Selroos O: Formoterol used as needed: clinical effectiveness. Resp Med 2001, 95(suppl B):S17-S20.

    Article  Google Scholar 

  21. Geelhoed GC, Landau LI, LeSouef PN: Evaluation of SaO2 as a predictor of outcome in 280 children presenting with acute asthma. Ann Emerg Med 1994, 23:1236–1241.

    PubMed  CAS  Google Scholar 

  22. Chien JW, Ciufo R, Novak R, et al.: Uncontrolled oxygen administration and respiratory failure in acute asthma. Chest 2000, 117:728–733.

    Article  PubMed  CAS  Google Scholar 

  23. Rowe BH, Spooner C, Ducharme FM, et al.: Early emergency department treatment of acute asthma with systemic corticosteroids. In Cochrane Database of Systematic Reviews. Issue 2:2002.

  24. Ratto D, Alfaro C, Sipsey J, et al.: Are intravenous corticosteroids required in status asthmaticus. JAMA 1988, 260:527–529.

    Article  PubMed  CAS  Google Scholar 

  25. O’Driscoll BR, Karla S, Wison M, et al.: Double blind trial of steroid tapering in acute asthma. Lancet 1993, 341:324–327.

    Article  PubMed  CAS  Google Scholar 

  26. Rowe BH, Spooner CH, Ducharme FM, et al.: Corticosteroids for preventing relapse following acute exacerbations of asthma. In The Cochrane Database of Systematic Reviews. Issue 2:2002.

  27. Rodrigo G, Rodrigo C: Inhaled flunisolide for acute severe asthma. Am J Resp Crit Care Med 1998, 157:698–703.

    PubMed  CAS  Google Scholar 

  28. Volvovitz B, Bentur L, Finkelstein Y, et al.: Effectiveness and safety of inhaled corticosteroids in controlling acute asthma attacks in children who were treated in the emergency department: a controlled comparative study with oral prednisolone. J Allergy Clin Immunol 1998, 102:605–609.

    Article  Google Scholar 

  29. Schuh S, Reisman J, Alshehri M, et al.: A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med 2000, 343:689–694. A double-blind randomized trial of 100 children with acute severe asthma that found a single high dose (2 mg) of inhaled fluticasone propionate to be less effective than 2 mg/kg of prednisone in preventing hospitalizations. This study draws our attention to the need for larger, randomized controlled trials to clarify the role of high-dose ICS in acute asthma management.

    Article  PubMed  CAS  Google Scholar 

  30. Edmonds ML, Camargo Jr CA, Pollack CV Jr, Rowe BH: Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. In The Cochrane Database Systematic Reviews. Issue 2:2002.

  31. Rowe BH, Bota GW, Fabris L, et al.: Inhaled budesonide in addition to oral corticosteroids to prevent relapse following discharge from the emergency department: a randomized controlled trial. JAMA 1999, 281:2119–2126.

    Article  PubMed  CAS  Google Scholar 

  32. Qureshi F, Pestian J, Darius P, Zaritsky A: Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med 1998, 339:1030–1035.

    Article  PubMed  CAS  Google Scholar 

  33. Rodrigo GJ, Rodrigo C: First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med 2000, 161:1862–1868.

    PubMed  CAS  Google Scholar 

  34. Stoodley RG, Aaron SD, Dales RE: The role of ipratropium bromide in the emergency management of acute asthma exacerbation: meta-analysis of randomized clinical trials. Ann Emerg Med 1999, 34:8–18. A meta-analysis of 10 trials involving 1377 patients that found modest benefit without increase in adverse events in the addition of ipratropium bromide to _ agonist during acute asthma in adults.

    Article  PubMed  CAS  Google Scholar 

  35. Rowe BH, Bretzlaff JA, Bourdon C, et al.: Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. In The Cochrane Database of Systematic Reviews. Issue 2:2002.

  36. Parameshwaran K, Belda J, Rowe BH: Addition of intravenous aminophylline to beta2-agonists in adults with acute asthma. In The Cochrane Database of Systematic Reviews. Issue 2:2002.

  37. Travers A, Jones AP, Kelly K, et al.: Intravenous beta2-agonists for acute asthma in the emergency department. In The Cochrane Database of Systematic Reviews. Issue 2:2002.

  38. Rodrigo G, Rodrigo C, Pollack C, Rowe B: Helium-oxygen mixture for non-intubated acute asthma patients. In The Cochrane Database of Systematic Reviews. Issue 2:2002.

  39. Kress JP, Noth I, Gehlbach BK, et al.: The utility of albuterol nebulized with heliox during acute asthma exacerbations. Am J Resp Crit Care Med 2002, 165:1317–1321.

    Article  PubMed  Google Scholar 

  40. Garrett J, Williams S, Wong C, Holdaway D: Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid. Arch Dis Child 1998, 79:12–17.

    Article  PubMed  CAS  Google Scholar 

  41. McFadden ER Jr, Elsanadi N, Dixon L, et al.: Protocol therapy for acute asthma: therapeutic benefits and cost savings. Am J Med 1995, 99:651–661.

    Article  PubMed  Google Scholar 

  42. Shreshta M, Bidadi K, Gourlay S, Hayes J: Continuous versus intermittent albuterol at high and low doses in the treatment of acute severe asthma in adults. Chest 1996, 110:42–47.

    Google Scholar 

  43. Schuh S, Parkin P, Rajan A, et al.: High versus low dose, frequently administered nebulized albuterol in children with severe acute asthma. Pediatrics 1989, 83:513–518.

    PubMed  CAS  Google Scholar 

  44. Emerman CL, Cydulka RK: Factors associated with relapse after emergency department treatment of acute asthma. Ann Emerg Med 1995, 26:6–11.

    Article  PubMed  CAS  Google Scholar 

  45. Emerman CL, Woodruff PG, Cydulka RK, et al.: Prospective multicenter study of relapse following treatment for acute asthma among adults presenting to the emergency department. Chest 1999, 115:919–927. A large, multicenter prospective cohort study with 939 subjects that identified several historical features associated with increased risk of relapse in the 2 weeks following emergency department discharge. History of numerous emergency department/urgent care visits in the past year, several triggers for asthma, longer duration of symptoms (1-7 days), and a home nebulizer were associated with increased relapse rate. PEFR did not predict relapses.

    Article  PubMed  CAS  Google Scholar 

  46. Marquette CH, Saulnier F, Leroy O, et al.: Long term prognosis of near fatal asthma: a 6-year follow-up study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma. Am Rev Resp Dis 1992, 46:76–81.

    Google Scholar 

  47. Magadle R, Berar-Yanay N, Weiner P: The risk of hospitalization and near-fatal and fatal asthma in relation to perception of dyspnea. Chest 2002, 121:329–333. A recent study reiterating that patients with a low perception of dyspnea are at increased risk of emergency department visits, hospitalizations, and near-fatal and fatal asthma episodes.

    Article  PubMed  Google Scholar 

  48. Suissa S, Blais L, Ernst P: Patterns of increasing beta-agonist use and the risk of fatal or near-fatal asthma. Eur Resp J 1994, 7:1602–1609.

    Article  CAS  Google Scholar 

  49. Newman KB, Mason UG, Schmaling KB: Clinical features of vocal cord dysfunction. Am J Resp Crit Care Med 1995, 152:1382–1386.

    PubMed  CAS  Google Scholar 

  50. Wood RP 2nd, Milgrom H: Vocal cord dysfunction. J Allergy Clin Immunol 1996, 98:481–485.

    Article  PubMed  Google Scholar 

  51. Mak H, Johnston P, Abbey H, et al.: Prevalence of asthma and health service utilization of asthmatic children in an inner city. J Allergy Clin Immunol 1982, 70:367–372.

    Article  PubMed  CAS  Google Scholar 

  52. Park CL, Frank AL, Sullivan M, et al.: Influenza vaccination of children during acute asthma exacerbation and concurrent prednisone therapy. Pediatrics 1996, 98(2 pt 1):196–200.

    PubMed  CAS  Google Scholar 

  53. Lieu TA, Quesenberry CP, Capra M, et al.: Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics 1997, 100:334–341.

    Article  PubMed  CAS  Google Scholar 

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Roy, S.R., Milgrom, H. Managing outpatient asthma exacerbations. Curr Allergy Asthma Rep 3, 179–189 (2003). https://doi.org/10.1007/s11882-003-0032-7

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