eMedicine Specialties > Emergency Medicine > Pulmonary

Asthma: Follow-up

Author: Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Contributor Information and Disclosures

Updated: Jul 2, 2009

Follow-up

Further Outpatient Care

  • In general, the patient may be discharged from the hospital if the peak expiratory flow (PEF) or the patient's personal best expiratory flow rate is 70% or more of predicted rate and if symptoms are minimal or absent. It is important during therapy that the patient's predicted PEFR is based on the gender, height, and age of the patient.
  • Patients who have mild symptoms but have PEF of 50-69% of predicted or personal best could be considered for discharge if high-risk factors for relapse are not present. However, patients with PEF of 50-69% of predicted or personal best who may be unable to obtain medications for psychiatric or socioeconomic reasons have a lower admission threshold.
  • Consider referral to an asthma specialist, as consultation and guidance have been shown to reduce the risk of future ED visits.
    • ED staff should emphasize the importance of follow-up care after the ED visit for education about asthma and for initiation of environmental and pharmacologic interventions that can prevent future exacerbations and otherwise improve the patient's quality of life.
    • Asthma education efforts after the ED visit usually can address a much larger number of issues than during the actual ED visit, when teaching needs to be extremely focused. Nevertheless, a preventive message should be delivered at all clinical encounters.
    • At the more comprehensive post-ED visit session—in the allergist or pulmonologist office, or in special asthma programs set up by the ED or primary care practice—potential topics include asthma triggers (viral URIs, allergens such as cats), the proper use of inhaler medications, the use of spacers and value of oral rinsing after use of inhaled corticosteroids, and the significance of nocturnal exacerbations (10-fold more asthmatics are intubated at night). The patient should have a written action plan telling him or her what to do in response to certain symptoms or certain PEF values. Many educational sessions are based on the action plan and its use.
    • ED staff also should emphasize the importance of not running out of medications or even running low on medications (note MDI only reliable for number of actuations listed on the canister; almost no patient counts the number of actuations, and floating techniques for canister are unreliable and no longer recommended). Tell the patient to keep an extra canister, especially of inhaled beta-agonists.
  • In general, discharging a patient on effective inhaled corticosteroids (eg, medium-dose budesonide or fluticasone) is beneficial. Most ED patients will not follow up with a primary care provider (PCP) in the weeks after the ED visit and will not receive inhaled corticosteroids unless it is started at ED or hospital discharge.

Complications

  • Complications of severe asthma include the following:
    • Respiratory distress/arrest
    • Death

Prognosis

  • The prognosis is excellent if compliant with proper therapies.
  • Risk factors for death from asthma include labile asthma, history of more than 3 ED visits or more than 2 hospitalizations, either ICU admission or endotracheal intubation within the past year, recent withdrawal from corticosteroids, current use of systemic corticosteroids, comorbid conditions (eg, heart disease, psychiatric disease, drug abuse), and concomitant adverse socioeconomic conditions.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Presumptive diagnosis of asthma, especially new onset - Asthma may actually be a misdiagnosis and may reflect CHF, myocarditis, multiple pulmonary emboli, surreptitious vocal cord dysfunction, or panic disorder/hyperventilation.
  • Not obtaining PEFR on a patient and discharging the patient below 60-70% of his or her predicted
 


More on Asthma

Overview: Asthma
Differential Diagnoses & Workup: Asthma
Treatment & Medication: Asthma
Follow-up: Asthma
References
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Further Reading

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Keywords

asthma, asthma attack, asthma symptoms, asthma treatment, asthma evaluation, asthma assessment, asthma causes, airway obstruction, asthma management, asthma exacerbation, airway inflammation, bronchial asthma, asthma triggers, dyspnea, wheezing, shortness of breath, asthmatic, reactive airway disease, wheeze, bronchiolitis, acute asthma, asthma prevention, allergies, bronchial airways, bronchial airway narrowing, inflammation of the bronchi, bronchial smooth muscle contraction, airway narrowing, noisy breathing, difficult breathing, difficulty breathing, inhalers, lung disease

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Contributor Information and Disclosures

Author

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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