Updated asthma guidelines call for new ED protocols

For the first time in a decade, the National Asthma Education and Prevention Program has issued updated asthma guidelines, many of which will affect your ED.

At Massachusetts General Hospital in Boston, ED nurses already follow most of the new recommendations, including the selective use of adjunct treatments such as intravenous magnesium and heliox, says Carlos A. Camargo, MD, DrPH, an ED physician at the hospital and member of the panel that wrote the asthma guidelines. However, using peak flow meters to obtain an objective measure of acute asthma severity is an area that "always needs attention," he says. "I think this one item really needs a local champion, which could definitely be an ED nurse," he says. There is often an inability to find peak flow meters in a busy ED, notes Camargo, and ensuring availability of the meters and their proper use could be part of the champion's role.

Physician history not always correct

Lack of peak flow assessment is due partly to the mistaken belief that the clinician knows the exacerbation severity by history and exam alone, he says. "Studies show that physician assessments are not always accurate," Camargo says.

There also is a misconception that peak flow must be checked in "everyone or no one," says Camargo. "The new guidelines recognize that peak flow measurement should not be done in patients with obvious respiratory extremis," he says. "But even in these patients, later, when they improve, there is value to checking peak flow to assess severity and monitor further improvements."

Massachusetts General's ED has a standing order for the triage nurse to give albuterol to patients with acute asthma, reports Camargo. "This results in the onset of b-agonist treatment in less than 10 minutes for the vast majority of patients," he says. "The staff are also very attuned to use of systemic corticosteroids, with most getting this treatment in the first half-hour of the visit."

How your ED will be affected

Here are key changes in the asthma guidelines that will affect your ED:

• New doses of medications are recommended.

For treatment of exacerbations, levalbuterol is added as a short-acting b-agonist treatment. This is an option to albuterol, says Susan L. Janson, DNSc, RN, ANP, AE-C, FAAN, a nationally certified asthma educator and member of the panel that wrote the asthma guidelines. "The addition of ipratropium to albuterol still is recommended in the ED, but no longer recommended during hospitalization," she says.

Reduced doses and frequency of administration of oral corticosteroids are now recommended in severe exacerbations. In addition, magnesium sulfate or heliox can be considered for severe exacerbation, and inhaled corticosteroids can be considered for patients being discharged.

The new recommended doses of oral corticosteroids including prednisone, prednisolone, methlyprednisolone in the ED are:

— Child dose (< 12 yrs): 1 mg/kg in two divided doses (maximum = 60 mg/day) until peak expiratory flow (PEF) is 70% of predicted or personal best;

— Adult dose: 40-80 mg/day in one or two divided doses until PEF reaches 70% of predicted or personal best.

• The guidelines note the limited value of pulmonary function measures in very severe exacerbations.

The previous guidelines suggested that everyone should get an initial peak flow reading, but clearly that would be inappropriate in the sickest of patients, says Camargo. "The 2007 guidelines clarify this point."

If the patient is in obvious extremis, treatment should not be delayed in order to measure pulmonary function, says Janson. "However, serial pulmonary function measurements should be started within one hour of initial treatment," she says.

• For assessment of hypoxemia, there is renewed emphasis on monitoring oxygen saturation serially.

"You should not rely on a single spot check to assess severity," says Camargo. "The key is serial testing. In some places, this is current practice; in others, it is not."

Emergency nurses should measure oxygen saturation with pulse oximetry continuously or at frequent intervals in all patients, but especially in infants with asthma exacerbation, says Janson.

• There are different cut points of PEF or forced expiratory volume in 1 second (FEV1).

The guidelines reinstate the 1991 cut points of FEV or PEF to indicate the goal for discharge from the urgent care or emergency setting (≥ 70% predicted FEV1 or PEF), for patients for whom response to therapy is incomplete, and for patients who usually require continued treatment in the ED (40%-69% predicted).

"These cut points differ from those used to determine long-term asthma control and treatments, thus underscoring the distinction between acute and chronic asthma management," says Janson.

Sources/Resource

For more information about the updated asthma guidelines, contact:

  • Carlos A. Camargo, MD, DrPH, Director, EMNet Coordinating Center, Massachusetts General Hospital, 326 Cambridge St., Suite 410, Boston, MA 02114. Phone: (617) 726-5276. E-mail: ccamargo@partners.org.
  • Susan L. Janson, DNSc, RN, ANP, AE-C, FAAN, Professor of Nursing and Medicine, University of California, San Francisco, San Francisco, CA 94143-0608. Phone: (415) 476-5282 Fax: (415) 476-6042. E-mail: susan.janson@nursing.ucsf.edu.

The Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma — Full Report, 2007 can be downloaded at no charge at www.nhlbi.nih.gov. Or to obtain a free single copy, contact The National Asthma Education and Prevention Program, NHLBI Health Information Center, P.O. Box 30105, Bethesda, MD 20824-0105. Phone: (301) 592-8573. Fax: (240) 629-3246.