Updated asthma guidelines are here: Are you giving the right medications?

Emergency departments need to update their protocols

When a 35-year-old woman came to the emergency department (ED) at MetroHealth Medical Center in Cleveland for a minor laceration, she had trouble speaking in full sentences due to her asthma. "I asked her about her exposures, daily symptoms, and what she uses for her asthma," recalls Rita K. Cydulka, MD, MS, associate professor in the department of emergency medicine at Cleveland-based Case Western Reserve University School of Medicine and the ED physician who cared for the patient.

She discovered that although the woman had severe persistent asthma, she was using "rescue" medications such as short-acting beta2-agonists many times a day instead of using "controller" medications such as inhaled corticosteroids on a regular basis. "I spent a lot of time talking to her about her disease, prescribed her a short burst of oral steroids, a few days of rescue beta2-agonists and both a long-acting beta agonist and a high-dose inhaled corticosteroid, and advised that she see an asthma specialist," she says.

Months later, the patient wrote Cydulka to say that the treatment plan had completely changed her life. "For the first time in years, she is able to enjoy activities that she hadn’t participated for in years, such as walking with her husband, because she thought that people with asthma just couldn’t do those things," she says.

That scenario illustrates the dramatic impact that appropriate interventions and education can have on asthma patients in the ED, says Cydulka. You should change your practice to reflect newly updated guidelines from the Bethesda, MD-based National Asthma Education and Prevention Program’s (NAEPP) Expert Panel for the diagnosis and management of asthma, Cydulka advises. (See Stepwise Approach for Managing Asthma.) "Protocols should be updated to ensure proper evaluation, education, and treatment of asthmatics in the ED," she says.

Here are key changes in the guidelines:

• Inhaled corticosteroids now are recommended for any type of persistent asthma, even mild. There is a change in the guidelines for treating children with mild or moderate persistent asthma, says Cydulka. "They now recommend starting them on inhaled corticosteroids as a controller medication," she explains.

According to Barbara Weintraub, RN, MSN, MPH, CEN, coordinator for pediatric emergency services at Northwest Community Hospital in Arlington Heights, IL, this is the single most important change in the guidelines. Previously, the only patients discharged with steroids were moderate to severe persistent asthmatics who were discharged with oral prednisone, prelone, or orapred, she explains. "The new guidelines suggest that patients be discharged with both oral and inhaled steroids, begin the inhaled steroids immediately, and transition off the oral steroids within a week or so," says Weintraub.

Cydulka adds that this advice now applies to infants and children who have had more than three episodes of wheezing in the past year that have lasted more than one day and have affected sleep, and who have risk factors for the development of asthma, such as parental history of asthma or atopic dermatitis, wheezing apart from colds, peripheral blood eosinophilia, or allergic rhinitis.

The patients should stay on the inhaled corticosteroids until they have been relapse-free for three to six months and have made it through their "bad" season, if their asthma has a seasonal component, Weintraub advises. "This will mean children will be on steroids for longer periods of time and will require more follow-up care," she adds.

Weintraub recommends updating your ED protocols to reflect this change in therapy, and she points to studies demonstrating that patients immediately placed on inhaled steroids had much better long-term control, fewer relapses, and better overall lung function months later. Previously, many EDs discharged patients without steroids with instructions to follow up later. "The feeling was that the primary care physician should decide whether inhaled steroids were indicated or not," she says.

The updated guidelines indicate that patients with persistent asthma always should be discharged from the ED with inhaled steroids, says Weintraub. "We should not be discharging patients from the ED without this intervention," she underscores.

To address concerns about adverse effects, the NAEPP’s Expert Panel reviewed data on the effects of inhaled steroids used in children on vertical growth, bone mineral density, occular toxicity, and suppression of the hypothalamus pituitary adrenal axis, notes Karen Huss, RN, DNSc, APRN-BC, FAAN, associate professor at Johns Hopkins University School of Nursing in Baltimore. "Strong evidence supports that the use of inhaled corticosteroids at recommended doses does not have frequent, clinically significant, or irreversible adverse effects on any of the outcomes reviewed," she says.

She explains that inhaled corticosteroids are shown to improve health outcomes for children with mild or moderate persistent asthma, although there is a small risk of delayed growth. "We need to reassure parents that the studies showed that there was no effect on vertical growth or on bone density from these therapies, which is a big difference from long-term oral steroids," says Weintraub.

• Long-acting inhaled beta2-agonists in combination with low to medium doses of inhaled corticosteroids are recommended for patients with moderate persistent asthma. There is a change in the recommendation for moderate persistent asthma, says Cydulka. The preferred treatment for patients older than age 5 is the addition of long-acting beta2-agonists to low-to-medium doses of inhaled corticosteroids, she says.

"In the updated guidelines, the use of combination therapy is emphasized even more than before," says Huss. Adjunctive therapy combinations have not been studied in children younger than 5, Huss cautions. "In this age group, there are two options: either low-dose inhaled corticosteroids and long-acting inhaled beta2-agonists, or medium-dose inhaled corticosteroids," she says. Long-term controller therapy still is strongly recommended for patients of any age with persistent asthma, whether mild, moderate, or severe, says Huss. "As previously, the medications required to maintain long-term control is different depending on the severity," she adds.

The severity of the patient’s asthma should be assessed. When an asthmatic woman was carried into Cydulka’s ED by her husband, she was cyanotic and near apneic. Upon arrival in the ED, she was intubated and ventilated, given continuous nebulized albuterol through endotracheal tube, several ipratropium nebulizer treatments through endotracheal tube, intravenous solumedrol, intravenous magnesium, and admitted to the intensive care unit, says Cydulka. "She was extubated within four hours and sent home within 24 hours after consulting with our asthma specialist," she says.

Cydulka says cases such as this one illustrate that patients may need significant education on managing and evaluating their own asthma, and this need may be revealed only when a life-threatening exacerbation brings them to the ED. Your goal should be to prevent such incidents from occurring, she says. "I think that the patient’s day-to-day existence with asthma is often overlooked in a busy ED," she says.

Cydulka recommends asking asthma patients:

— if they have symptoms every day;

— if they cough daily;

— if they are awakened at night because of their asthma;

— if they are unable to participate in activities because of their asthma.

Cydulka suggests using the frequency of each of these as a guide to diagnose the severity of the patient’s asthma and develop treatment plans. (See Respiratory Assessment Flow Sheet.) "By familiarizing yourself with current guidelines and management plans for asthmatics, you can stop thinking of asthma as an acute, episodic disease and start thinking of it as a chronic condition that requires daily medication to control," she says.

Sources and resource

For more information about the updated asthma guidelines, contact:

Rita K. Cydulka, MD, MS, Department of Emergency Medicine, Room BG3-68, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109. Telephone: (216) 778-2864. Fax: (216) 778-5349. E-mail: rcydulka@metrohealth.org.

Karen Huss, RN, DNSc, APRN-BC, FAAN, Associate Professor, Johns Hopkins University School of Nursing, 525 N. Wolfe St., Room 416, Baltimore, MD 21205. Telephone: (410) 614-5296. Fax: (410) 955-7463. E-mail: khuss@son.jhmi.edu.

Barbara Weintraub, RN, MSN, MPH, CEN, Coordinator, Pediatric Emergency Services, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: bweintraub@nch.org.

The Executive Summary of the NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma — Update on Selected Topics 2002 (NIH Publication No. 02-5075) can be downloaded at no charge at www.nhlbi.nih.gov/guidelines/asthma/index.htm. Print copies of the executive summary and the full report (which also will be accessible on-line) will be available in September for $7.50 each for up to 24 sets; $6.36 each for 25-99 sets; and $6 each for 100 or more sets. Prices do not include shipping and handling. To order, contact:

National Heart, Lung, and Blood Institute Information Center, P.O. Box 30105, Bethesda, MD 20824-0105. Telephone: (301) 592-8573. Fax: (301) 592-8563. E-mail: nhlbiinfo@rover.nhlbi.nih.gov. The on-line catalog is available at http://emall.nhlbihin.net.