Break vicious cycle of repeat asthma visits

Don’t send patients home without a plan

Giving asthmatic patients inhaled corticosteroids reduces return visits to the ED and improves quality of life, but most EDs don’t do this, according to a just-published study.1

Patients with persistent asthma, whether mild, moderate, or severe, should be started on daily inhaled corticosteroids as the preferred treatment, says Nina M. Fielden, MSN, RN, CEN, clinical nurse specialist for the ED at Cleveland Clinic Foundation. "This includes children, as the benefits of the steroids far outweigh the potential but small risk of delayed growth," she says. (See the ED’s tool for classifying asthma symptoms.)

Infants and young children who have more than three wheezing episodes in the previous year that lasted longer than one day and affected sleep and who have risk factors for asthma should be started on inhaled corticosteroids, adds Fielden.

"Alternative treatments for adults and children include a leukotriene modifier," she adds.

To improve care of asthma and prevent return visits, do the following:

• Use a protocol.

At St. Joseph Medical Center in Towson, MD, ED nurses initiate a protocol for patients who need bronchodilator therapy. Nurses assess the patient’s respiratory rate, pulse oximetry and lung sounds, and determine if the patient could benefit from a nebulizer treatment. If so, the respiratory therapist is called to assess the patient, and nebulizer treatments are given from a predetermined set of standing orders.

The protocol lists criteria for mild, moderate, and severe presentations, based on respiratory rate, pulse oximetry, and whether the patient is retracting. "They can give one to three treatments or start a continuous nebulizer if the patient warrants," says Vicki Blucher, RN, BSN, CEN, clinical educator for the ED.

Because the physician doesn’t need to see the patient before the protocol is initiated, treatment is expedited, with about 10 minutes per patient saved, she says.

At Hospital of the University of Pennsylvania in Philadelphia, most asthma patients are given an immediate nebulizer treatment of albuterol and atrovent at triage, says Michelle Langrehr, RN, MSN, CRNP, ED nurse. "Soon after being evaluated, they are given an oral dose of prednisone," she says. "If patients improve after three nebulizer treatments and oral steroids, they are discharged home to follow up with their primary care doctor, usually with an albuterol metered dose inhaler and oral steroids."

If patients do not improve after three treatments, with no improvement in symptoms and continued decreased pulse oximetry and peak flow, they usually are admitted, says Langrehr.

• Give patients an asthma management plan.

"There is evidence that using an Asthma Action Plan in asthma self-management can reduce ED visits and improve lung function, says Fielden.

At Cleveland Clinic’s ED, all asthma patients are sent home with an Asthma Action Plan, which includes a list of daily, rescue, and emergency medications and peak flow monitoring information. "We send them home with an inhaler and a peak flow meter if they don’t already have one," she says. "We also send them home on inhaled steroids if they currently aren’t on them."

The ED has more than 30 patient education handouts to give asthma patients on topics including asthma medications, how to use an inhaler, how to use a peak flow meter, asthma triggers, resources, exercise and asthma, school and asthma, and a daily asthma diary to keep track of peak flow readings, medications, and symptoms.

"If they do not have a pulmonary physician, an appointment is made for them with one, either pediatric or adult," Fielden says.

While treating a 34-year-old woman who reported having bad asthma attacks for two days, a nurse at Langrehr’s ED was able to identify her trigger for asthma flare-ups, which was upper respiratory infections. "The nurse reviewed with the patient how to use her metered dose inhaler and provided her with a spacer, which she had not used before," says Langrehr.

The patient received three nebulizer treatments and oral prednisone and her peak flow increased from 200 to 400 upon discharge, she reports.

• Use BiPAP on asthma patients instead of intubating, if possible.

Research shows that using bilevel positive airway pressure (BiPAP) in severe asthmatic patients can alleviate the attack quicker, improve lung function, and significantly reduce the need for hospitalization.2

At Cleveland Clinic’s ED, BiPAP is used to prevent an intubation and possible intensive care unit admission as a result, says Fielden. "We use BiPAP as a first-line treatment for patients in acute respiratory failure if they are conscious," she says. "Nebulized bronchodilators and steroids can be given via BiPAP as well."

When using BiPAP, nurses should assess heart and respiratory rate, pulse oximetry, and arterial blood gases to determine if respiratory failure is improving or worsening, and assess the patient’s level of consciousness, says Fielden.

"Patients may require intubation if they cannot maintain consciousness," she says. "Watch for signs of tiring out such as accessory muscle use and whether they coordinate their respiratory effort with the ventilator."


  1. Cydulka RK, Tamayo-Sarver JH, Wolf C, et al. Inadequate follow-up controller medications among patients with asthma who visit the emergency department. Ann Emerg Med 2005; 46:316-322.
  2. Soroksky A. Stav D. Shpirer I. A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest 2003; 123:1,018-1,025.


For more information on caring for asthma patients in the ED, contact:

  • Vicki Blucher, RN, BSN, CEN, Clinical Educator, Emergency Department, St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204. Telephone: (410) 337-1524. Fax: (410) 337-1118. E-mail:
  • Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, ED, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (216) 444-0153. Fax: (216) 444-9734. E-mal:
  • Michelle Langrehr, RN, MSN, CRNP, Emergency Department, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Telephone: (215) 662-3920. E-mail: