Treating
asthma in the emergency department (ED) always involves the potentially difficult decision as to whether to discharge the patient, to continue treatment, or to admit to the hospital. The following are useful guidelines. (1) The duration of the
bronchospasm, frequency of visits, history of previous endotracheal intubation, pulse rate, and accessory muscle use are findings affecting successful discharge from the ED. (2) Patients with peak expiratory flow rate (PEFR) of < 20% and who do not respond to inhalant
therapy, with PEFR values persisting at < 40% of predicted, will require 4 or more days to resolve and should be admitted to the hospital. (3) Patients with a PEFR between 40% and 70% of predicted after initial inhalant
therapy may well be responsive to
steroids in the ED, but an ED will adequately need to care for the patient for 5 to 12 hours while waiting for the onset of action of
glucocorticoids. Discharged with
glucocorticoids, this group has a 6% relapse rate within 10 days of the ED visit. (4) Patients with a PEFR of > or = 70% have a 14% relapse rate after discharge without
glucocorticoids. Other reasons to consider admission are
pneumonia,
barotrauma, lability, prominent psychiatric difficulties, poor access to medications, poor educability, fear of
steroids, patients on
glucocorticoids or those who have recently stopped
glucocorticoids, and evening discharges of patients from the ED, which all predispose to relapses of acute
asthma. To decrease the relapse rate, provocative factors should be reviewed with the patient, as well as access to medication and use of spacers,
inhaler techniques, PEFR meters, self-management plans, and referral to a defined appointment at 24 to 48 hours of the ED visit.