A discharge program to avoid repeat visits.
An 18-year-old male presents to the emergency department due to concerns for worsening asthma. The patient is breathing okay, but has wheezing on lung auscultation and is coughing in the room.
He states his inhaler was empty yesterday from increased use. Then due to school and work, he was unable to get into his PCP for a refill. He has woken up the past two nights due to wheezing and is using his inhaler daily.
The patient said he is having trouble exercising because his breathing gets a lot worse when he is exerting himself, particularly outside running. On review of the patient’s records, he has presented at least two other times in the past few months for similar complaints.
This is a pretty typical presentation of a mild to moderate asthma exacerbation that can be appropriately treated in the ED with a breathing treatment or a few puffs of an inhaler. It’s what we do next however that will determine how well the patient fairs upon discharge.
Review
Before we discuss treatment, a quick review of asthma and asthma severity will help understand disease severity and formulate treatment options. In basic terms, asthma is a complex disease that involves the airway, marked by bronchial wall thickening, edema and secretions. This causes restricted air flow, particularly upon exhalation, leading to wheezing. Often, asthma can be mediated by an allergic reaction or hypersensitivity, but can also be exercise induced.
Exacerbations are classified by the frequency and severity of symptoms. In the ED, we will take care of all of these and the majority will improve with a combination of short acting beta-agonist (SABAs), often albuterol and an antimuscarinic agent (ipratropium) inhaled or nebulized, with the addition of systemic steroids. More severe cases may require escalation of care and admission, but the vast majority will be appropriate for discharge home.
As EM providers, we know how to treat the acute asthma exacerbation, but we can do more to help keep the patient from needing to return. Based on the patients presenting symptoms and course of exacerbations we can use the 2020 GINA guidelines to determine the patients appropriate discharge regimen.
Treatment
Treating asthma exacerbation essentially revolves around attacking secretions, inflammation and if possible, the triggers. Here is a stepwise approach to treating uncomplicated asthma patients that could benefit from an adjustment in their outpatient regimen once they are appropriate for discharge.
Almost all of these treatment options are reasonable and appropriate to be started in the emergency department. The exception may be initiating long-acting beta agonist (LABA), as these require close follow-up and come with the highest risk of significant side effects.
- Step 1 – SABA [Albuterol, Levalbuterol] MDIs and Nebulizers are used PRN for exacerbations and are considered “rescue” meds. All asthma patients need to have this and ideally use it with a spacer to optimize the delivery of medication. For mild asthmatics, they may not require any additional medications.
- SABAs cause bronchodilation via B2 receptors, have a rapid onset (one- to five-min.) and last on the order of three- to six-hours. Little systemic effects, but can cause tachycardia and even some anxiety.
- Increase exhalation volume (FEV1)
- Step 1.5 – Addition of an antimuscarinic [Ipratropium Bromide (Atrovent ®)] MDI or Nebulizer often combined with albuterol as [Combivent MDI]. This is the mainstay of treatment in the ED as a DuoNeb and is available for home use as well.
- Decrease secretions and bronchoconstriction -> increase FEV1
- Ipratropium bromide is the quaternary analog of atropine that can be delivered into the lung by inhalation, but is not readily absorbed into the systemic circulation.
- Step 2-5 – Inhaled Corticosteroids (ICS) [beclomethasone (QVAR ®), budesonide (Pulmicort ®), fluticasone (Flovent ®)] typically as MDIs as well. This medication can be initiated at a low dose in the ED and titrated up in the outpatient setting as needed.
- Reduces inflammation via multiple pathways -> increase FEV1
- Onset of action is within days, but full effect can take weeks
- Additionally, it potentiates B2 agonists (SABA, LABA) via upregulation of receptor sites that get washed out by frequent beta-agonist use
- Step 4-5 – LABA [Formoterol, Salmeterol] as MDI
- Combined with ICS: [Symbicort ® (Budesonide + Formoterol), Advair ® (Fluticasone + Salmeterol)]
- Same mechanism as SABA, but slower onset and longer acting with q Day or BID dosing
- NOT intended for mono-therapy due to desensitization of B2 receptors and need to be used in conjunctions with ICS.
- Step 5+ – Oral/Parenteral Corticosteroids [prednisone, prednisolone, dexamethasone, methylprednisolone] oral or IV.
- Same mechanism as ICS, but with systemic absorption
- Use should be limited in duration to avoid system steroid effects (adrenal crisis, Cushing’s, etc)
- Often used in the ED setting as a stop-gap for exacerbations instead of adding ICS.
- Bonus Treatment – Consider second generation H1 blocker [cetirizine, loratadine, etc] q Day dosing
- Have bronchodilatory properties
- Address environmental component
- May be year round to targeted to seasonal allergy symptoms
Case Conclusion
Upon discharge, the patient was sent home with a new albuterol inhaler and was also started on a low dose inhaled corticosteroid.
Additionally, it was recommended he try cetirizine daily for the next few weeks and if helpful, anytime he is using his rescue inhaler more frequently. Fortunately, with this change in treatment regimen, the patient was able to avoid a subsequent return ED visit and according to his PCP notes, has been doing well.
In this case, the patient didn’t require oral steroids and was started on a maintenance low-dose inhaled steroid. Even if an oral steroid burst was required, it might still be beneficial to initiate inhaled corticosteroids.
In summary, not all asthma exacerbations are made equal and not all asthmatics should get the same treatment regime and approach. As EM providers, we are skilled at treating acute asthma exacerbation of all severity.
With a good H&P and discussion with the patient, we have the ability to have a significant impact on the severity of the disease and improve patient quality of life with a tailored treatment approach for those being discharged with the goal of preventing a return visit.
References:
- 2019 GINA Main Report – Global Initiative for Asthma – GINA. Global Initiative for Asthma – GINA. Published 2019. https://ginasthma.org/gina-reports/
- Spector SL, Nicodemus CF, Corren J, et al. Comparison of the bronchodilatory effects of cetirizine, albuterol, and both together versus placebo in patients with mild-to-moderate asthma. J Allergy Clin Immunol. 1995;96(2):174-181. doi:10.1016/s0091-6749(95)70005-6
- Treatment of Asthma. tmedweb.tulane.edu. Published October 27, 2020. https://tmedweb.tulane.edu/pharmwiki/doku.php/treatment_of_asthma
- McFarlin Anna. Asthma. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recJcsRr7c5n59oJq/Asthma. Updated October 11, 2020.