June 2013 Management Of Acute Asthma Volume 15, Number 6 In The Emergency Department Authors Steven G. Schauer, DO Staff Physician, Bayne-Jones Army Community Hospital, Fort Polk, LA Abstract Peter J. Cuenca, MD Staff Physician, San Antonio Military Medical Center, San Antonio, TX Jeremiah J. Johnson, MD Asthma is primarily a clinical diagnosis that is made from a Staff Physician, San Antonio Military Medical Center, San Antonio, TX combination of historical features and clinical examination find- Sasha Ramirez, DO ings. The mainstay of asthma treatment includes short-acting beta Resident Physician, San Antonio Military Medical Center, San Antonio, TX agonist therapy (albuterol) and steroids. Handheld inhalers are Peer Reviewers sufficient for most inhaled therapy; all patients on inhalers should Syed Ali, MD, MS be provided with a spacer. The severity of asthma exacerbations is Assistant Professor of Medicine, Section of Emergency Medicine, Baylor determined by 3 features: (1) clinical presentation, (2) peak expira- College of Medicine, Houston, TX tory flow rates, and (3) vital signs. Additional testing, such as chest Scott D. Weingart, MD, FCCM Associate Professor of Emergency Medicine, Director, Division of ED x-ray and blood gas measurements, is reserved for select patients. Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY Spirometry aids in the diagnosis of asthma and measurement Susan R. Wilcox, MD of severity, but it is not always required, nor should it be solely Former Attending Physician in Emergency Medicine/Surgical ICU, Massachusetts General Hospital; currently Anesthesiology Resident, relied upon to make disposition decisions. Inhaled ipratropium Massachusetts General Hospital, Boston, MA decreases hospitalization rates, and it should be routinely used. Levalbuterol provides little to no advantage over less-expensive CME Objectives racemic albuterol. Noninvasive positive pressure ventilation may Upon completion of this article, you should be able to: be utilized in patients with moderate to severe exacerbations. 1. Identify and distinguish key features of mild to severe asthma and triage patients based on initial history and physical examination. Ketamine may be considered in severe exacerbations, but it should 2. Formulate a broad differential diagnosis of new-onset asthma not be used routinely. Magnesium sulfate may be beneficial in based on a patient’s age and comorbidities. severe asthma exacerbations, but routine use for mild to moderate 3. Describe the underlying pathophysiology of asthma and the basic exacerbations is not indicated. treatment options that are critical in the management of asthma. Editor-In-Chief Nicholas Genes, MD, PhD Keith A. Marill, MD Stephen H. Thomas, MD, MPH Research Editor Andy Jagoda, MD, FACEP Assistant Professor, Department of Assistant Professor, Harvard Medical George Kaiser Family Foundation Michael Guthrie, MD Professor and Chair, Department of Emergency Medicine, Icahn School School; Emergency Department Professor & Chair, Department of Emergency Medicine Residency, Emergency Medicine, Icahn School of Medicine at Mount Sinai, New Attending Physician, Massachusetts Emergency Medicine, University of Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical York, NY General Hospital, Boston, MA Oklahoma School of Community Sinai, New York, NY Medicine, Tulsa, OK Director, Mount Sinai Hospital, New Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, York, NY Professor and Chair, Department FACEP Jenny Walker, MD, MPH, MSW International Editors of Emergency Medicine, Carolinas Chairman, Department of Emergency Assistant Professor, Departments of Peter Cameron, MD Associate Editor-In-Chief Medical Center, University of North Medicine, Pennsylvania Hospital, Preventive Medicine, Pediatrics, and Academic Director, The Alfred Kaushal Shah, MD, FACEP Carolina School of Medicine, Chapel University of Pennsylvania Health Medicine Course Director, Mount Emergency and Trauma Centre, Associate Professor, Department of Hill, NC System, Philadelphia, PA Sinai Medical Center, New York, NY Monash University, Melbourne, Emergency Medicine, Icahn School Steven A. Godwin, MD, FACEP Michael S. Radeos, MD, MPH Ron M. Walls, MD Australia of Medicine at Mount Sinai, New Professor and Chair, Department Assistant Professor of Emergency Professor and Chair, Department of York, NY Giorgio Carbone, MD of Emergency Medicine, Assistant Medicine, Weill Medical College Emergency Medicine, Brigham and Chief, Department of Emergency Editorial Board Dean, Simulation Education, of Cornell University, New York; Women’s Hospital, Harvard Medical Medicine Ospedale Gradenigo, University of Florida COM- Research Director, Department of School, Boston, MA William J. Brady, MD Torino, Italy Jacksonville, Jacksonville, FL Emergency Medicine, New York Scott D. Weingart, MD, FCCM Professor of Emergency Medicine Amin Antoine Kazzi, MD, FAAEM Hospital Queens, Flushing, New York Associate Professor of Emergency and Medicine, Chair, Medical Gregory L. Henry, MD, FACEP Associate Professor and Vice Chair, Medicine, Director, Division of Emergency Response Committee, CEO, Medical Practice Risk Robert L. Rogers, MD, FACEP, Department of Emergency Medicine, ED Critical Care, Icahn School of Medical Director, Emergency Assessment, Inc.; Clinical Professor FAAEM, FACP University of California, Irvine; Medicine at Mount Sinai, New York, Management, University of Virginia of Emergency Medicine, University of Assistant Professor of Emergency American University, Beirut, Lebanon Medical Center, Charlottesville, VA Michigan, Ann Arbor, MI Medicine, The University of NY Maryland School of Medicine, Hugo Peralta, MD John M. Howell, MD, FACEP Peter DeBlieux, MD Baltimore, MD Senior Research Editors Chair of Emergency Services, Professor of Clinical Medicine, Clinical Professor of Emergency Hospital Italiano, Buenos Aires, Interim Public Hospital Director Medicine, George Washington Alfred Sacchetti, MD, FACEP James Damilini, PharmD, BCPS Argentina of Emergency Medicine Services, University, Washington, DC; Director Assistant Clinical Professor, Clinical Pharmacist, Emergency Dhanadol Rojanasarntikul, MD Emergency Medicine Director of of Academic Affairs, Best Practices, Department of Emergency Medicine, Room, St. Joseph’s Hospital and Attending Physician, Emergency Faculty and Resident Development, Inc, Inova Fairfax Hospital, Falls Thomas Jefferson University, Medical Center, Phoenix, AZ Medicine, King Chulalongkorn Louisiana State University Health Church, VA Philadelphia, PA Joseph D. Toscano, MD Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Shkelzen Hoxhaj, MD, MPH, MBA Scott Silvers, MD, FACEP Chairman, Department of Emergency Thailand; Faculty of Medicine, Francis M. Fesmire, MD, FACEP Chief of Emergency Medicine, Baylor Chair, Department of Emergency Medicine, San Ramon Regional Chulalongkorn University, Thailand Professor and Director of Clinical College of Medicine, Houston, TX Medicine, Mayo Clinic, Jacksonville, FL Medical Center, San Ramon, CA Suzanne Peeters, MD Research, Department of Emergency Eric Legome, MD Corey M. Slovis, MD, FACP, FACEP Emergency Medicine Residency Medicine, UT College of Medicine, Chief of Emergency Medicine, Professor and Chair, Department Director, Haga Hospital, The Hague, Chattanooga; Director of Chest Pain King’s County Hospital; Professor of of Emergency Medicine, Vanderbilt The Netherlands Center, Erlanger Medical Center, Clinical Emergency Medicine, SUNY University Medical Center; Medical Chattanooga, TN Downstate College of Medicine, Director, Nashville Fire Department and Brooklyn, NY International Airport, Nashville, TN Prior to beginning this activity, see the back page for faculty disclosures and CME accreditation information. Case Presentations asthma is reversible either spontaneously or with medication. A 19-year-old college student presents with marked Asthma is defined by its clinical, physiologic, dyspnea and dysphagia. He reports a history of asthma, and pathologic characteristics, with reversible for which he takes albuterol as his only medication. Over wheezing as the most common finding. From a the last 3 days, he has been coughing and wheezing with public health point of view, understanding the increasing severity. Even though he has been using his underlying causes of asthma and its exacerbants is albuterol inhaler every 2 hours, there has been minimal key to preventive strategies. From an emergency to no response. EMS administered a 10-mg albuterol medicine perspective, having clear strategies on how nebulizer treatment and magnesium sulfate intravenously to best manage acute presentations is key to good en route to the ED. Upon arrival, the patient appears in outcomes. This issue of Emergency Medicine Practice extremis, and you wonder if there is something you can do provides an evidence-based review of asthma as to avoid intubation . it relates to emergency department (ED) care and While establishing IV access and calling respira- establishes best-practice approaches to management. tory therapy for your first patient, a 24-year-old Hispanic female with a history of asthma who is 15 weeks pregnant Critical Appraisal Of The Literature presents with tachypnea and acute shortness of breath with audible wheezing. She has been taking albuterol and The Ovid MEDLINE®, CINAHL (Cumulative In- fluticasone at home with no relief of symptoms. She has a dex to Nursing and Allied Health Literature), and blood pressure