Kaiser
Permanente Clinical Practice Guidelines Hospital Care Guideline
for Management of Acute Exacerbation of Adult Asthma
CLINICAL
PRACTICE GUIDELINES
HOSPITAL CARE GUIDELINE for MANAGEMENT of
ACUTE
EXACERBATION of ADULT ASTHMA
ENDORSED BY:
CHIEFS OF
EMERGENCY MEDICINE
CHIEFS OF
HOSPITAL MEDICINE
CHIEFS OF
MEDICINE
CHIEFS OF
PULMONARY MEDICINE
SUMMARY of
RECOMMENDATIONS
The
recognition of asthma and
the assessment of the severity
of the exacerbation using pulmonary
function testing are
fundamental to optimal
management of acute asthma.
(NIH
guidelines)
Treat
episodes of
acute asthma aggressively
*
Maintain oxygen
saturation of 90%. (NIH Guidelines)
*
Rapidly reverse
airflow obstruction by using
inhaled beta-agonists and anti-cholinergics. Adding
anti-cholinergics to
beta-agonists in moderate
and severe acute asthma in the ED produces
a small,
statistically significant improvement
in lung function;15,30additionally a trend
toward
reduced hospitalization
has been shown. 11,10 (Grade
A)
*
Administer
oral
corticosteroids for moderate or severe
exacerbations. Systematic review of 6
RCTs concluded that there
was equal efficacy over a
range of moderate to high doses of corticosteroids
in acute
asthma requiring hospital admission.21
(Grade A)
*
Use
repetitive measures of
lung function to assess
response to treatment. (NIH Guidelines) Recognize
the patient
at high risk for life-threatening
exacerbation
*
Risk factors for
death include multiple previous
ED visits and hospitalizations, ICU admissions,
intubation, high
beta-agonist overuse and
signs of impending respiratory failure.
(NIH Guidelines)
At
discharge,
intensify therapy and provide a clearly
written interim treatment and
follow-up
plan
*
Include oral and
inhaled corticosteroids. Combined
therapy reduces return ED visits for on-going
asthma exacerbations.8,26(Grade
B) A
short course of oral steroids significantly reduces relapses
and decreases
beta-agonist use.27
(Grade A)
Arrange
for follow-up
with asthma care manager or personal
physician/nurse practitioner
within 7 days
*
Asthma
self-management education combined with
clinical monitoring reduces hospitalization, ED
visits, urgent visits, days
offwork or school, and
nocturnal asthma.12 (Grade A)
For pregnant women
with asthma, use similar principles
of care
*
Maintenance
inhaled corticosteroids reduce the
risk of an on-going exacerbation without increasing adverse outcomes
for mother and child.7,29,33
(Grade B)
Encourage
patients to
expect future improvement in self-management
skills
*
With
asthma care management,
most patients can learn
to recognize and avoid their asthma triggers,
monitor their
condition and adjust their medications
to avoid future ED visits and hospitalizations.12
(Grade A).
INTRODUCTION
This
guideline is intended for
use by physicians and
other medical professionals in the acute care, emergency
department and
hospital setting. It is intended
to provide a framework for diagnosing and
treating patients who
experience acute exacerbations
of asthma. In developing these recommendations,
KPNC
guideline team members reviewed
the NHLRBI Guidelines for the Diagnosis and
Treatment of Asthma (NIH
guidelines 1997)22
and the CAEP/CTS Asthma Advisory Committee Guidelines
for the Emergency
Management of Asthma in
Adults (Canadian guidelines 1996).4
These
national guidelines were
developed by expert panels
that considered scientific evidence and expert
opinion in formulating
recommendations. The KPNC
guideline team also reviewed subsequently
published
literature (1997-1999) on selected
topics.
A
KPNC
guideline on outpatient
treatment of adult asthma
is also available: Clinical Practice Guidelines
for Adult Asthma;
Kaiser Permanente Northern
California, May, 1997.24
EVIDENCE GRADING
Evidence
for new
guideline recommendations was graded
based on
the
following criteria
*
Grade A -
Supported by two or more well designed
randomized clinical trials
*
Grade B -
Supported by a single well-designed
randomized clinical trial or by two
or more non-randomized clinical
trials (case-control or cohort)
*
NIH Guidelines -
Supported by the NHLBI Guidelines
for the Diagnosis and
Treatment of Asthma22 which
are based on expert panel review of scientific evidence where
available and expert panel
opinion
where evidence is lacking
DEFINITION
of ASTHMA
Asthma,
whatever the severity,
is a chronic inflammatory
disorder of the airways. Airway inflammation
contributes to
airway hyper-responsiveness,
respiratory symptoms, disease chronicity
and airflow
limitation, including acute bronchoconstriction,
airway edema, mucus plug formation,
and airway wall
remodeling. These features
lead to bronchial obstruction.22,24
DIAGNOSIS
of ASTHMA
To
establish a diagnosis of
asthma, the clinician determines
that:
*
Episodic
symptoms of airway
obstruction arepresent
*
Airflow obstruction is at
least partially reversible
(rarely, long-term monitoring may be required
to document reversibility)
*
Alternate diagnoses that can
mimic asthma are excluded
(e.g. pulmonary embolism, heart
disease,
anemia, emphysema, chronic bronchitis)22,24
OCCULT ASTHMA
The diagnosis of
asthma is frequently missed. The most
common incorrect diagnosis is bronchitis.
Improved diagnosis
depends
upon:
*A
high index of
suspicion. Asthma often presents
as persistent cough or URI that does
not respond to usual
treatment.
*Routine
use of objective measures (peak flow and/or
spirometry)
Consider
asthma if the patient answers "yes'' to
any of
the following:
*Do
you have a troublesome
cough at night?
*Do
your colds usually "go to
the chest" or take more
than ten days for the cough to clear up?
*Have you had
recurrent
diagnoses of "bronchitis."
*Do
you have a cough or wheeze
after exercise?
*Have
you ever had an episode
or recurrent episodes of
wheezing?
*Do
you have a cough, wheeze
or chest tightness after
exposure to airborne allergens or pollutants?
*Do you use
anti-asthma
medication (e.g., over-the counter
inhaler or family member's inhaler)?
*Does anyone in
your immediate
family have asthma?
*Do
you have a personal
history of allergic rhinitis,
sinusitis or atopic dermatitis?22,24
EVALUATION
Important elements
of physical
examination
Assess
and document
signs and symptoms in Table
I, page 4.
Elements
of brief history
*
Onset and severity of
symptoms
*Triggers/precipitating
illness
*
Presence or absence of upper
airway obstruction
*
Current medications
*
Recent best peak flow - from
patient report, diary
or medical chart
*
Presence or absence
of written self-management
plan
*
Prior
hospitalizations, ED
visits for asthma, particularly
in last year
*Prior
mechanical ventilation,
intubation
*
Co-morbidities, especially
pulmonary or cardiac disease
or those which would be aggravated by
systemic corticosteroid therapy (diabetes,
peptic ulcer, hypertension, and psychosis)
*Smoking
history and/or
exposure: personal and household
members
Recognize
the
patient with risk factors for life-threatening exacerbation
*
History of sudden severe
exacerbation
*
History of multiple ED
visits or hospitalizations in
the previous year
*
Prior admission for asthma
to an intensive care unit,
prior intubation
*
High beta-agonist use
(greater than two canisters per
month)
*
Current
use of systemic
corticosteroids or recent withdrawal
from systemic corticosteroids
*
Co-morbidities, as from
cardiovascular diseases or
COPD
*
Difficulty perceiving
airflow obstruction or its severity Laboratory
studies - consider:
*
Arterial blood gas (ABG) if patient is failing
in his/her
respiratory effort, in severe distress or experiencing
altered mental status
*
Complete blood count (CBC)
*
Serum theophylline
concentration, if indicated
*
Serum electrolytes in
patients taking diuretics regularly,
or with cardiovascular disease or diabetes
*
Chest radiography in
patients who have complicating
cardiopulmonary process (chest
radiography is generally not necessary in
uncomplicated asthma)3,34,35
*
Electrocardiograms in
patients older than 50 with coexistent
heart disease, arrhythmia or COPD
TREATMENT-TAILORED
to SEVERITY of EXACERBATION
Inhaled
short-acting beta-agonists
*
Most effective means of
reversing airflow obstruction
* In
patients with moderate
and severe disease, initial
treatment is beta-agonist every 20
minutes
for one hour with reevaluation
*
Because of risk of
cardiotoxicity, use only selective
beta-agonists (albuterol) in high doses
*
Equivalent bronchodilation
can be achieved by metered
dose inhaler (MDI) with
spacer/holding chamber. Nebulized therapy
is appropriate in patients who cannot coordinate
inhalation with an MDI5
* In
severe exacerbations,
albuterol can be given up
to 15 mg/hr via continous nebulization, but
the
patient must be on a cardiac monitor
for potential cardiac arrhythmias and checked frequently for hypokalemia
Anticholinergics
*
Anticholinergics should be
added to initial treatment
of moderate and severe exacerbations10,11,15,17,30
*
Subsequent doses of
ipratropium can then be given:
4 puffs every 4-6 hours
Systemic
corticosteroids
*
For patients who have
moderate-to-severe exacerbations
and patients who do not respond
completely to initial beta-agonist therapy
*
Recommended regimen is oral
prednisone 40-60 mg/day
(alternative is IV methylprednisolone 60 mg/day), then
40 mg/day
until PEF reaches 70% of predicted
or personal best21
Inhaled
corticosteroids
*
Initiate or continue inhaled
corticosteroids in all
moderate to severe asthma patients at discharge1,8,23,25,31
Oxygen
*Maintain
an SaO2,
>90 percent (>95%
in pregnant women and in patients with coexistent
heart disease).
Monitor oxygen
saturation until a clear
response to bronchodilator therapy has occurred
Antibiotics
Antibiotics
- May be
necessary for co-morbid conditions
(sinusitis, bronchitis) but not usually recommended for treatment
Copyright
2000 The Permanente Medical Group, Inc.
MEDICATIONS
USED IN CHRONIC MAINTENANCE
*
Methyixanthines (theophylline, aminophylline)
- In patients currently using methyixanthines, it
may be appropriate to
continue
*
Leukotriene
modifiers (montelukast, zafirlukast)-
Non-formulary medications usually initiated and
monitored by asthma
specialists for moderate to severe
asthmatics, leukotriene modifiers may modify
the length and severity
of future asthma exacerbations
but there is no evidence of benefit for
acute treatment13,14,16,20
*
Long-acting
beta-agonists (salmeterol) - Similarly,
no evidence of benefit for acute asthma (Consensus
of the KPNC expert
group)
REPEAT ASSESSMENT
*
Make repeat assessments
after initial and third dose
of combined inhaled bronchodilator and anticholinergic
(approximately
60-90 minutes after initiating
treatment)
*
If
not improving, remember
to evaluate and treat for
complicating conditions such as sinusitis,
upper airway
obstruction (e.g. obstructive
sleep apnea), GERD, pneumonia
DECISION
to DISCHARGE from the EMERGENCY
DEPARTMENT
*
Dependent on
response to treatment (see Figure
I, page 3)
*
Prescribe
sufficient medications to continue
treatment after discharge
*
Demonstrate proper
metered dose inhaler and spacer
technique
*
Prescribe a peak
flow meter and demonstrate proper
technique
*
Provide written
interim treatment plan and advise
to avoid asthma triggers
*
Emphasize need for
continual, regular care in
an outpatient setting: appoint patient for
followup with asthma care manager
or personal physician within seven days
*
Provide
instruction on returning for care if
symptoms worsen
*
Provide
information about the KPNC Asthma Care
Management Program
HOSPITALIZATIONS
See
figure I, page 3
Indications
for hospitalization
*
Severe distress or
impending respiratory arrest
*
Severe airflow
obstruction despite treatment
with beta-agonists, inhaled and systemic
corticosteroids
and
anti-cholinergics (peak flow <50%andPCO2>42)
*
Need for supplemental O2
to maintain 02
saturation of 90% 4-
Prior history of similar,
severe, complicated exacerbations
The
principles of hospital care for asthma
*
Continue oxygen
*
Continue inhaled
bronchodilators and anticholinergics
*
Continue systemic
corticosteroids. Initiate or
continue inhaled corticosteroid therapy. Use
MDIs and spacers in the
hospital to
encourage compliance after discharge
*
Frequent
assessment, including clinical assessment
of respiratory distress and fatigue,objective
measurement of airflow
(PEF, FEV1). Monitor oxygen saturation
Provide patient
education.
The
hospital setting may make
patient more receptive
and provides a unique opportunity to review patient understanding
of:
*
Causes of
asthma exacerbation
*
Purposes and correct uses of
discharge medications
and peak flow measurements
*
Importance of follow-up and
continuing care
*
Actions to be taken for
worsening symptoms or peak
flow values
*
Asthma education resources
such as care management,
classes and clinics
CRITERIA
and
RECOMMENDATIONS for IMPENDING RESPIRATORY
FAILURE
Most
patients respond well to
therapy. A small minority
shows signs of worsening ventilation.
Signs
of impending respiratory
failure include:
*
Declining mental clarity
*
Altered consciousness, coma
*
Worsening fatigue with
declining respiratory rate
*
PCO2
of >42 mm Hg
*
pH<7.30-7.35
*
Respiratory rate > 35
*
Respiratory rate rapidly
declining
Some
patients may benefit
from assisted ventilation2,23
* Noninvasive
Positive
Pressure Ventilation ("Bi-PAP")
may benefit alert patients who are
not
responding to pharmacological intervention,
who have hypercapnic respiratory
failure
and are not in immediate need of
intubation
*
Invasive Ventilation: In
patients with altered mental
status/coma, mechanical ventilation
with
intubation is required.
When
to
intubate
*
Decision
to
intubate has subjective and objective
considerations
*
Once determined to
be necessary, intubation should
not be delayed
*
Patients
presenting with coma and signs of impending
respiratory failure should be
intubated immediately
*
Best performed
semi-electively if possible; before
the crisis of respiratory arrest
Key
principles of invasive mechanical ventilation6,32
*
Avoid barotrauma and
pneumothorax. Attempt to keep
plateau pressures low: not over 40
*
Utilize permissive
hypercapnia: allow CO2
to rise, pH to drop, keep respiratory rate low.
Bicarbonate drip should be considered to
keep pH at 7.2 or above
*
Use sedation and paralysis
to prevent spontaneous ventilation
HOSPITAL
DISCHARGE FOLLOWING TREATMENT
for SEVERE
ASTHMA
Recognize
patients at highest
risk for recurrence.
Interventions may include brief, intensive
educational
intervention in the hospital prior
to enrollment in care management
program. Risk
factors include:
<>Difficulty
in accepting a chronic disease diagnosis
and following a self-management plan
<>
Difficulty
mastering asthma skills including peak
flow monitoring, and metered dose inhaler and spacer technique
<>
Non-adherence
to medication regimens
<>
Inability to
control exposure to environmental
triggers
<>
Discharge
medication should include short acting
inhaled beta-agonist and sufficient oral
and inhaled corticosteroids
to ensure that patients continue their treatment plan until their
follow-up
visit
<>
Administer
pneumovax per vaccination guidelines
and/or influenza vaccine (annually
October-March) on morning
of discharge
<>
Use of home
nebulizer treatments is discouraged.
MDIs are preferable to home nebulizers in terms of cost, mobility and
prevention
of tachyphylaxis
<>
Review or
develop a written interim treatment plan
<>
Prescribe
peak flow meter and review how to use
it
<>
Assess
follow-up needs and refer patients to primary
care, care management, or specialty care as appropriate
ACUTE
ASTHMA
DURING PREGNANCY
*Asthma
exacerbations during pregnancy are
common
*Neonatal
outcomes are
superior when maternal symptoms
are controlled and oxygenation and
pulmonary function
are optimized, yet under treatment
with corticosteroids is often observed,
leading to an
increased likelihood of ongoing
exacerbation7,33
*
Pregnancy is not a
contraindication to use of inhaled
beta-agonist or inhaled or systemic steroids
*
Maintenance treatment with
inhaled anti-inflammatories
during pregnancy reduces the
risk of
asthma exacerbation 29,33
*
Rapid therapeutic
intervention at the time of an exacerbation
is imperative to prevent impaired
maternal and fetal
oxygenation. In addition, oxygen saturation
should be maintained at greater
than 95%18
*
Principles for
managing asthma exacerbations
during pregnancy are similar to those for
general management: repetitive lung
function measurements, therapy with repeat doses of
inhaled beta-agonists, early administration
of systemic corticosteroids, discharge on inhaled
corticosteroids.18,26
*
Notify obstetrician of the
ED visit and coordinate
close follow-up.
FOLLOW-UP
CARE
The
hallmark of effective
asthma treatment is patient
understanding of asthma triggers and ability
to intervene with
appropriate beta-agonist and
anti-inflammatory medications using the "step-wise
approach" to
medication adjustment based on
a self-management plan. Set the expectation
that most patients
can learn to recognize
and avoid their asthma triggers, monitor their
condition and adjust
their medications to avoid
or intervene early in the course of a future exacerbation.
Also,
remind patients that the high
dose corticosteroids they are using immediately
post
ED and hospital visits
will be adjusted downward
over time during their follow-up care.
The
KPNC Adult Asthma Care Management Program
offers:
*
Proactive outreach
to
asthmatic members after ED and
hospital visits
*
Comprehensive follow-up
evaluation including confirming
diagnosis, pre- and post-
bronchodilator spirometry, educational needs
assessment and appropriate referrals
*
Clinical monitoring and
medication adjustment
*
Individual and
group asthma education Asthma
care manager
services are provided in all KPNC
service areas in a combination of individual and
group settings.
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ACKNOWLEDGMENTS
Clinical
Leader
Kenneth
Greene, MD, Medicine;
Santa Clara
Work
Group
Tom
Dailey, MD, Pulmonary
Medicine;Santa Clara
Charlotte
Edwards, RN; TPMG
Department of Quality &
Utilization (DOQU)
Yolanda
Mawson, RN, Care
Coordination; Sacramento
Julie
Nack, PharmD, Pharmacy;
Fairfield
Joseph
Robinow, MD, UM Chief;
Vallejo
Paul
Roggero, MA, Respiratory
Care;San Francisco
Andrea
Wagner, MD, Emergency
Medicine;San Francisco
Project
Management
Laura
Skabowski, MS; DOQU
Kathleen
Martin; DOQU
Data
Analysis
Carol
Remmers, MPH; DOQU
Maqdooda
Merchant, MS/MA; DOQU
Betsy
Stone, DrPH; DOQU
Graphic
Design
Gail
Holan; Curvey Graphic
Design
This
guideline was reviewed by
over 40 physicians, nurses,
respiratory therapists, phamiacists and other
medical
professionals
representing a variety of departments
from all facilities. For a complete list of
reviewers,
see the on-line
version at http:/cl/kp.org
CONTACT
INFORMATION
Kaiser
Permanente Northern
California
TPMG
Department of Quality and
Utilization
1800
Harrison Street, 4th Floor
Oakland,
CA 94612
510-987-2950
or tie-line
8-427-2950
To
obtain more information
about KPNC Clinical Practice
Guidelines, printed copies, or
permission to reproduce any
portion, please contact
the TPMG Dept. of Quality & Utilization,
or send an e-mail
message to clinical.guidelines@kp.
org
KPNC
Clinical Practice
Guidelines and implementation
tools can be viewed on-line on
the Kaiser Permanente
Northern California intranet
at http://cl.kp.org
CME
Credit. Continuing
Education Credit for physicians
and nurses is available for review
of this guideline. The
CME Pre-Test and Post-Test
is available on-line at http://cl.kp.org
or by calling
510-987-2950 or tie-line
8-427-2950.
This
website is accessible
only from the Kaiser Permanente
computer network. Disclaimer
The
Permanente Medical Group
(TPMG) Clinical Practice
Guidelines have been developed
to assist clinicians
by providing an analytical
framework for the evaluation and treatment
of selected common
problems encountered in
patients. These guidelines are not
intended to establish a
protocol for all patients
with a particular condition. While the
guidelines provide one
approach to evaluating a problem,
clinical conditions may
vary significantly from
individual to individual.
Therefore, the clinician must exercise
independent judgment
and make decisions based
upon the situation presented.
While
great care has been
taken to assure the accuracy
of the information presented, the reader
is advised that TPMG
cannot be responsible for
continued currency of the information,
for any errors or
omissions in this guideline,
or for any consequences arising
from its use.
Copyright
2000 The Permanente Medical Group, Inc.
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