Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- January 2008.

The recommendations for diagnosis and management of asthma are presented in the form of two algorithms: Diagnosis and Management of Asthma and Emergency Department or Inpatient Management with 32 components, accompanied by detailed annotations. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.

Class of evidence (A-D, M, R, X) and key conclusions (I-III, Not Assignable) definitions are repeated at the end of the "Major Recommendations" field.

Clinical Highlights

• Conduct interval evaluations of asthma including medical history and physical examination, assessment of asthma triggers and allergens, measurement of pulmonary function, and consideration of consultation and/or allergy testing. (Annotation #11)
• Assess control using objective measures and the asthma control test. (Annotation #12)
• Match medical intervention with asthma control and adjust to correspond with change over time. (Annotation #13)
• Provide asthma education to patients and parents of pediatric patients. Education should include basic facts about asthma, how medications work, inhaler technique, a written action plan including home peak flow rate monitoring or a symptom diary, environmental control measures, and emphasis on the need for regular follow-up visits. (Annotation #14)
• Patients should receive appropriate follow-up as per Diagnosis and Management of Asthma guideline. (Annotation #15)
• Early intervention with bi-level positive airway pressure (PAP) may prevent mechanical intubations. (Annotation #27)

Diagnosis and Management of Asthma Algorithm Annotations

1. Patient Presents with Symptoms of Asthma

   Symptoms suggestive of asthma include episodic wheezing and cough with nocturnal, seasonal, or exertional characteristics. Infants and children with frequent episodes of "bronchitis" are likely to have asthma. Atopic and positive family histories for asthma, particularly when associated with previously mentioned symptoms, should encourage one to consider a diagnosis of asthma.

   Eliciting symptoms should emphasize characterizing the current classification scheme that describes frequency per week, changes in physical activity, diurnal variation, and seasonal variation. It is important to recognize that patients with asthma are heterogeneous, falling into every age group, from infancy to older age, and presenting a spectrum of signs and symptoms that vary in degree and severity from patient to patient as well as within an individual patient over time [R].

2. Previous Diagnosis of Asthma?

   At each evaluation, it is important to consider whether or not a previous diagnosis was correct.

   • History and physical consistent with diagnosis
   • Response to therapy consistent with symptoms

3. Establish Diagnosis of Asthma and Determine Level of Severity

   Key Points:

   • The diagnosis of asthma is based on the patient's medical history, physical examination, pulmonary function tests, and laboratory test results.
   • Spirometry is recommended for the diagnosis of asthma.
   • The level of asthma severity is determined by both impairment and risk.

   Asthma Triggers

   • Viral respiratory infections
   • Environmental allergens
   • Exercise, temperature, humidity
   • Occupational and recreational allergens or irritants
   • Environmental irritants (perfume, tobacco smoke, wood burning stoves)
   • Drugs (aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], beta blocker) and food (sulfites)

   Other Historical Components

   • Emergency room visits and hospitalization
   • Medication use (especially oral steroids)
   • Lung function, peak expiratory flow rate (PEFR) variability
   • Associated symptoms (e.g., rhinitis, sinusitis, gastroesophageal reflux disease [GERD])

   Clinical Testing

   • Accurate spirometry is recommended in every patient 5 years of age or older at the time of diagnosis.
   • Additional studies done, tailored to the specific patient.
   • Allergy testing (skin testing, in vitro specific immunoglobulin E [IgE] antibody testing)
   • Chest radiography, to exclude alternative diagnosis
   • Bronchial provocation testing if spirometry is normal or near normal
   • Sinus x-rays or computed tomography (CT) scan
   • Gastroesophageal reflux disease (GERD) evaluation
   • Complete blood count (CBC) with eosinophils, total IgE, sputum exam

   Spirometry is the cornerstone of the laboratory evaluation that enables the clinician to demonstrate airflow obstruction and establish a diagnosis of asthma with certainty. Spirometry is essential for assessing the severity of asthma in order to make appropriate therapeutic recommendations. The use of objective measures of lung function is recommended because patient-reported symptoms often do not correlate with the variability and severity of airflow obstruction. Testing should be performed in compliance with the American Thoracic Society standards. Obstructive and restrictive ventilatory defects can generally be determined using forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) ratio [R].

   Spirometry is generally valuable in children 5 years of age or older; however, some children cannot conduct the maneuver depending on developmental ability. Spirometry measurements (FEV₁, FVC, and FEV₁/FVC) before or after the patient inhales a short-acting bronchodilator should be undertaken for patients in whom the diagnosis of asthma is being considered. Airflow obstruction is indicated by reduced FEV₁ and FEV₁/FVC values relative to reference or predicted values. Significant reversibility is indicated by an increase of 12 percent or greater and 200 mL in FEV₁ after inhaling a short-acting bronchodilator.

   Investigation into the role of allergy, at least with a complete history, should be done in every patient, given high prevalence of positive skin tests among individuals with asthma and the benefits of limiting exposure to known allergens. History may help to distinguish seasonal allergies but may be inadequate for perennial allergies. Eosinophil count and IgE may be elevated in asthma; however, neither test has sufficient specificity or sensitivity to be used alone in a diagnosis. The chest x-ray and electrocardiogram are usually normal in asthma but may be useful to exclude other pulmonary or cardiac conditions. Sputum examination may be helpful if sputum eosinophilia or infection is suspected.

   There are several clinical scenarios in children that have a frequent association with asthma and should strongly suggest asthma as a possible diagnosis. These include recurrent pulmonary infiltrates (especially right middle lobe infiltrates) with volume loss that clear radiologically within two to three days, and the diagnosis of pneumonia without fever. Asthma may cause radiologic uncertainty since mucus plugging and atelectasis may be interpreted as infiltrates.

   Diagnostic spirometry and a methacholine challenge test, if necessary, are important to clinching the diagnosis. The patient's history and response to therapy should guide other diagnostic tests when considering alternative diagnoses. Follow-up spirometry every one to two years in mild asthmatics will reconfirm the diagnosis and objectify serial change and level of control. More frequent monitoring should be considered for the moderate and severe persistent categories.

   See Table 1, "Classifying Asthma Severity in Children 5-11 Years" and Table 2, "Classifying Asthma Severity in Youths and Adults" in the original guideline document.

   (See the original guideline document for additional information concerning differential diagnostic possibilities for asthma.)

4. Acute Asthma Exacerbation?

   Symptoms of an acute asthma episode include progressive breathlessness, cough, wheezing, or chest tightness. An acute asthma episode is characterized by a decrease in expiratory airflow that can be documented and quantified by measurement of lung function (spirometry or PEFR). Indications for emergency care include:

   • Peak flow less than 50% predicted normal
   • Failure to respond to a beta₂ agonist
   • Severe wheezing or coughing
   • Extreme anxiety due to breathlessness
   • Gasping for air, sweaty, or cyanotic
   • Rapid deterioration over a few hours
   • Severe retractions and nasal flaring
   • Hunched forward

5. Assess Severity of Asthma Exacerbation

   Key Points:

   • Severity should be promptly assessed using objective measures of lung function.
   • Patients experiencing an acute asthma exacerbation need a focused history and physical examination and measurement of airflow.

   Patients presenting with an acute exacerbation of their asthma should receive prompt evaluation to assess the severity of their symptoms. Treatment should begin as rapidly as possible even while still assessing severity.

   Assessment of asthma severity should include history, physical examination, an objective measure of lung function, either FEV₁ or PEFR, oxygen saturation, and other tests as indicated.

   History

   • Symptoms consistent with asthma
   • Severity of symptoms, limitations, and sleep disturbance
   • Duration of symptoms
   • Current medical treatment plan
   • Adherence to medical treatment plan
   • Rescue medication use
     • Recent use of short acting beta₂-agonists
     • Number of bursts of oral steroids in past year
   • Review Asthma Action Plan and daily charting of peak flows
   • Previous emergency department (ED) visits or hospitalization
   • Record triggers:
     • Upper respiratory infection (URI)
     • Bronchitis, pneumonia, sinusitis
     • Exposure to allergens or irritants
     • Exercise
     • GERD

   Clinicians treating asthma exacerbations should be familiar with the characteristics of patients at risk for life-threatening deterioration. See Table 3, "Risk Factors for Death from Asthma" in the original guideline document.

   Lung Function

   • Spirometry (FEV₁) – preferred, FEV₁/FVC

     or

   • Peak expiratory flow rate
   • Pulse oximetry

   Physical Exam

   • Vital signs: Temperature, blood pressure, pulse rate, respiratory rate, pulsus paradoxus
   • Alertness
   • Ability to talk
   • Use of accessory muscles
   • Auscultation of chest
   • Color

   Laboratory Studies

   Treatment with bronchodilators should not be delayed for laboratory studies. Tests which may be useful include:

   • Arterial blood gases (ABGs)
   • Chest x-ray (CXR)
   • Complete blood count (CBC)
   • Electrocardiogram (EKG)
   • Electrolytes
   • Theophylline level (if appropriate)

   See Table 4, "Assessment of Severity" in the original guideline document.

8. Management of Asthma Exacerbation

   Key Points:

   • Treatment is begun with inhaled short-acting beta₂-agonists administered by meter dose inhaler (MDI)/spacer or nebulizer.
   • Further intensification of therapy is based on severity, response and prior history, but typically includes a short course of oral corticosteroids [R].

   Treatment

   Usual initial treatment is with short-acting beta₂-agonist (albuterol) administered by nebulizer or MDI/spacer.

   Alternatives:

   Epinephrine: (1:1000)

   • Adults: 0.3 to 0.5 mg subcutaneously or intramuscularly every 20 minutes up to three doses
   • Pediatrics: 0.01 mg/kg up to 0.3 to 0.5 mg subcutaneously or intramuscularly every 20 minutes up to three doses

   Ipratropium added to nebulized beta₂-agonist (albuterol)

   • Nebulized dose for adults and those over 12 years of age is 0.5 mg every 4 hours. Not U.S. Food and Drug Administration (FDA)-approved for any indication in those under 12 years of age.
   • Ipratropium is not currently FDA-approved for use in asthma.

   Levalbuterol

   • Dose for adolescents 12 years of age and over and adults is 0.63 mg (via nebulizer) three times daily (every six to eight hours); may increase to 1.25 mg via nebulizer three times daily (every six to eight hours) if patient does not exhibit adequate response.
   • Dose for children 6 to 11 years of age is 0.31 mg (via nebulizer) three times daily. Routine dosing should not exceed 0.63 mg three times daily.

   Corticosteroids

   • Initiate or increase anti-inflammatory medication:
     • Inhaled corticosteroids
     • Cromolyn/nedocromil
     • Consider leukotriene modifiers
   • Strongly consider systemic corticosteroids in patients with acute asthma exacerbation. Corticosteroids aid symptom resolution and prevent asthma relapse [A].

   Note: The Food and Drug Administration has reported that salmeterol monotherapy may be associated with an increased risk of death from asthma.

   Antibiotics are not recommended for the treatment of acute asthma except for those patients with signs of acute bacterial infection, fever and purulent sputum.

9. Assess Response to Treatment

   Good Response:

   • PEFR or FEV₁ greater than 70% predicted normal
   • No wheezing on auscultation

   Incomplete Response:

   • PEFR or FEV₁ 50 to 70% predicted normal
   • Mild wheezing
   • Consider hospitalization, particularly for high-risk patients (see chart in annotation #4)

   Poor Response:

   • PEFR or FEV₁ less than 50% predicted normal
   • No improvement in respiratory distress
   • Strongly consider hospitalization
   • Continue inhaled beta₂-agonist every 60 minutes
   • Start oral prednisone unless contraindicated
     • Adult: short course "burst" 40 to 60 mg/day as single or two divided doses for 3 to 10 days
     • Pediatric: short course "burst" 1 to 2 mg/kg day in two divided doses, maximum 60 mg/day for 3 to 10 days

10. Does Patient Need ED or Inpatient Asthma Management?

    A recent study suggests that most children who require hospitalization can be identified by a repeat assessment one hour after initial treatment [D]. After one hour, those children who continue to meet the criteria for a severe exacerbation have greater than 86% chance of requiring hospitalization; those who meet the criteria for moderate exacerbation at one hour have an 84% chance of requiring hospitalization; and those whose assessment has remained the same or dropped to the mild level have only an 18% chance of requiring hospitalization. These severity assessment studies highlight the importance of regular, multifaceted assessments and close observation of children and adolescents who present to the office or ED with acute asthma exacerbations [R].

11. Evaluation

    Evaluation of asthma should include the following:

    • Medical history
    • Use of a validated asthma questionnaire
    • Assess asthma triggers/allergens
    • Physical examination
    • Measure pulmonary function.
    • Consider specialty consultation.

    Medical History

    • Disruption of usual activities (work, school, home)
    • Sleep disturbance
    • Level of usage of short-acting beta₂-agonist
    • Adherence to medical treatment plan
    • Interval exacerbation of symptoms (either treated by self or a health care provider)
    • Symptoms suggesting comorbid conditions or alternative diagnosis
    • Side effects of medications

    Reassessment of medical history can elicit factors that affect overall asthma control and sense of well-being [D]. The key symptoms that should alert the clinician include disruptive daytime symptoms and disturbances of sleep; symptoms early in the morning that do not improve fifteen minutes after short-acting beta₂-agonist are a predictor of poor control. The quantity of short-acting beta₂-agonist that is being used should be discussed since overuse can be a marker of the potentially fatality-prone asthmatic [C]. The use of a quality of life tool or questionnaire can assist to elicit history [D].

    Self-Assessment with a Validated Asthma Questionnaire

    The self-assessment questionnaires that can be completed at office visits are intended to capture the patient's and family's impression of asthma control, self-management skills, and overall satisfaction with care. Several multidimensional instruments have been developed to assess control (http://www.nhlbi.nih.gov/guidelines/asthma/index.htm) [D].

    Assess Asthma Triggers/Allergens

    • Inquire about exposure to triggers and allergens (e.g., occupational, pets, smoke).
    • Allergy testing is recommended for patients with persistent asthma who are exposed to perennial indoor allergens.

    Physical Examination

    • Assess signs associated with asthma, concurrent illness, or medication side effects.
    • Height in children
    • Head, eyes, ears, nose, throat, lungs, heart, skin

    It is important to discuss any potential medication side effects as this often has a direct relationship to compliance. Common side effects from inhaled steroids include oral candidiasis and dysphonia. Beta₂-agonists may cause tachycardia, tremor, or nervousness. Individuals on long-term oral corticosteroids or frequent bursts of steroids need to be monitored for complications of corticosteroids use such as osteoporosis, hypertension, diabetes, and Cushing's syndrome.

    The height of individuals on corticosteroids should be monitored over time. The potential effect on linear growth in children is important because these drugs tend to be used over long periods of time. Cumulative data in children suggest that low-to-medium doses of inhaled corticosteroids may have the potential of decreasing growth velocity, but this effect is not sustained in subsequent years of treatment, is not progressive, and may be reversible [A, R].

    Inhaled glucocorticoids used to treat asthma have been shown to have deleterious effects on bone mineral density and markers of bone mineral metabolism. The risk of fracture attributable to inhaled or nasal glucocorticoids is uncertain [A].

    The remainder of the physical exam either supports or refutes conditions and comorbidities discussed above (see history).

    Measure Lung Function

    It is important to measure lung function at each follow-up visit. The two main methods are spirometry and PEFR. Spirometry is more precise and yields more information than PEFR. It is helpful to verify the accuracy of the peak flow meter. It is useful when certain physical limitations affect accuracy of PEFR (example - very young or elderly, neuromuscular or orthopedic problems) [R].

    Spirometry is recommended:

    • For initial diagnosis or to reassess or confirm diagnosis
    • After treatment is initiated or changed, and once symptoms and PEFR have stabilized to document attainment of "near normal pulmonary function"
    • At least every one to two years to assess maintenance of airway function; more often as severity indicates

    Regular monitoring of pulmonary function is particularly important for asthma patients who do not perceive their symptoms until obstruction is severe [C].

    PEFR:

    • Used for follow-up, not for diagnosis

    PEFR provides a simple, quantitative, and reproductive measure of severity of airflow obstruction. The results are more reliable if the same type of meter, and preferably the patient's own, is used.

    During interval assessment, the clinician should question the patient and review records to evaluate the frequency, severity, and causes of exacerbation. Triggers that may contribute should be reviewed. All patients on chronic maintenance medication should be questioned about exposure to inhalant allergens.

    Consider Specialty Consultation

    Referral is recommended for consultation or care to a specialist in asthma care (allergist or pulmonologist, or other physicians who have expertise in asthma management, developed through additional training and experience) [C] when:

    • Patient has had a life-threatening asthma exacerbation.
    • Patient is not meeting the goals of asthma therapy after three to six months of treatment. An earlier referral or consultation is appropriate if the physician concludes that the patient is unresponsive to therapy.
    • Signs and symptoms are atypical, or there are problems in differential diagnosis.
    • Other conditions complicate asthma or its diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, vocal cord dysfunction [VCD], GERD, chronic obstructive pulmonary disease [COPD]).
    • Additional diagnostic testing is indicated (e.g., allergy skin testing, rhinoscopy, complete pulmonary function studies, provocative challenge, bronchoscopy).
    • Patients require additional education and guidance on complications of therapy, problems with adherence, or allergen avoidance.
    • Patient is being considered for immunotherapy.
    • Patient requires step 4 care or higher. Consider referral if patient requires step 3 care.
    • Patient has required more than two bursts of oral corticosteroids in one year or has an exacerbation requiring hospitalization.
    • Patient requires confirmation of a history that suggests that an occupational or environmental inhalant or ingested substance is provoking or contributing to asthma. Depending on the complexities of diagnosis, treatment or the intervention required in the work environment, it may be appropriate in some cases for the specialist to manage the patient over a period of time or to co-manage with the primary care physician (PCP).

12. Determine Level of Asthma Control

    Key Points:

    • The level of control is based on the most severe impairment or risk category.
    • The level of asthma control (well controlled, not well controlled, or poorly controlled) is the degree to which both dimensions of the manifestations of asthma—impairment and risk—are minimized by therapeutic intervention.
    • The level of control at the time of follow-up assessment will determine clinical actions—that is, whether to maintain or adjust therapy.

    See Table 5, "Assessing Asthma Control in Children 5-11 Years of Age" and Table 6, "Assessing Asthma Control in Youths 12 Years of Age through Adults" in the original guideline document.

13. Step Care of Pharmacologic Treatment

    The aim of asthma therapy is to maintain control of asthma with the least amount of medication and hence minimize the risk for adverse effects. The stepwise approach to therapy, in which the dose and number of medications and frequency of administration are increased as necessary and decreased when possible, is used to achieve this control. Since asthma is a chronic inflammatory disorder of the airways with recurrent exacerbations, therapy for persistent asthma emphasizes efforts to suppress inflammation over the long-term and prevent exacerbations. See tables below for management approach for asthma.

    Based on data comparing leukotriene receptor antagonists (LTRAs) to inhaled corticosteroids, inhaled corticosteroids are the preferred treatment option for mild persistent asthma in adults, and by extrapolation until published data become available, for children. LTRAs are an alternative, although not preferred, treatment. [Conclusion Grade I: See Conclusion Grading Worksheet -- Appendix A - Annotation #13 (Leukotriene Receptor Antagonists [LTRAs]) in the original guideline document.] [A, M, R].

    NOTE: Annual influenza vaccinations are recommended for patients with persistent asthma [R].

    See Appendix B, "Usual Dosages for Quick-Relief Medications" in the original guideline document.

Table. Management Approach for Asthma: Children 5 to 11 Years of Age

Adapted from: Global Initiative for Asthma, 2006; National Heart, Lung, Blood Institute EPR-3, 2007.

Abbreviations: ICS, inhaled corticosteroids; LABA, Long-acting beta₂-agonist

Table. Management Approach for Asthma

12 Years of Age and Older

Adapted from: Global Initiative for Asthma, 2006; National Heart, Lung, Blood Institute EPR-3, 2007.

Abbreviations: ICS, inhaled corticosteroids; LABA, Long-acting beta₂-agonist; IgE, immunoglobulin E.

14. Asthma Education

    Key Points:

    • Asthma self-management education is essential to provide patients with the skills necessary to control asthma and improve outcomes.
    • Asthma self-management education should be integrated into all aspects of asthma care, and it requires repetition and reinforcement.

    Asthma self-management should include:

    • Begin at the time of diagnosis and continue through follow-up care.
    • Involve all members of the health care team.
    • Introduce the key educational messages by the principal clinician, and negotiate agreements about the goals of treatment, specific medications, and the actions patients will take to reach the agreed-upon goals to control asthma.
    • Reinforce and expand key messages (e.g., the patient's level of asthma control, inhaler techniques, self-monitoring, and use of a written asthma action plan) by all members of the health care team.
    • Occur at all points of care where health professionals interact with patients who have asthma, including clinics, medical offices, emergency departments and hospitals, pharmacies, homes and community sites (e.g., schools, community centers).

    Regular review, by an informed clinician, of the status of the patient's asthma control is an essential part of asthma self-management education. Teach and reinforce at every opportunity.

    Supervised self-management (using patient education and adjustments of anti-inflammatory medication based on PEFR or symptoms coupled with regular medical review, utilization of adherence to medication) reduces asthma morbidity. This reduction includes lost work days, unscheduled office visits, and ED and hospital admissions [A, M].

    Refer to the original guideline document for additional information on asthma education including basic facts about asthma, how medications work, inhaler technique, environmental control measures, written asthma action plan, need for adherence, and developing an active partnership with the patient and family.

    Sample Asthma Action Plans are attached in Appendix F of the original guideline document.

    See also Minnesota Department of Health Action Plan at http://www.mnasthma.org/AAP/.

15. Schedule Regular Follow-up Visits

    Asthma is a chronic inflammatory lung disease, and all chronic diseases need regular follow-up visits. Practitioners need to assess whether or not control of asthma has been maintained and if a step down in therapy is appropriate. Further, practitioners need to monitor and review the daily self-management and action plans, the medications, and the patient's inhaler and peak flow monitoring techniques.

    Regularly scheduled follow-up visits are essential to ensure that control is maintained and the appropriate step down in therapy is considered. The exact frequency of visits is a matter of clinical judgment. If asthma is uncontrolled or a change in medication or clinical status has occurred, the patient should be followed in two to six weeks for an evaluation. A stable asthma patient should be followed at regular intervals of one to six months.

Emergency Department or Inpatient Management Algorithm Annotations

18. Assess Severity of Asthma Exacerbation

    See Annotation #5.

21. Initial Treatment

    Also see Annotation #8, "Management of Asthma Exacerbation."

    Usual treatment is with short-acting beta₂-agonist by metered dose inhaler or nebulizer:

    • Albuterol or Albuterol HFA (90 micrograms per puff) 4-8 puffs
    • Albuterol solution 2.5 to 5 mg by nebulizer
    • Levalbuterol MDI solution 1.25 to 2.5 mg by nebulizer

25. Treatment (Incomplete Response)

    Key Points:

    • Systemic corticosteroids should be used for all patients who do not favorably respond to the initial beta₂-agonist therapy.
    • Anticholinergic therapy may increase lung function and may decrease hospital admission rate.

    Corticosteroids

    Parenteral and enteral administration of corticosteroids requires about 6 to 24 hours to be effective. Intravenous (IV) and oral routes of corticosteroid administration appear to be equivalent [A]. Medium to high doses of corticosteroids appear to be better than low doses; however, there is still a large range, roughly 160 mg methylprednisolone per day or 2 mg/kg/day in children. There is no evidence to support very high doses of steroids [A, M]. The National Asthma Education and Prevention Program guidelines recommend that patients admitted to the hospital should receive IV or oral steroids [R].

    There may be a role for inhaled high-dose corticosteroids in the emergency department in addition to the IV or oral route; however, the data do not support this as standard of care at this time [A, M].

    In adult asthmatic cases where intolerance or non-compliance with oral steroid therapy is a concern, consider the use of intramuscular (IM) methylprednisone [A].

    Anticholinergics

    Ipratropium bromide or another anticholinergic may be used as an additional bronchodilator in conjunction with a beta₂-agonist in cases of acute moderate to severe asthma. [Conclusion Grade II: See Conclusion Grading Worksheet B – Annotation #25 (Anticholinergic Therapy) in the original guideline document]. Its most beneficial effects appear to be in multiple doses in more severe exacerbations [M]. Literature has been inconsistent but indicates that anticholinergic therapy may increase FEV₁ or PEFR [A, M], may decrease hospital admission rates slightly [A], may decrease the amount of beta₂-agonist needed, and may prolong bronchodilator effect. These findings were not always statistically significant, and some studies found no benefits [A]. There were no significant adverse reactions. In view of this, it is recommended to consider anticholinergic use in moderate to severe asthma exacerbations [M].

27. Treatment (Poor Response)

    See Appendix A, "Dosages of Drugs for Asthma Exacerbations in the Emergency Medical Care or Hospital" in the original guideline document.

    Key Points:

    • Early intervention with bi-level positive airway pressure may prevent mechanical intubations.
    • Heliox may be a secondary therapy in asthma patients who do not respond to first-line therapies.
    • Ketamine should be considered for use only in severe asthma exacerbations.
    • The decision when to discharge from the emergency department or admit to the hospital must be individualized and depends on response to treatment, pulmonary function and socioeconomic factors.
    • Magnesium sulfate may be beneficial in the treatment of acute asthma.
    • Reassess patients shortly after inpatient admission.

    Intermittent Nebulization versus Continuous Nebulization

    A recent meta-analysis suggests equivalence of continuous versus intermittent albuterol in treating asthma. This is determined by spirometry measurement and rates of admission to the hospital [M]. There does not seem to be any advantage of higher doses of albuterol for continuous nebulization. There was no difference in lung function in patients treated with 7.5 mg or 15 mg of albuterol [A]). Utilizing albuterol and ipratropium bromide continuously versus albuterol alone demonstrated a trend toward improvement in reducing the length of stay in the emergency department and in hospital admission rates [A].

    Bi-level Positive Airway Pressure (Bi-Level PAP)

    Bi-level PAP therapy should be considered for patients presenting with an acute asthma exacerbation. Accumulating studies have shown a benefit in using Bi-level PAP for patients presenting with non-cardiogenic respiratory failure. These studies included, but were not limited to, patients with asthma exacerbations.

    Heliox

    There is not enough evidence from large, prospective, randomized controlled trials to recommend heliox as first-line therapy in patients with asthma exacerbations. However, it is recommended that heliox be considered [M] as a secondary therapy in patients with a severe asthma exacerbation who are not responding to first-line therapies.

    Ketamine

    Ketamine and propofol are anesthetic agents with neuro-regulatory properties resulting in bronchodilation. The use of ketamine has shown benefit in improving airway parameters [D], but increased side effects have resulted in longer hospitalizations [M]. Increased side effects of increased secretions, dysphorea and hallucinations are noted. Clinical data suggests that in the non-intubated patient the side effects may cancel benefit. Some reported case reports suggest benefit in intubated patients [M]. Well-controlled studies are required to make a clear strong recommendation for use. Use of ketamine has been pursued only in severe asthmatic exacerbations.

    Magnesium Sulfate

    There is insufficient evidence to support the routine use of IV magnesium in the emergency room setting [M, R]. However since it is safe and inexpensive, it should be considered for use in patients with severe asthma exacerbations.

    Leukotrienes

    The evaluation of leukotrienes for acute asthma care is in its infancy. Pulmonary function has been shown to improve more rapidly when a leukotriene administered orally is added to the standard therapy of asthma care (beta₂-agonists/corticosteroids) in emergency room settings [R, A]. More studies are needed to confirm these reports.

    Montelukast in acute asthma management has been shown to improve pulmonary function in randomized controlled trials [A]. However, statistical significance could not always be maintained.

    The evidence is too preliminary to recommend leukotriene modifiers in acute asthma exacerbations.

29. Admit to Hospital?

    Also see Annotation #10, "Does Patient Need ED or Inpatient Asthma Management?"

    The decision when to discharge from the ED or admit to the hospital must be individualized and depends on response to treatment, pulmonary function, and socioeconomic factors. It is important to consider risk factors for asthma-related death [R]. Actual length of stay in the ED will vary; some departments have the ability for more extended treatment and observation, provided there is sufficient monitoring and nursing care.

    Response to initial treatment in the ED can be based on a repeat assessment approximately 60 to 90 minutes after initiating bronchodilator therapy, which is a better predictor of the need for hospitalization than is the severity of an exacerbation on presentation [C]. Evaluation includes the patient's subjective response, physical findings, O₂ saturation and measurement of airflow. Other aspects to consider include duration and severity of symptoms, course and severity of prior exacerbations, medications used at the time of the exacerbation, access to medical care and medications, adequacy of support and home conditions, and presence of psychiatric illness. Pretreatment O₂ saturation less than 90%, persisting respiratory acidosis, or severe obstruction that does not improve with the administration of sympathomimetics indicates the need for hospitalization [R].

    Discharge is appropriate if FEV₁ or PEFR has returned to greater than or equal to 80% personal best or predicted, and symptoms are minimal or absent. Patients with an incomplete response (FEV₁ or PEFR 50% to 80%), and with mild symptoms should be assessed individually and may be appropriate for discharge with consideration of the above factors. It is recommended that patients with a rapid good response be observed for 30 to 60 minutes after the most recent dose of bronchodilator to ensure stability of response before being discharged home.

30. Continue Management in Hospital

    Patients being admitted from the ED with an acute asthma exacerbation should be reassessed shortly after admission, with special emphasis on whether the patient is showing any clinical signs of improvement or deterioration (see Annotation #5, "Assess Severity of Asthma Exacerbation"). Objective data should include repeating of the patient's FEV₁ or PEFR. A complete physical exam should include emphasis on the patient's respiratory rate, air entry on lung exam, and the presence/absence of signs of increased work of breathing, such as supraclavicular or intercostal retractions.

    Consider other illnesses and comorbidities. These may also cause dyspnea, chest tightness and wheezing.

    • Viral pneumonitis
    • Pneumothorax
    • Pulmonary embolism
    • Vocal cord dysfunction syndrome
    • Chronic obstructive pulmonary disease
    • Pulmonary edema
    • Endobronchial obstruction (tumor or foreign body)
    • Acute hypersensitivity pneumonitis
    • Epiglottitis [D]

32. Discharge Home

    Key Points:

    • At discharge, provide patients with necessary medications and education in how to use them, instruction in self-assessment, an action plan for managing recurrence of airflow obstruction, and a follow-up appointment.

    It is recommended that follow-up with an asthma care provider occur within one week of discharge.

    Medications

    See the table below for hospital discharge checklist for patients with asthma exacerbations.

    • Inhaled beta₂-agonist every two to six hours.
    • Systemic corticosteroids are almost always the treatment of choice in patients with acute asthma exacerbation. Corticosteroids aid symptom resolution and prevent asthma relapse.
    • Initiate or increase anti-inflammatory medication:
      • Inhaled corticosteroids

        The role of inhaled corticosteroids after an emergency room visit is controversial [M, A]. However, it is the consensus of the guideline development group that inhaled corticosteroids should be encouraged at the time of discharge.

      • Consider leukotriene modifiers as an additive therapy.
    • Antibiotics are not routinely used but may be warranted if patient has signs of acute bacterial infection, fever and purulent sputum.
    • Long-acting beta₂-agonists as monotherapy are NOT recommended.

    See Annotation #14 for asthma education and action plan.

    See Annotation #15 for follow-up care.

    Table. Hospital Discharge Checklist for Patients with Asthma Exacerbations

    Intervention	Dose/Timing	Education/Advice
    Inhaled medications (metered-dose inhaler + spacer/holding chamber) Beta2-agonist Corticosteroids	Select agent, dose, and frequency (e.g., albuterol) 2-6 puffs every 3-4 hours as needed Medium dose	Teach purpose. Teach technique Emphasize need for spacer/holding chamber. Check patient technique.
    Oral medications	Select agent, dose and frequency (e.g., prednisone 20 mg twice daily for 3-10 days)	Teach purpose. Teach side effects.
    Peak flow meter	Measure a.m. and p.m. PEF and record best of three tries each time.	Teach purpose. Teach technique. Distribute peak flow diary.
    Follow-up visit	Make appointment for follow-up care with primary clinician or asthma specialist.	Advise patient (or caregiver) of date, time, and location of appointment within 7 days of hospital discharge.
    Action plan	Before or at discharge	Instruct patient (or caregiver) on simple plan for actions to be taken when symptoms, signs, and PEF values suggest recurrent airflow obstruction.

    Source: National Heart, Lung, Blood Institute EPR-2, 1997

    Special Populations

    Asthma in Pregnancy

    The goals of asthma management in pregnancy include reducing medication toxicity, teratogenicity and preserving uteroplacenta circulation. Changes in the mother's asthma status are expected in almost half of patients, with half of these expecting a worsening of asthma status, particularly if previous pregnancies had similar outcomes. Typical changes of pregnancy—those of increased heart rate, respiratory rate and decreases in baseline CO₂ levels—can lead to underdiagnosing asthma severity if not recognized.

    The treatment of acute asthma in pregnancy follows the guidelines for acute asthma care, keeping in mind the goals of the management and changes in physiology.

    Albuterol is the preferred short-acting beta₂-agonist and has not been linked to adverse fetal outcomes in follow-up studies. Inhaled corticosteroids (ICS) are the preferred treatment for long-term control medication. Budesonide is the preferred ICS because more data are available on using budesonide in pregnant women than are available on other ICSs, and the data are reassuring [R]. Systemic steroids, if used in the first trimester, may, though rarely, increase the frequency of cleft palate and possibly be associated with development of preeclampsia. However, the risk to both mother and fetus of an unmanaged severe asthmatic attack overshadows the medication observed risks [R].

Definitions:

Classes of Research Reports

1. Primary Reports of New Data Collection:

   Class A:

   • Randomized, controlled trial

   Class B:

   • Cohort study

   Class C:

   • Non-randomized trial with concurrent or historical controls
   • Case-control study
   • Study of sensitivity and specificity of a diagnostic test
   • Population-based descriptive study

   Class D:

   • Cross-sectional study
   • Case series
   • Case report

2. Reports that Synthesize or Reflect upon Collections of Primary Reports

   Class M:

   • Meta-analysis
   • Systemic review
   • Decision analysis
   • Cost-effectiveness study

   Class R:

   • Consensus statement
   • Consensus report
   • Narrative review

   Class X:

   • Medical opinion

Conclusion Grades

Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.

Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is uncertainty attached to the conclusion because of inconsistencies among the results from different studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.

Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results from different studies or because of serious doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.

Grade Not Assignable: There is no evidence that directly supports or refutes the conclusion.

• Diagnosis and Management of Asthma
• Emergency Department or Inpatient Management

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

• Diagnosis and management of asthma: percentage of patients with asthma with spirometry or peak flow meter reading documented in the medical record at the last visit.


• Diagnosis and management of asthma: percentage of children with uncontrolled asthma who are on inhaled corticosteroids medication.


• Diagnosis and management of asthma: percentage of adults with uncontrolled asthma who are on inhaled corticosteroids medication.


• Diagnosis and management of asthma: percentage of patients with asthma with education about asthma documented in the medical record.

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org.

ICSI's conflict of interest policy and procedures are available for review on ICSI's Web site at www.icsi.org.

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

• Diagnosis and management of asthma. Executive summary. Bloomington (MN): Institute for Clinical Systems Improvement, 2008 Mar. 1 p. Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.
• Health care order set: admission for asthma order set. Bloomington (MN): Institute for Clinical Systems Improvement, 2008 Jan. 18 p. Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.
• ICSI pocket guidelines. May 2007 edition. Bloomington (MN): Institute for Clinical Systems Improvement, 2007.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

Additionally, a sample asthma action plan can be found in Annotation Appendix E in the original guideline document. Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

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