Management of acute asthmatic attacks in a local emergency department before and after the introduction of guidelines

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1 Hong Kong Journal of Emergency Medicine Management of acute asthmatic attacks in a local emergency department before and after the introduction of guidelines SH Tsui, ASK Sham, M Chan-Yeung, HK Tong Introduction: Objective assessment and management of acute asthma is often sub-optimal in busy emergency departments. This study examined the effect of the introduction of guidelines on asthma management in the emergency department. Materials & Methods: All patients (>2 years old) presented to the emergency department for acute asthmatic attacks over a period of 1 year were included. Guidelines for the management of acute asthma were introduced after the first quarter of the study year. Analysis was made to compare the assessment, treatment and discharge planning of patients presenting with acute asthma to the emergency department before and after the introduction of the guidelines. Results: After the introduction of the guidelines, there was a significant increase in the measurement of peak expiratory flow rate (PEF) and oxygen saturation as part of patient assessment for asthma severity. Such an improvement did not result in a change in hospital admission rate. There was a significant increase in the proportion of patients discharged with a course of oral corticosteroids, a significant reduction in the use of oral bronchodilators in the younger age group and antibiotics in the older age group. Conclusions: The introduction of guidelines for the management of acute asthma and education of the clinicians in the emergency department has resulted in improvement in the overall management and discharge planning for asthma patients. (Hong Kong j.emerg. med. 2002;9: ) Keywords: Acute asthma, emergency department, guidelines, peak expiratory flow rate Introduction Asthma is a common and potentially life threatening disease. The hospital emergency department serves an important role in the management of acute asthmatic attacks. It provides resuscitation for patients suffering from life threatening attacks, identifies those who need in-patient care, delivers emergency treatment and Correspondence to: Tsui Sik Hon, MBBS, FHKCEM, FHKAM(Emergency Medicine) Queen Mary Hospital, Accident and Emergency Department, 102 Pokfulam Road, Pokfulam, Hong Kong mshtsui@netvigator.com Tong Hon Kuan, MBBS, FHKCEM, FHKAM(Emergency Medicine) Queen Mary Hospital, Department of Medicine, 102 Pokfulam Road, Pokfulam, Hong Kong Sham Sze King, Arthur, MSc Chan-Yeung, Moria, FRCPC, FCCP arranges appropriate referral for those with milder attacks. However, studies have identified common problems in the management of this condition by clinicians in emergency departments. These often include the lack of objective measurement of airflow obstruction, over-reliance on beta-2-agonist and insufficient use of systemic steroids, and poor followup arrangement. 1-3 Several guidelines have been published to help clinicians improve and maintain the standard of care. 4-8 The objective of this study was to assess the management of patients with asthma who attended the emergency department of a hospital before and after the introduction of guidelines for management of these patients. Materials and methods Patients who were seen in the emergency department of a regional teaching hospital with a diagnosis of

2 132 Hong Kong j. emerg. med.! Vol. 9(3)! Jul 2002 asthma between 18th August 1998 and 17th August 1999 were subjects of this study. Those who were entered into the study must be over the age of 2 years and demonstrated an improvement in peak expiratory flow rate (PEF) by more than 15% after the inhalation of an aerosol bronchodilator or before discharge from the emergency department. If no measurement of PEF was obtained, the patient must have a compatible clinical history and documented improvement in other parameters such as improvement in breathing, heart rate or arterial oxygen saturation; or a previous history of emergency admission for treatment of asthma and documented improvement in PEF before and after aerosol bronchodilator at that time. The information obtained included demographic data, date and time of visits; blood pressure, pulse rate, respiratory rate, oxygen saturation (SpO 2 ) and peak expiratory flow rate (PEF) before and after the inhalation of an aerosol bronchodilator; treatment given in the emergency department such as oxygen, -agonist (salbutamol) inhalation, steroids (oral or IV). The outcome (admitted, discharged or discharged against medical advice); discharge plan (with or without follow up, discharged with referral) and discharge medications (aerosol bronchodilator, oral bronchodilator, oral steroid, antibiotics and others, e.g. antihistamines, cough mixtures and antipyretics) were also obtained. Guidelines for the management of asthma in the emergency department based on the recommendation of the British Thoracic Society 4 were introduced on 15th November (Appendix 1) The guidelines emphasized on the use of objective parameters such as measurement of PEF in the assessment of patients. It recommended the early and liberal use of corticosteroids and inhaled bronchodilators in the emergency department. The flow chart of the British Thoracic society was posted up for reference. The medical and nursing staff of the emergency department were briefed on the guidelines; they were also encouraged to follow the guidelines during department staff meetings. On the 10th February, a special form (asthma form) to enhance the management of patients with asthma was also introduced. (Figure 1) The form allowed the staff to enter relevant history (previous history of asthma, use of asthma medications), PEF measurements before and after bronchodilator and before discharge. The staff was encouraged to complete the form on each patient with asthma. Analysis The following periods were compared: Period 1 before the introduction of guidelines, 18th August to 14th November 1998; Period 2 two weeks after the introduction of the guidelines until the introduction of the asthma form, 30th November 1998 to 10th February 1999; Period 3 two weeks after the introduction of the "asthma form" until the end of the study, 25th February 1999 to 24th May 1999; and Period 4 from 25th May to 17th August This period was used to observe the performance of the staff about six months after the introduction of the guidelines. Patients were divided into those under the age of 15 (Paediatrics) and those aged 15 years and above (Adults). Patient management such as performance and recording of physical findings, investigations, treatment, outcome and discharge planning during periods 2, 3 and 4 were compared with period 1 for each of the two age groups. Chi-square tests, corrected for multiple comparisons, were used to test for differences between periods for discrete variables while Scheffe multiple range tests were used to test for differences between periods for continuous variables. Results There were 1206 visits to the emergency department from 18th August 1998 to 17th August The utilization rate of the "asthma form" was 63% in period 3 and increased to 80% in period 4.

3 Tsui et al./asthma management before & after introduction of guidelines 133 History Chief complaint/duration Associated Symptoms Consulted *GP/GOPD/A&E *Yes/No this attack? Progress? Details of last attack: When? Lasted for? Admitted? No. of attacks (Unscheduled visits to doctors) last 12 months Previous ICU Admission *Yes/No *Smoker/Non-smoker Packs/day Usual FU Clinic *Sp OPD/GOPD/GP/prn Usual Medications: *Inhaled β-agonist/inhaled Steroids/Oral Steroids/Theophyllines Others/Remarks Other Medical Illnesses: Physical Examination O Wheeze X Crepitation Other PE Findings: *Predicted/Personal Best PFR l/min Progress: Data Initial Assessment 2nd Assessment 3rd Assessment Time Pulse Rate/PR / / / SaO 2 (*Rm Air/ %O 2 ) % % % PFR l/min l/min l/min % of predicted PFR % % % Remarks *Circle if appropriate Figure 1. Asthma History Sheet. Table 1 shows the characteristics of the patients and the results of the assessment, treatment, outcome, discharge planning, and discharge medications during each period for patients under 15 years of age. Before the introduction of the guidelines, 87% of patients had determination of respiratory rate; about half had measurement of blood pressure and SpO 2 and one quarter had measurement of PEF. After the introduction of the guidelines, there was a significant increase in each of the subsequent period (period 2, 3, and 4 vs. 1) in the proportion of patients who had measurement of oxygen saturation and PEF before and after the inhalation of an aerosol bronchodilator. However, the proportions of patients who had PEF measurements were still around 50%. The proportion of patients <15 years of age treated with oxygen, -agonists and systemic steroids while in the emergency department increased from period 1 to period 2 and continued in the same level for periods 3 and 4. The increase, however, was not statistically significant. The proportion of admissions to the hospital for further treatment was lower, but not significant, during periods 3 and 4 compared to periods 1 and 2. The proportion of patients given oral steroids on discharge significantly increased in periods 2, 3, and 4 compared to period 1. This was accompanied by a significant reduction in the percentage of patients prescribed oral bronchodilators. Antibiotics were prescribed less frequently to patients in periods 3 and 4 compared to periods 1 and 2. The findings among patients 15 years of age are shown in Table 2. The proportion of patients who had oxygen saturation measured in period 1 was higher than those under the age of 15 (85.6%), increased to

4 134 Hong Kong j. emerg. med.! Vol. 9(3)! Jul 2002 Table 1. Patient assessment, treatment, outcome, and discharge planning and medications by periods of study (<15 years of age)+ Period 1 Period 2 Period 3 Period 4 N History n (%) Male 69 (66.3) 85 (59.4) 71 (60.2) 61 (67.0) Previous history of asthma 86 (82.7) 119 (83.2) 106 (89.8) 82 (90.1) Physical examination n (%) Blood pressure 56 (53.8) 90 (62.9) 76 (64.4) 55 (60.4) Pulse 104 (100.0) 143 (100.0) 118 (100.0) 91 (100.0) Respiratory rate 91 (87.5) 122 (85.3) 109 (92.4) 85 (93.4) Oxygen saturation 55 (52.9) 95 (66.4) 92 (77.9)* 79 (86.8) PEF before bronchodilator 27 (25.9) 75 (52.4)* 65 (55.1)* 44 (48.4)* after bronchodilator 27 (25.9) 74 (51.7)* 63 (53.4)* 47 (51.6)* Treatment n (%) Oxygen 86 (82.7) 128 (89.5) 110 (93.2) 83 (91.2) -agonists by inhalation 97 (93.3) 143 (100.0) 116 (98.3) 90 (98.9) Systemic steroids 3 (2.9) 6 (4.2) 8 (6.8) 10 (11.0) Outcome n (%) Admitted 44 (42.3) 62 (43.4) 41 (34.7) 35 (38.5) Discharged home 49 (47.7) 57 (39.9) 53 (44.9) 36 (39.6) Discharged with referral 9 (8.7) 18 (12.6) 16 (13.6) 16 (17.6) Discharged with follow up 2 (1.9) 2 (1.4) 5 (4.2) 1 (1.1) Discharge medications n agonist by inhalation 11 (18.3) 28 (34.6) 30 (39.0) 21 (37.5) Oral steroids 7 (11.7) 35 (43.2)* 53 (68.8)* 40 (71.4)* Oral bronchodilators 32 (53.3) 21 (25.9)* 20 (26.0)* 12 (21.4)* Antibiotics 18 (30.0) 25 (30.9) 12 (15.6) 12 (21.4) + N and (%) represent the number and % of patients who had measurement or treatment or various medications prescribed on discharge * Differences between periods 2, 3, 4 and 1 significant at p <0.016 (corrected for multiple comparison) 96.5% in period 4. A significantly higher proportion of patients had PEF measurements during periods 2, 3, and 4 compared to period 1. There was also no change in the proportion of hospital admissions but the proportion of patients who were discharged with a referral to outpatient or specialist clinics increased from 9.1% during period 1 to 18.8% during period 4. Among those who were discharged, only 35.9% were given a short course of oral steroids in period 1; the proportion increased significantly in the subsequent periods with 79% given this drug in period 4. The proportion given antibiotics decreased significantly in periods 3 and 4 compared to period 1. Tables 3 and 4 compare the severity of asthma in patients who were admitted to hospital with those who were discharged after treatment in the emergency department for periods 1 and 2 for both age groups. In both age groups, patients who were admitted had higher mean pulse rate, respiratory rate and lower mean oxygen saturation and PEF (before and after bronchodilator) to suggest that they had more severe asthma compared to those who were discharged. The differences were statistically significant for most of the parameters. The severity of asthma (pulse rate, respiratory rate, oxygen saturation and PEF) for those admitted into hospital was compared between the periods of study (periods 1 to 4). While differences were found among those in the younger age group with patients seen during period 1 having more severe asthma (higher respiratory rate and lower oxygen saturation) than those in period 2, differences were not found between any periods among the older age group (data not shown).

5 Tsui et al./asthma management before & after introduction of guidelines 135 Table 2. Patient assessment, treatment, outcome, and discharge planning and medications by periods of study ( 15 years of age)+ Period 1 Period 2 Period 3 Period 4 N History n (%) Male 67 (50.3) 105 (52.5) 74 (45.4) 80 (55.6) Previous history of asthma 122 (92.4) 183 (91.5) 150 (92.0) 138 (95.8) Physical examinations n (%) Blood pressure 131 (99.2) 200 (100.0) 163 (100.0) 143 (99.3) Pulse 131 (99.2) 200 (100.0) 163 (100.0) 144 (100.0) Respiratory rate 100 (75.8) 163 (81.5) 147 (90.2)* 139 (96.5)* Oxygen saturation 113 (85.6) 172 (86.0) 143 (87.7) 139 (96.5) PEF before bronchodilator 93 (70.5) 174 (87.0)* 141 (86.5)* 128 (88.9)* after bronchodilator 96 (72.7) 169 (84.5)* 135 (82.8) 130 (90.3)* Treatment n (%) Oxygen 110 (83.3) 176 (88.0) 147 (90.2) 137 (95.1) -agonists by inhalation 131 (99.2) 193 (96.5) 160 (98.2) 142 (98.6) Systemic steroids 12 (9.1) 36 (18.0) 36 (22.1) 47 (32.6) Outcome n (%) Admitted 40 (30.3) 68 (34.0) 54 (33.1) 39 (27.1) Discharged home 72 (54.5) 91 (45.5) 73 (44.8) 72 (50.0) Discharged with referral 12 (9.1) 25 (12.5) 26 (16.0) 27 (18.8) Discharged with follow up 3 (2.3) 4 (2.1) 2 (1.2) 0 (0) Discharge medications n agonist by inhalation 47 (51.1) 72 (55.3) 52 (47.7) 63 (60.0) Oral steroids 33 (35.9) 77 (58.3)* 80 (73.4)* 83 (79.0)* Oral bronchodilators 30 (32.6) 32 (24.2) 25 (22.9) 26 (24.8) Antibiotics 36 (39.1) 35 (26.5) 23 (21.1)* 19 (18.1)* + N and (%) represent the number and % of patients who had measurement or treatment or various medications prescribed on discharge * Differences between periods 2, 3, 4 and 1 significant at p <0.016 (corrected for multiple comparison) Table 3. Comparison of asthma severity for those admitted into hospital and those discharged during baseline (period 1) Under 15 years of age Age 15 years and over Admitted (44) Discharged (60) Admitted (40) Discharged (92) Age years (mean and sd) 5.0±2.8 (44) 6.9±3.3 (60)* 53.4±37.6 (40) 37.6±16.8 (92)* Pulse (beats/min) 129±20.5 (44) 114±18 (60)* 101±24 (40) 92±18 (91)* Respiratory rate (n/min) 34.4±8.9 (38) 28.3±6.1 (53)* 27.9±6.3 (31) 23.3±4.8 (69)* SpO 2 % 91.9±5.9 (22) 95.2±2.9 (33)* 94.8±3.6 (36) 96.4±1.9 (77)* PEF (L/min) before bronchodilator 78±36 (6) 146±75 (21)* 164±66 (19) 258±102 (74)* after bronchodilator 152±86 (6) 208±82 (21) 212±83 (20) 338±113 (76)* *p <0.05 by unpaired t test for differences between those admitted and those discharged Table 4. Comparison of asthma severity for those admitted into hospital and those discharged during baseline (period 2) Under 15 years of age Age 15 years and over Admitted (62) Discharged (81) Admitted (68) Discharged (132) Age years (mean and sd) 6.1± ±3.7* 56.5±22.5 (68) 34.3±15.3 (132)* Pulse (beats/min) 120±24 (62) 114±19 (81) 110±18 (68) 96±19 (132)* Respiratory rate (n/min) 28.9±6.6 (56) 26.0±5.1 (66)* 26.7±5.0 (54) 23.5±4.3 (109)* SpO 2 % 94.6±2.5 (39) 95.5±2.7 (56) 93.9±3.1 (63) 96.1±2.7 (109)* PEF (L/min) before bronchodilator 138±85 (24) 193±90 (51)* 168±74 (47) 259±101 (127)* after bronchodilator 152±88 (24) 246±92 (50)* 214±77 (47) 350±104 (122)* *p <0.05 by unpaired t test for differences between those admitted and those discharged

6 136 Hong Kong j. emerg. med.! Vol. 9(3)! Jul 2002 Discussion In this study we found that there were deficiencies in the assessment, treatment and discharge planning of patients with asthma in the emergency department in a local hospital. The introduction of guidelines for management of these patients and the education of the medical staff resulted in a significant improvement in the management of these patients. Before the introduction of the guidelines, the assessment of asthma patients was not adequate as not all patients had their vital signs and oxygen saturation measured or recorded. PEF was only recorded in a quarter of patients below the age of 15 years and about 70% in those over the age of 15 years. For patients younger than the age of 6 years, it is not easy nor possible to measure PEF but measurement of oxygen saturation should be possible. After the introduction of the guidelines and the education of the medical and nursing staff, assessment of asthma severity improved: a significantly higher percentage of patients in both age groups had measurement of oxygen saturation and PEF before and after inhalation of an aerosol bronchodilator. Our findings are in keeping with a recent study by Emonds and colleagues 9 who found a significant increase in the percentage of patients who had PEF measurement after the introduction of guidelines for the management of asthma in the emergency department. The use of systemic steroids for treatment of acute asthma attacks in the emergency department was low. The introduction of the guidelines resulted in an increase in the percentage of patients who received systemic steroids in the emergency department but the overall proportion was still low during period 4 (11% and 32.6% respectively for the two age groups). Early use of systemic steroids in the emergency department has been shown to reduce hospital admission rate for patients with acute asthma. 10 It is desirable to give systemic steroids to all patients in the emergency department if there is no contraindication. The increase in the use of objective measurements of asthma severity such as measurement of oxygen saturation and PEF did not change the proportion of admissions to the hospital. This suggests that other criteria were used, in addition to objective measurements, in making decisions for hospital admission. During the period immediately after the introduction of the guidelines, patients in the younger age group who were admitted tend to have less severe asthma. Abishegamanaden and coworkers 11 compared the outcome of patients who followed two different protocols in the emergency department in a hospital in Singapore and found that the PEF guided protocol (discharge for those whose PEF reached >60% predicted) resulted in a higher rate of hospital admission than those that followed the usual routine without including PEF. In two other studies, the most important predictor for hospital admission was the degree of dyspnoea although objective measurements such as PEF and oxygen saturation were helpful adjuncts for decision making. 12,13 The proportion of hospital admissions from the emergency department for asthma varied considerably between reports from different countries, being lowest in Doha, Qatar 14 where only 7.5% of all emergency department visits for asthma were admitted to hospital for all age groups. For adults, the rate of hospital admission in Hong Kong is comparable to those reported in the United Kingdom 15 and New Zealand 16 but higher than that reported in Toronto, Canada (16%). 16 It is difficult to compare the hospital admission rate in different countries as hospital admission is dependent on many factors such as the availability of beds, the severity of asthma and type of asthma management programs available in the community. Asthma is a chronic disease and requires long-term treatment with anti-inflammatory drugs for those with persistent symptoms. After treatment for the acute episode in the emergency department, it is necessary to provide continued care for the patient. The introduction of the guidelines has resulted in better discharge planning with more patients being referred for follow-up in outpatient clinics or specialist clinics. Referral to asthma specialists has been shown to reduce relapses in asthma emergency room visits. 17 Although the proportion referred for follow-up treatment after

7 Tsui et al./asthma management before & after introduction of guidelines 137 discharge was still relatively low, many patients who were not referred had regular follow-up by their family physicians or some out-patient clinics. The most important change with the introduction of the guidelines was the change in the prescribing pattern of the physicians for patients with asthma at the time of discharge from the emergency department. A significantly high proportion of patients was given a course of oral steroids on discharge accompanied by a reduction in the prescription of oral bronchodilators in the younger age group and antibiotics in the older age group. A short course of oral steroids after emergency room treatment of acute asthma has been shown to be effective in the prevention of early relapse. 18 Inhaled steroids were not available for physicians in the emergency department during the study period but were readily available in all the out-patient clinics that provided the follow-up care of the patients. We did not conduct a follow-up study of these patients to find out whether the early relapse rate has been reduced as a result of a short course of oral steroids. The improvement of patient assessment and treatment continued 9 months after the introduction of the guidelines. The introduction of a special "asthma form" 3 months after the introduction of the guidelines might have served as a useful reminder to the physicians in the emergency department and has helped to reinforce the guidelines. Conclusion Guidelines for the management of asthma and education of the clinicians in the emergency department are useful in improving the overall management and better discharge planning for these patients. Consideration should be given to introduce such guidelines for the management of asthma to all emergency departments. References 1. Reed S, Diggle S, Cushley MJ, et al. Assessment and management of asthma in an accident and emergency department. Thorax 1985;40(12): Kwong T, Town I, Holst PE, et al. A study of the management of asthma in a hospital emergency department. NZ Med J 1989;102(878): Ebden P, Carey OJ, Quinton D, et al. A study of acute asthma in the accident and emergency department. Br J Dis Chest 1988;82(2): The Guidelines Coordinating Committee. Guidelines on asthma management. Thorax 1997;52(suppl 1):S1-S Beveridge RC, Grunfeld AF, Hodder RV, et al. Guidelines for the emergency management of asthma in adults. CAEP/CTS Asthma Advisory Committee. Canadian Association of Emergency Physicians and the Canadian Thoracic Society. CMAJ 1996;155(1): Woolcock A, Rubinfeld J, Scale JP, et al. Thoracic Society of Australia and New Zealand. Asthma management plan, Med J Aust 1989;151(11-12): Expert panel on the management of asthma: gudielines for the diagnosis and management of asthma. Expert Panel Report (NIH publ no ) National Asthma Education Program, National Heart, Lung, and Blood Institute, National Institute of Health, Bethesda, MD Hargreave FE, Dolovich J, Newhouse MT. The assessment and treatment of asthma: a conference report. J Allergy Clin Immunol 1990; 85(6): Emond SD, Woodruff PG, Lee EY, et al. Effect of an emergency department asthma program on acute asthma care. Ann Emerg Med 1999;34(3): Bowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids (Cochrane Review). In The Cochrane Library, Issue 3, Oxford: Update Software. 11. Abisheganaden J, Ng SB, Lam KH, et al. Peak expiratory flow rate guided protocol did not improve outcome in emergency room asthma. Singapore Med J 1998;39(11): Kerem E, Tibshirani R, Canny G, et al. Predicting the need for hospitalization in children with asthma. Chest 1990;98(6): Kunitoh H, Nagatomo A, Okamoto H, et al. Predicting the need for hospital admission in patients with acute bronchial asthma. J Asthma 1996;33(2): Dawod ST, Ehlayel MS, Osundwa VM. Acute asthma: treatment and outcome of 2000 consecutive pediatric emergency room visits in Doha, Qatar. J Asthma 1996; 33(2): Chidley KE, Wood-Baker R, Town GI, et al. Reassessment of asthma management in an accident and emergency department. Respir Med 1991;85(5): Rea HH, Garrette JE, Mulder J, et al. Emergency room care of asthmatics: a comparison between Auckland and Toronto. Ann Allergy 1991;66(1): Zeiger RS, Heller S, Mellon MH, et al. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol 1991; 87(6): Chapman KR, Verbeek PR, White JG, et al. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. N Engl J Med 1991;324(23):

8 138 Hong Kong j. emerg. med.! Vol. 9(3)! Jul 2002 Appendix 1. Guidelines for the management of acute asthmatic attacks in emergency department Triage Nurse 1. Assess severity and give appropriate triage category. 2. Measure vital signs including: i) BP/P ii) Temperature/SpO 2 iii) Resp. Rate iv) Peak Flow Rate (PEF) in all patients except the very young (<5 yr.) and the very sick. Please comment if patient's technique is poor. v) Ask for patient's Body Height (in metre) N.B. 1 inch = 2.54 cm If patient does not know his Body Height, measure it after initial stabilization and treatment. vi) Document predicted PEF by referring to Normogram. 3. Give oxygen if necessary. Case Medical Officer 1. Assess severity of attack by: i) Patient's past history and details of present episode. Note previous A&E visits, hospitalizations, intubations and current anti-asthma medications. ii) Physical Examination. iii) Percentage of predicted PEF or best PEF (if Known). iv) Perform appropriate investigation if necessary: ABG (SpO 2 <92), electrolytes, CXR etc. Try to categorize patient's attack into various levels of severity. 2. Manage patient with reference to flow charts issued by British Thoracic Society. Points to Emphasize: 1. Inhaled salbutamol may be given every 20 min or even continuously in the initial period if the response is not satisfactory. 2. Early and more liberal use of corticosteroid is recommended for asthmatic attacks. Recommended initial dosage is 40 mg of prednisone/prednisolone po or 200 mg of hydrocortisone IV. 3. Admission to O room can be considered for patients with moderate attacks and severe attacks who show good response to initial treatment. 4. Consider direct ICU admission for patients with life threatening attacks. 5. Refer to Paediatrics Flow Charts for management of children. 6. Blacken the special case B1 circle for all asthma patients for statistical purpose. Actions on Discharge 1. Identify and treat trigger factor. 2. Give maintenance oral steroid. The recommended dosage is prednisone/prednisolone 30 mg/day (0.6 mg/kg) for 1 week. No tapering off is needed. 3. Routine use of antibiotics is not recommended. 4. Inhaled -agonist gives fewer side effects than oral one. 5. Check drug delivery technique. 6. Make sure that patient has adequate FU or referral arrangement: Medical/GP/GOPD/A&E/PRN Charts for Reference: 1. Flow charts for Management of asthma in A&E Dept. by British Thoracic Society. (Adults and Children) 2. Predictive Normogram for PEF - Chinese Males and Females.

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