Current therapeutic practice in the management of acute severe asthma

A retrospective comparative study of in-hospital management of acute severe asthma: 1984 vs 1989

Recent controversies examining the management of acute asthma prompted us to investigate whether there had been any significant changes in our management practices. We therefore audited the charts of all patients admitted to a large tertiary-care university-affiliated hospital with a primary diagnosis of acute asthma during the years of 1984 and 1989. A total of 67 patients' charts were reviewed (39 in 1984 and 28 in 1989). The mean age and initial flow rates (FEV1 or peak expiratory flow rate [PEFR]) were similar. In the emergency room, chest radiographs and arterial blood gas analyses were done more frequently than objective measures of flow. Fifty-one percent (20/39) of the patients had no measurement of flow in the emergency room in 1984 and 39 percent (11/28) in 1989 (p > 0.05). In both years, approximately 20 percent of the patients had no record of flow rates during their hospitalization (21 percent [8/39] in 1984 and 18 percent [5/28] in 1989). More studies of the blood were ordered in 1989, including hepatic enzyme and electrolyte measurements for no clear reasons. The clinical utility of chest radiographs was negligible. While the vast majority of patients received systemic corticosteroids in both years (85 percent [33/39] in 1984 and 96 percent [27/28] in 1989), 23 percent (9/39) and 18 percent (5/28) were discharged without oral steroid therapy in 1984 and 1989, respectively (p > 0.05). There was a significant decline in the use of aminophylline (95 percent [37/39] to 54 percent [15/28]; p < 0.05) and an increase in the use of ipratropium bromide (15 percent [6/39] to 75 percent [21/28]; p < 0.05) in 1989. Theophylline levels were less likely to be measured in 1989, and the majority of levels in both years were either subtherapeutic or toxic. No patients were discharged with peak flow meters or recorded action plans, although follow-up arrangements were recorded in 87 percent (34/39) and 96 percent (27/28) of the patients in 1984 and 1989. We conclude that while improvements in in-hospital management of asthma were noted in 1989, suboptimal management practices are still common.

Reversible T-wave abnormality in severe acute asthma: an electrocardiographic sign of severity

Reversible electrocardiographic (ECG) abnormalities are well recognized in severe acute asthma. Inferior lead T-wave abnormalities have only rarely been reported, and their frequency and significance have not been well documented. We studied 70 consecutive patients with severe acute asthma on admission to hospital and during recovery, in order to examine the frequency and natural history of such changes and to document their relationship to the severity of the attack. Twenty-two patients (34%) had inferior lead T-wave inversion on ECGs performed within 1 h of admission (group 1), whereas the rest did not (group 2). Apart from sinus tachycardia this was the most common ECG abnormality. Patients with inferior T-wave inversion were found to have more severe asthma in terms of degree of pulsus paradoxus, peak expiratory flow rate, forced expiratory volume in 1 s and arterial blood oxygen tension. Ten group 1 and ten group 2 patients underwent two-dimensional echocardiography during the acute phase of their illness and during recovery. Six (60%) group 1 patients showed echocardiographic evidence of right ventricular pressure overload compared with only one (10%) patient in group 2 (P less than 0.02). Following recovery, voluntary hyperventilation and exercise testing in ten group 1 patients failed to reproduce the ECG changes seen on admission. Reversible inferior lead T-wave abnormalities may occur in the severe acute asthma and appear to be related to the severity of the attack.

Trends and district variations in the hospital care of childhood asthma: results of a regional study 1970-85

Trends and district variations in the pre-hospital and hospital care of children aged 0-14 years admitted with acute asthma were surveyed in all 13 districts of a health region by examining case notes for 1970, 1978, and 1985. From 1970 to 1985 there was a substantial increase in admissions and some reduction of hospital stay. Over this time adrenergic drugs remained the most frequently used treatment with a large shift towards selective beta2 agonists administered by nebulisation. Use of corticosteroids fell in the under 5s with a decrease in the parenteral route of administration but rose in the 5-14 age group with an increase in the oral route of administration. There was an increase the use of oral xanthines but this was outweighed by falls in the use of suppositories and in parenteral administration. The use of antibiotics became less frequent and that of sedatives and antihistamines fell to almost nil. There were also important changes in other aspects of management, notably an increase in the use of lung function tests (from 3% to 70%) and falls in the use of chest radiographs, blood tests, bacteriology, and physiotherapy. In nearly all aspects of management there were significant and often very extreme variations in practice between districts, which were unlikely to be explained by differences in morbidity. These variations would be a suitable focus for medical audit, with the aim of establishing which treatment regimens have the best outcome and avoiding unnecessary cost and discomfort. Because early hospital drug treatment is closely related to the type of treatment given before admission such audit activities would need to include general practitioners.

Changes in hospital management of acute severe asthma by thoracic and general physicians in Birmingham and Manchester during 1978 and 1985

Hospital management of acute severe asthma in 14 large hospitals in Birmingham and Manchester was audited in a random 20% of 1196 patients aged 15-45 years admitted in 1985. Of the 239 admissions randomised, 192 were suitable for study. Results were compared with those from a study in the same hospitals using the same methods in 1978. The age and sex of the patients and their smoking history, duration of asthma, and hospital attendance were similar in 1978 and 1985. A much smaller proportion of patients presented with symptoms of over seven days' duration in 1985 (8.5%) than in 1978 (26%). The inpatient management of asthma appears to have improved in both thoracic and general units, with more thorough functional assessments, more frequent performance of relevant investigations (arterial blood gases and peak expiratory flow rates) and more frequent use of recommended treatment (nebulised bronchodilators, oral and intravenous corticosteroids). Less difference was found in 1985 between units with a specialist thoracic interest and those without, though some differences remained in 1985 in monitoring of peak expiratory flow rate and arterial blood gases, outpatient prescribing, and follow up arrangements. Inhaled preventive medication was prescribed more frequently than in 1978. In 1985 there was a 56% increase in admissions for asthma. The proportion of severely ill patients was similar to that in 1978, but in the most severe functional grade mean arterial carbon dioxide tension was higher in 1985 and more patients were ventilated. Our results suggest that hospital management by thoracic and general physicians has improved over the period 1978-85. Patients presented earlier in 1985, though there seems to have been an increase in asthma of all grades of severity.

Has the management of asthma improved?

Asthma morbidity and mortality are reported to be rising in the UK, despite increased sales of anti-asthmatic drugs. To determine whether recent advances in therapy have been beneficial the results of the 1970-71 and 1981-82 national morbidity surveys in general practice and the Department of Health and Social Security surveys of prescribing for 1968 to 1985 have been examined. Between 1970-71 and 1981-82 the number of asthmatics diagnosed rose by 75%, but, for the average asthmatic, consultation, home visit, and outpatients referral rates fell significantly by 19%, 44%, and 32%, respectively. Over the same period total prescribing for airflow obstruction rose by 76%. The proportion of treatment aimed at attack prevention increased from 10.6% to 19.4%. Thus for the average asthmatic management has improved because fewer consultations are required. Increased use of inhaled topical steroids and sodium cromoglycate is probably responsible for this improvement. Nevertheless preventive treatment remains under-prescribed and asthma is still underdiagnosed.