Internal Medicine Journal 2003; 33: 406–413
Snapshot of acute asthma: treatment and outcome of patients with acute asthma treated in Australian emergency departmentsA.-M. KELLY,*1,2,5 C. POWELL*3,4,5 and D. KERR*1
1Joseph Epstein Centre for Emergency Medicine Research and 2Department of Emergency Medicine, Western Hospital, Departments of 3Emergency Medicine and 4General Paediatrics, Royal Children’s Hospital and 5The University of Melbourne, Melbourne, Victoria, Australia*For the Snapshot of Asthma Study Group 2000 and 2001. Abstract
tered included: (i) salbutamol to 90%, (ii) ipratropium
Aims:To characterize presentations due to acute asthma
bromide to 59% and (iii) corticosteroids to 71%. Only
at Australian emergency departments (ED), including
six patients received aminophylline. Spacer use for sal-
their severity, treatment and disposition.
butamol was rare (1%) in adults and only moderate
Methods:This prospective, observational study involved
(43%) in children. Sixty-five percent of patients were
38 departments of emergency medicine throughout
discharged home from the ED. Less than 1% of patients
Australia participating in the Snapshot of Asthma Study
required ventilatory assistance, of which half was pro-
Group project 2000 and 2001. Data were collected
vided non-invasively. One percent of patients were
for patients presenting with acute asthma between
admitted to the intensive-care unit or high-dependency
21 August 2000 and 3 September 2000, and 20 August
2001 and 2 September 2001 and included demograph-
Conclusion:Overall adherence to treatment guidelines
ics, severity classification, treatment and disposition.
was good. There appears to be underuse of spacers and
Results:There were 1340 acute asthma presentations in
corticosteroids in some groups and overuse of ipra-
the study periods. Of these presentations, 67% were for
tropium bromide. The majority of patients are treated
children aged <15 years. Asthma severity (according to
and discharged from the ED. (Intern Med J 2003; 33:
the Australian National Asthma Guidelines classifi-
cation) was ‘mild’ in 49% of cases; ‘moderate’ in 45% ofcases; and ‘severe’ in 6% of cases. Treatment adminis-
Key words: asthma, management, outcome, guidelines.
patients, their families and health professionals withinformation to improve the standard of asthma care. As
Asthma is common in Australia and can be life-
part of this process, The National Asthma Campaign has
threatening. The National Asthma Campaign
facilitated the development of asthma management
(Australia) has been working for some years to provide
guidelines.1 This document covers all aspects of asthma
Correspondence to: A-M Kelly, Joseph Epstein Centre for Emergency Hospital, Qld); Dr. R. Day (Hornsby and Ku-Ring-Gai Hospital, Medicine Research, Department of Emergency Medicine, Western Hospital, NSW); Dr. D. Cruse (Joondalup Hospital, WA); Dr. E. Merfield Footscray, 3011 Vic., Australia. Email: Anne-Maree.Kelly@wh.org.au.(Launceston Hospital, TAS); Dr. C. Gavaghan (Lismore Hospital, Received 16 September 2002; accepted 16 January 2003.NSW); Dr. D. Lewis-Driver (Logan Hospital, Qld); Dr. B.Sadlier (Mackay Base Hospital, Qld); Dr. A. Rosengarten (Maroondah Hospital, Funding: 2001 data collection was supported by a grant from Vic.); Dr. R. Pitt (Mater Hospital, Qld); Dr. P. Rosengarten (Monash Commonwealth Department of Health and Ageing.Medical Centre, Vic.); Dr. J. Roberts (Port Macquarie Hospital, NSW); Dr. H. Hunt (Rockhampton Base Hospital, Qld); Dr. C. Powell (The * The Asthma Snapshot Study Group comprised: Dr. P. Love (Albury Royal Children’s Hospital and Sunshine Hospital, Vic.); Dr. R. Clark Base Hospital, NSW); Dr. G. McInerney (Auburn Hospital, NSW); Dr. (Royal Children’s Hospital, Qld); Dr. D. Palmer (Royal Darwin G. Campaign (Ballarat Base Hospital, Vic.); Dr. L. Dann (Bankstown Hospital, NT); Dr. G. Fulde (St. Vincent’s Hospital, NSW); Dr. N. Hospital, NSW); Dr. L. Pouw (Box Hill Hospital, Vic.); Dr. S. Andrew-Small (Townsville Base Hospital); Assoc. Prof. D. Taylor (The Royal Starkey (Caboolture Hospital, Qld); Dr. S. Brazenor (Calvary Hospital, Melbourne Hospital, Vic.); Dr. J. Raftos (Sutherland Hospital, NSW); ACT); Dr. M. Chu (Canterbury Hospital, NSW); Dr. A. Tankel (Coffs A/ Prof D. Richardson (The Canberra Hospital, ACT); Dr. S. Curran Harbour, NSW); Dr. J. Wenzel (Dandenong Hospital, Vic.); Dr. A. (Wagga Wagga Base Hospital, NSW); Prof. A. Kelly (Western Hospital, Yuen (Epworth Hospital, Vic.); Dr. T Elisizo (Flinders Medical Centre, Vic.); Dr. A. Bezzina (Wollongong Hospital, NSW); Dr. J. Raftos SA); Dr. J. Hodge (Fremantle Hospital, WA); Dr. D. Green (Gold Coast (Women’s and Children’s Hospital, SA).Snapshot of acute asthma in Australia
management, including the assessment and management
participating hospitals volunteered and data were col-
of acute attacks. In particular, it sets down guidelines for
lected locally. This project was considered an audit by
the management of patients presenting to emergency
most centres and was hence exempted from the require-
departments (ED), stratified according to the severity of
ment for ethics committee approval. Ethics committee
the episode. Evidence from the United Kingdom2,3 and
approval was obtained for those centres where it was
a small, single-centre Australian study4 suggest that
compliance with asthma management guidelines is
The subjects included patients aged 1–60 years (in the
2000 study) and 1–55 years (in the 2001 study) with a
The primary aim of the present study was to compare
physician-confirmed diagnosis of acute asthma. Patients
reported actual patient management with that recom-
aged >55 years (2001) and >60 years (2000) were
mended by the National Asthma Guidelines (NAG). A
excluded to minimize overlap with chronic obstructive
secondary aim was to characterize presentations due to
airways disease. Patients aged <1 year were excluded to
acute asthma to Australian ED with respect to demo-
minimize overlap with bronchiolitis.
graphics, severity, disposition and outcome. This is the
Data collected included: (i) demographic information,
first multicentre study of its type conducted in Australia.
(ii) duration of attack, (iii) classification of the severityof the attack according to medical officer assessment
(iv) treatment, (v) disposition (home; ward; intensive-
This prospective, observational study was conducted
care unit (ICU)/high-dependency unit; transfer) and
in 38 Australian ED between 21 August 2000 and
3 September 2000, and 20 August 2001 and 2 Sep-
Actual treatment and disposition was compared to the
tember 2001 (not all hospitals participated in both data-
recommendations in NAG (Tables 3 and 4).
collection periods). All ED accredited for training by the
Data were collected by clinical staff at each hospital,
Australasian College for Emergency Medicine were
entered onto a specifically designed form and analysed
contacted by mail and invited to participate. The 38
using descriptive statistics. Quality checks on the data
Initial assessment of severity of acute asthma in children†
†Adapted from the Asthma Management Handbook (page 12).1 ‡% predicted.
Initial assessment of severity of acute asthma in adults†
†Adapted from the Asthma Management Handbook (page 12).1 ‡% predicted. Internal Medicine Journal 2003; 33: 406–413
e IV when no response to aerosol salbutamol
Oral prednisolone (1 mg/kg per dose daily)
Initial management of acute asthma in children
Internal Medicine Journal 2003; 33: 406–413
Snapshot of acute asthma in Australia
e IV if no response to aerosol (i.e.
ere asthma and those not responding.
tainty exists regarding the benefits of this
Initial management of acute asthma in adults
Internal Medicine Journal 2003; 33: 406–413
collected were not performed. Descriptive analysis was
Treatment given to adults is summarized in Table 6.
Ipratropium bromide was again commonly administeredin all severity groups. There is some underuse of corti-
costeroids in the moderate group. Four patients receivedaminophylline (1%) and four patients received paren-
There were 1340 acute asthma presentations recorded
teral adrenaline (1%). Nine patients required ventilatory
for the 38 participating ED during the study period.
support (2%). For five of these, non-invasive ventilatory
Sixty-seven percent of patients were aged ≤15 years. The
age distribution is shown in Fig. 1. The severity distribu-
Overall, 62% of children and 70% of adults were
tion was different between the adult and child groups,
with the adult group having higher severity distribution(P = 0.0015).
Treatment given to children is summarized in
Table 5. Of note, nebulisers are used much more
NAG1 provide recommendations for the assessment and
commonly than spacers for the delivery of aerosol
treatment of acute asthma in Australia. This is the first
β-agonists. Ipratropium bromide (IB) was commonly
study to examine how well these guidelines are followed
used in all severity groups, despite the guideline
recommendation that it is not needed in mild and
Overall adherence to the guidelines with respect to
moderate severity groups. There is underuse of cortico-
steroids, particularly for the severe group. Two patients
Corticosteroids have been shown to reduce admission
received aminophylline (0.2%) and only one child
rates, relapse rates and the need for additional β-2
required ventilatory support (0.1%).
agonists.5–7 In the present study there was someunderuse of corticosteroids in both adults and childrenwho were classified as having moderate or severe asthma. The reason for this is unclear. Possible explanationsinclude documentation errors (i.e. steroids were givenbut not recorded), and an under-classification of severitycompared with the NAG by the treating doctor.
Oxygen also appears to be under-administered in the
severe group for both adults and children. This is,however, very likely to be a documentation effect. Thevast majority of these patients received inhaled
β-agonists by nebuliser, which is commonly oxygen-
Age distribution of the study sample.
Treatment given to children (<16 years of age) stratified by National Asthma Guidelines (NAG) severity classification
combined for 2000 and 2001 for all presentations (892 presentations, 52 missing NAG severity data)
Internal Medicine Journal 2003; 33: 406–413
Snapshot of acute asthma in Australia
NAG recommend IB administration be reserved for
push for change to spacer use recently. Published
patients with severe asthma for both adults and children.
evidence suggests that delivery via this method is as
Studies in children and adolescents with severe asthma
effective as delivery by nebuliser.13 In paediatrics, many
(forced expiratory volume in 1 second (FEV ) or peak
centres have already changed over to the use of spacers
expiratory flow (PEFR) <50%), suggest that multiple
for acute asthma.14,15 There are data suggesting that
doses, administered in the first hour of treatment along
treatment with spacers has less side-effects,16,17 a
with β-2 agonists, may have an influence on admission
shorter period of time in ED,17 quicker response to
rate.8 They may also have an impact on cost.9 There is
treatment,18 a reduced hospital-admission rate and
good evidence that ipratropium does not have a role in
possible reduced morbidity.19,20 There are concerns
mild to moderate asthma when sufficient β-2 agonists
about cost and this has yet to be addressed in an
are used.10 Further, a meta-analysis of four trials
Australian population, however some data suggest that
spacers are cheaper.19,20 In adults, the case for spacers
concludes that there appears to be a modest, statistically
is less compelling. The study of Cates and Rowe
significant benefit with the use of IB, but raises doubts
suggests that the choice of delivery method should
about whether the effect size found is clinically signifi-
reflect patient preference, practice situations and formal
cant.11 This is supported by a recent randomized
controlled trial (RCT) involving 180 people with severe
The low rate of aminophylline use is concordant with
acute asthma (FEV <50%) which demonstrated that
the guidelines and current evidence in adult studies.21 In
ipratropium significantly improved lung function and
paediatrics, some doubt about the role of aminophylline
that, after 3 h, subjects were more likely to be discharged
persists. One RCT, including 163 children with severe
home (20% vs. 39%; P < 0.01).12 Given the evidence
asthma, demonstrated that, in asthma that was unre-
and the cost of routine use of IB, the NAG position is
sponsive to initial treatment, aminophylline may still
justifiable. Our data confirm unnecessary use of ipratro-
have a role in reducing the intubation rate.22
pium. Given the unit cost of IB of approximately $A18
The use of therapies not included in the current guide-
per dose, elimination of its use in the mild and moderate
lines – in particular intravenous (IV) adrenaline and
groups could translate into considerable drug-cost
non-invasive ventilation (NIV) – is interesting. There is
savings per year. Unfortunately this study’s methodology
no published evidence supporting the use of IV adrena-
does not allow us to estimate the potential cost savings.
line rather than IV salbutamol. That said, adrenaline has
The finding of a low rate of spacers to deliver
the potential advantage of bronchial vasoconstriction as
β-agonist was somewhat surprising; particularly in the
well as bronchodilation and potentially greater efficacy
treatment of children, where there has been a significant
in sudden onset (anaphylactoid) asthma. This is an area
Treatment given to adults (>15 years of age) stratified by National Asthma Guidelines (NAG) severity classification
classification combined for 2000 and 2001 for all presentations (448 presentations, 27 missing NAG severity data, complete data-set 421 adults)
ICU, intensive care unit; IV, intravenous; HDU, high-dependency unit; CPAP, non-invasive ventilation using continuous positive airway pressure. Internal Medicine Journal 2003; 33: 406–413
requiring further study. With respect to NIV, there is
some evidence that it results in rapid correction ofgas exchange abnormalities,23 and assists inspiratory
Although most cases presenting to EDs are moderate,
muscles.24 Although there are case reports/small series
6% of patients have severe asthma. The overall
reporting its successful use,25,26 there is currently no
compliance with the treatment guidelines was good.
conclusive evidence that it reduces the requirement for
There appears to be underuse of spacers and cortico-
steroids and overuse of IB. The majority of patients
An important finding of the present study was that
are treated and discharged from the ED.
severity classification based on initial assessment was nota good predictor of the need for hospital admission. The
NAG state that patients with moderate asthma ‘willprobably need admission’ and that ‘ICU should be
1 National Asthma Campaign. Asthma Management Handbook
considered’ for those in the severe group. This study
1998. Melbourne: National Asthma Campaign Ltd; 1998.
found that 60% of adults and 44% of children in the
2 Lipworth BJ, Jackson CM, Ziyaie D, Winter JH, Dhillon PD,
Clark RA. An audit of acute asthma admissions to a respiratory
moderate severity classification and 26% of adults and
unit. Health Bull (Edinb) 1992; 50: 389–98.
18% of children in the severe classification could be
3 Hart SR, Davidson AC. Acute adult asthma – assessment of
discharged home after a period of treatment in the ED.
severity and management and comparison with British Thoracic
Data were not, however, collected on whether any of
Society Guidelines. Respir Med 1999; 93: 8–10.
these patients represented requiring admission as part of
4 Gibson PG, Talbot PI, Hancock J, Hensley MJ. A prospective
the same asthma episode. Given that the NAG recom-
audit of asthma management following emergency asthma
mendations provide a potential avenue for litigation if
treatment at a teaching hospital. Med J Aust 1993; 158: 775–8.
they are not followed, this finding may lead to a reconsid-
5 Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy
eration of the strength of the recommendation regarding
in acute exacerbations of asthma: a meta-analysis. Am J Emerg
disposition of this group of patients. It is possible that the
6 Edmonds ML, Camargo CA Jr, Pollack CV Jr, Rowe BH. Early
NAG guideline recommendations were based on old or
use of inhaled corticosteroids in the emergency department
incomplete information about ED asthma management
treatment of acute asthma. Cochrane Database Syst Rev 2001;
or that asthma management in ED has improved since
this section of the guidelines was written.
7 Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW.
The present study has some limitations that should be
Early emergency department treatment of acute asthma with
considered when interpreting the results. The ED that
systemic corticosteroids. Cochrane Database Syst Rev 2001; 1:
participated did so voluntarily. They may represent ED
with a particular interest in asthma management and
8 Plotnick LH, Ducharme FM. Combined inhaled anticholinergics
generalisability to the broader range of ED might
and beta2-agonists for initial treatment of acute asthma in
therefore be questioned. Patients were identified
children. Cochrane Database Syst Rev 2000; 4: CD000060.
9 Lord J, Ducharme F, Stamp RJ, Littlejohns P, Churchill R. Cost
prospectively, however some data were collected retro-
effectiveness of inhaled anticholinergics for acute childhood and
spectively and are therefore subject to documentation
adolescent asthma. Br Med J 1999; 319: 1470–71.
weakness. Although every attempt was made to include
10 Ducharme F, Davies GM. Randomised controlled trial of
all eligible patients, some may have been missed. The
ipratropium bromide and frequent low doses of salbutamol in the
diagnosis of asthma was based on physician judgement
management of mild and moderate acute pediatric asthma.
rather than objective measures of lung function, thus
some of the patients included may not have been
11 Rodrigo G, Rodrigo C, Burschtin O. Ipratropium bromide in
suffering from asthma. The sample does, however,
acute adult severe asthma: a meta analysis of randomized
represent a ‘real world’ sample and thus we consider the
controlled trials. Am J Med 1999; 107: 363–70.
treatment patterns found to be valid. The sample has an
12 Rodrigo GJ, Rodrigo C. First line therapy for adult patients with
acute asthma receiving multiple dose protocol of ipratropium
over-representation of children. This is partly explained
bromide plus albuterol in the emergency department. Am J Resp
by the prevalence of the condition among children and
Crit Care Med 2000; 161: 1862–8. Also available from URL:
the participation of several children’s hospitals. There
may also be an element of parental behaviour in seeking
13 Cates CJ, Rowe BH. Holding chambers versus nebulisers for
asthma care. This is supported by the higher severity
beta-agonist treatment of acute asthma. Cochrane Database Syst
classification distribution in the adult group.
Future directions for this research include:
14 Powell CVE, Maskell G, Marks MK, South M, Robertson CF.
(i) exploring whether there are different phenotypes of
Successful implementation of spacer treatment guideline for acute
acute asthma with different patterns of response to treat-
asthma. Arch Dis Child 2001; 84: 142–6.
ment, (ii) evaluating whether an assessment after 1 h of
15 Gazarian M, Henry RL, Wales SR, Micallef BE, Rood EM,
O’Meara MW et al. Evaluating the effectiveness of evidence-based
treatment is a better indicator of need for admission than
guidelines for the use of spacer devices in children with acute
initial assessment, (iii) determining the characteristics of
asthma. Med J Aust 2001; 174: 394–7.
patients who re-present to the ED and how this might be
16 Robertson CF, Norden MA, Fitzgerald DA, Connor FL,
avoided and (iv) evaluating whether participation in this
Van Asperen PP, Cooper PJ et al. Treatment of acute asthma:
study process affects asthma management in the study
salbutamol via jet nebuliser vs spacer and metered dose inhaler.
J Paediatr Child Health 1998; 34: 142–6. Internal Medicine Journal 2003; 33: 406–413
Snapshot of acute asthma in Australia
17 Chou KJ, Cunningham SJ, Crain EF. Metered dose inhalers with
22 Yung M, South M. Randomised controlled trial of aminophylline
spacers vs nebulizers for pediatric asthma. Arch Pediatr Adolesc
for severe acute asthma. Arch Dis Child 1998; 79: 405–10.
23 Meduri GU, Cook TR, Turner RE, Cohen M, Leeper KV.
18 Rubilar L, Castro-Rodriguez JA, Girardi G. Randomized trial of
Noninvasive positive pressure ventilation in status asthmaticus.
salbutamol via metered–dose inhaler with spacer versus nebulizer
for acute asthma in children less than 2 years of age. Pediatr
24 Shivaram U, Donath J, Khan FA, Juliano J. Effects of continuous
positive airway pressure in acute asthma. Respiration 1987; 52:
19 Dewar AL, Stewart A, Cogswell JJ, Connett GJ. A randomised
controlled trial to assess the relative benefits of large Volume
25 Mansel JK, Stogner SW, Norman JR. Face-mask CPAP and
spacers and nebulisers to treat acute asthma in hospital. Arch Dis
sodium bicarbonate infusion in acute severe asthma and metabolic
20 Leversha AM, Campanella SG, Aickin RP, Asher MI. Costs and
26 Vilianis G, Piazza L, Bobo D, Hellmann F, Coaloa M, Bracco G.
effectiveness of spacer versus nebulizer in young children with
CPAP with face mask in severe asthma. Description of a clinical
moderate and severe acute asthma. J Pediatr 2000; 136: 497–502.
case. Minerva Anestesiol 1986; 52: 281–4.
21 Parameswaran K, Belda J, Rowe BH. Addition of intravenous
aminophylline to beta2-agonists in adults with acute asthma. Cochrane Database Syst Rev 2000; 3: CD002742. Internal Medicine Journal 2003; 33: 406–413
TERMS AND CONDITIONS: When you successfully redeem this offer as specified below, you will receive: one (1) 5 cup rice cooker and 12 qt tamale steamer from IMUSA® and one (1) cookbook of your choice. The rice cooker and tamale steamer cookware set from IMUSA® and cookbook of your choice will be sent FREE by mail to qualifying consumers. To redeem this offer at any participating retailer, pur
Improving the function of the appropriate glands or organs can help optimize the body’s performance and contribute to RESTORING a more normal body shape. By years of consuming excess sugar, low calorie diets, dieting from one type diet to another and toxic chemical exposure the endocrine system can get damaged, this can disrupt or block glandular function. Over or underproduction of horm