Emergency Room Treatment of Acute Bronchial Asthma

George A. Sprecace M.D., J.D., F.A.C.P. and Allergy Associates of New London, P.C.
www.asthma-drsprecace.com

PROBLEM: EMERGENCY ROOM TREATMENT OF
ACUTE BRONCHIAL ASTHMA

1) ACUTE ASTHMATICS: Differentiate between

a) occasional acute, uncomplicated episode of short duration; and
b) prolonged acute episode superimposed on long-standing substantial asthma, especially if steroid-dependent.
THESE CONDITIONS MUST BE TREATED DIFFERENTLY!

2) EVALUATION: For all patients - Pertinent history and pertinent physical exam; Review of all medications taken regularly as well as occasionally, including “alternative “ medications; Peak expiratory flow (PEF) measurements upon arrival in the ER and before planned discharge; serum theophyllin level for all patients taking this medication; toxicology survey when this problem is suspected. For prolonged - chronic - patients, CBC/Diff, ESR, Chest x-rays, and also Arterial Blood Gas Analysis (ABG).

3) TREATMENT: Remember that excessive use of beta-agonist medications, whether used by the patient before the ER visit by means of oral inhalers or nebulizers, or in the emergency room, can contribute to worsening of acute asthma.

a) Determine whether there exists superimposed infection (?viral or bacterial), and treat if present. These are not normal patients, but asthmatics and chronic bronchitics; and antibiotic treatment is definitely indicated . Consider amoxycillin, augmentin, bactrim DS, Biaxin, or vibramycin. Note that Zithromax, a good antibiotic, is generally NOT USEFUL for these categories of respiratory disease patients.
b) Determine if there already exists abuse of beta-agonists by the patient (eg. albuterol). If so, start treatment with Atrovent ( in the absence of infection) and/or theophyllin IV. Later in the treatment, albuterol - or preferrably Xopenex (levalbuterol) - may be tried.

If not, start treatment with albuterol or Xopenex inhalation therapy. The question of the number of treatments, or whether the inhalation therapy should be continuous for an extended period or intermittent, is the subject of some controversy. But what is not in question is that this should not be the only treatment that the patient with acute asthma receives while in the ER.
The patient may need theophyllin and / or steroids IV or by mouth. He will also probably be somewhat dehydrated if the attack has lasted any length of time; this should also be addressed in the ER.
And the patient should be given an inhalational steroid to use at least for the next week, until he or she visits his physician or a certified allergist. Specific referral to a specific physician should be arranged while the patient is in the ER.
If the patient is a smoker, the critical importance of smoking cessation should be stressed. (Please see my offering on that subject, elsewhere on this web site).
Finally, substantial increase in the PEF measurement (and in the ABG where indicated) should be documented before discharge.
THIS TYPE OF DETAILED APPROACH IS NOT BEING USED IN MANY EMERGENCY ROOMS IN AMERICA, A FACT WHICH IS CONTRIBUTING TO MULTIPLE ER VISITS, UNNECESSARY HOSPITALIZATIONS, AND TO DEATHS FROM ACUTE ASTHMA.

Please see also the other offerings on Bronchial Asthma on this web site.
Specifically, attention is referred to the following Abstracts also listed above:
# 54,63,66,68,200,281,286,303,307,496,497,570,759,774,775,776,783,836,892,937.

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