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Allergy Asthma Respir Dis. 2015 Jan;3(1):30-34. Korean.
Published online Jan 31, 2015.
© 2015 The Korean Academy of Pediatric Allergy and Respiratory Disease; The Korean Academy of Asthma, Allergy and Clinical Immunology
Critical pathway of acute asthma attack for the Emergency Center: patients' outcomes and effectiveness
Dong Woo Leem,1 Kyung Hee Park,1,2 Il Joo Moon,1 Sung Ryeol Kim,1 Beom Seok Koh,1 Hye Jung Park,1,2 Jae-Hyun Lee,1,2 and Jung-Won Park1,2
1Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
2Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea.

Correspondence to: Jae-Hyun Lee. Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea. Tel: +82-2-2228-1987, Fax: +82-2-393-6884, Email:
Received August 04, 2014; Revised September 30, 2014; Accepted October 04, 2014.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (



Early recognition and management of asthma attack is critical before it becomes worse. We developed critical pathway (CP) of asthma attack at Emergency Center (EC) for making undelayed decision and management of asthma attack.


Acute asthma attack assessment and treatment (4AT) CP began on April 1st 2012 and recruited the patients for 18 months. This study enrolled the patients who were older than 15 years and visited EC for dyspnea and wheezing. Initial assessment was done measuring peak expiratory flow rate (PEFR), oxygen saturation (SaO2). Once CP is activated, oxygen, inhalation of short acting β2 agonist, and injection of corticosteroid were administered to the patients. Every hour after CP activated, we reassess the patients' response and make decisions whether to admit or discharge.


Until January 10th 2014, 62 patients enrolled in this study. Seven patients hospitalized for asthma and 40 patients discharged. The other 15 patients were deactivated as they were diagnosed of heart failure, myocardial infarction, aortic dissection, anaphylaxis, chronic obstructive pulmonary disease and pneumonia for the causes of dyspnea. Mean Interval from EC arrival to 4AT activation was 32.6±29.1 minutes and the mean interval from 4AT activation to position decision was 254.5±302.0 minutes. Among 47 patients who were diagnosed with asthma attack, 13 patients were not aware of asthma before this attack. Forty patients were discharged at EC after management of CP. Among them, 34 patients revisited clinic, but 6 patients did not. We called back to the lost 6 patients but only 3 patients were connected. Even they visited EC due to asthma attack, 2 patients had no insight of importance of regular management and the other one promised to revisit.


CP was successful for early management of asthma attack. However, 15% of discharged patients never show up again. So, education program about the importance of ongoing management of asthma for prevention of asthma attack is needed.

Keywords: Asthma; Critical pathways; Emergency treatment


Fig. 1
Acute asthma attack assessment and treatment critical pathway (CP) flow of this study. Included patients are who visits emergency center (EC) for dyspnea and wheezing. Patients who had dyspnea and wheezing caused by cardiovascular diseases, other pulmonary diseases or malignancy rather than asthma were excluded. After initial treatments, patients were reassessed their response every hour by measured peak expiratory flow rate (PEFR) and SaO2. Responsiveness assessed 3 categories. Favorable response was patients who were resolved wheezing sound and dyspnea, increased PEFR more than 150% from basal measurement and SaO2 checked more than 92%. Incomplete response was patients who were remaining wheezing and dyspnea, didn't exceed SaO2 more than 92%, and increased PEFR less than 150% from basal. Poor response include patients who were increased PEFR less than 30% from basal, PaO2 less than 60 mmHg and/or PaCO2 more than 45 mmHg in arterial blood gas analysis. When reassessment proceed, made a decision either admission or discharge. P/Ex, physical examination; EKG, electrocardiography; MI, myocardial infarction; UA, unstable angina; CHF, congestive heart failure; IV, intravenous; SaO2, arterial oxygen saturation; PaCO2, partial pressure of arterial carbon dioxide; PaO2, partial pressure of arterial oxygen; min, minutes; ICU, intensive care uint; PRN, pro re nata; Mcg, microgram; BID, bis in die.
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Fig. 2
Patients flow of this study. Total 62 patients were enrolled in 4AT (acute asthma attack assessment and treatment) CP program. Fifteen patients were diagnosed as other disease for their cause of dyspnea and deactivated. Along finally enrolled 47 patients, 40 patients (85%) discharged, and 7 patients (15%) admitted. CP, critical pathway; COPD, chronic obstructive pulmonary disease.
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Table 2
Patients' outcomes and effectiveness of 4AT CP (n=47)
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Table 3
Patients' characteristics by admission status
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