Dong Woo Leem; Kyung Hee Park; Il Joo Moon; Sung Ryeol Kim; Beom Seok Koh; Hye Jung Park; Jae-Hyun Lee; Jung-Won Park

doi:10.4168/aard.2015.3.1.30

Journal List > Allergy Asthma Respir Dis > v.3(1) > 1059118

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Leem, Park, Moon, Kim, Koh, Park, Lee, and Park: Critical pathway of acute asthma attack for the Emergency Center: patients’ outcomes and effectiveness

Original Article

Allergy Asthma Respir Dis 2015;3(1):30-34.

Published online: 12 January 2015

DOI: https://doi.org/10.4168/aard.2015.3.1.30

Critical pathway of acute asthma attack for the Emergency Center: patients’ outcomes and effectiveness

Dong Woo Leem¹, Kyung Hee Park^1,², Il Joo Moon¹, Sung Ryeol Kim¹, Beom Seok Koh¹, Hye Jung Park^1,², Jae-Hyun Lee^1,², Jung-Won Park^1,²

^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, E-mail: PARKJW@yuhs.ac

Received 4 August 2014 Revised 30 September 2014 Accepted 4 October 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusion

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

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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 ex-ceed 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, in-travenous; 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.

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.

Table 1.

Patients’ characteristics (n=47)

Characteristic	Value
Gender, n (%)
Male	15 (31.9)
Female	32 (68.1)
Mean age (yr), mean±SD	41±16.5
Asthma management state, n (%)
Newly diagnosed	13 (27.7)
Other hospital F/U	28 (59.6)
Our allergic-asthma clinic F/U	6 (12.8)

CP, critical pathway; SD, standard deviation; F/U, followup.

Table 2.

Patients’ outcomes and effectiveness of 4AT CP (n=47)

Variable	Value
Decision, n (%)
Admit	7 (14.8)
Discharge	40 (85.2)
Followed up after discharge, n (%)
Our clinic	23 (57.5)
Other clinic	11 (27.5)
followup loss	6 (15.0)
Duration (min), mean±SD
EC arrival to CP activation	32.6±29.1
CP activation to position decision	254±302

4AT, acute asthma attack and treatment; CP, critical pathway; SD, standard deviation; EC, Emergency Center.

Table 3.

Patients' characteristics by admission status

Variable	Admitted (n=7)	Discharged (n=40)	P-value
Age (yr)	51.3±18.4	39.6±15.7	0.093
Vital signs
Initial PR (/min)	114.0±15.6	101.1±19.6	0.103
Initial RR (/min)	20.0±4.6	20.0±7.9	0.548
Initial BT (°C)	36.8±0.4	36.7±0.5	0.318
Initial SaO₂ (%)	89.9±5.9	92.7±6.1	0.238
Final SaO₂ (%)	94.3±4.0	98.9±1.6
Lung function
Initial PEFR (L/min)	110.0±39.6	148.2±64.9	0.111
Final PEFR (L/min)	121.4±40.6	257.5±97.0
Interval change of PEFR (%)	12.9±16.0	85.1±50.7

Values are presented as mean±standard deviation. PR, pulse rate; RR, respiratory rate; BT, body temperature; SaO₂, arterial oxygen saturation; PEFR, peak expiratory flow rate. P-value was calculated by using a Mann-Whitney U-test.

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