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Disposition decisions should take into account a combination of subjective parameters, such as resolution of wheezing and improvement in air exchange, as assessed by auscultation and patient opinion, and objective measures, such as normalization of FEV ! or PEFR. The ideal combination of elements needed for successful discharge without risk of early relapse has not yet been determined. 36 Some degree of residual airflow obstruction, airway lability, and inflammation persists after treatment and discharge from the ED.

No single treatment program can be recommended for all patients discharged home from the ED following treatment of exacerbation. Although several studies have demonstrated that a short course of oral steroids and b2-agonist bronchodilators reduce relapse rates among discharged patients, 37 other studies have reported high relapse rates regardless of ED management and use of steroids.36 Patients with a history of previous ED visits and hospitalization are at highest risk of relapse, regardless of management.36

Current guidelines help to determine hospitalization and discharge criteria based on response to aggressive treatment. A good response to treatment is demonstrated by complete resolution of symptoms and a PEFR or FEV1 of greater than 70 percent predicted. Such individuals can be safely discharged home. Patients with a poor response to treatment are defined as those with persistent symptoms and FEV1 or PEFR of less than 50 percent predicted. Such patients are likely to have persistent wheezing and dyspnea at rest despite intensive treatment in the ED and should be admitted. An incomplete response to treatment—the midground—is defined as some persistence of symptoms and a PEFR or FEV1 between 50 to 70 percent predicted. Most asthmatics treated in the ED fall into this category. They may be discharged home safely, provided they have no risk factors for death from asthma (XabJe...64-2)■17 Patients who fail to improve adequately over a several-hour period because they are in the late phase of their exacerbation and those with significant risk factors for death from asthma should be admitted to either an observation unit or the hospital.1,17

The role of observation units in the care of acute asthma exacerbation is currently being determined. Although early studies indicated no reduction in hospitalization rates after treatment in ED observation units, more recent studies indicate that 59 percent of asthmatics admitted to observation units where strict care protocols are followed are successfully treated and discharged.3 39

Follow-up care must be arranged following an acute exacerbation to ensure resolution and to review the long-term medication plan for the chronic management of asthma. High relapse rates, despite the routine use of steroids, strongly suggest the need for follow-up within days of the ED visit. 36 Patients with asthma must have an appropriate written plan of action that addresses both routine care and care of worsening symptoms.

Education of patients must become an integral part of ED care. ED personnel should provide basic education on asthma and help link patients with a primary care providers or asthma specialists while providing discharge instructions. Review of patient's discharge medication, use of inhaler technique, and the use of peak flow monitoring are just some of the issues ED physicians can teach and emphasize (Table.. ..6.4.-6).

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Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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