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Acute asthma: observations regarding the management of a pediatric emergency room
G J Canny1, J Reisman, R Healy
1Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Emergency room asthma care for children was reviewed. Underuse of key asthma medications and poor assessment practices led to high hospitalization rates and preventable deaths.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Medicine
- Clinical Management
Background:
- Inadequate assessment and treatment of acute asthma contribute to severe morbidity and mortality.
- Emergency room (ER) management of acute asthma in children requires careful evaluation and appropriate therapeutic interventions.
Purpose of the Study:
- To review the management of acute asthma in a pediatric emergency room setting.
- To identify potential areas for improvement in the assessment and treatment of acute asthma in children.
Main Methods:
- Retrospective review of 3,358 emergency room visits for acute asthma in 1,864 children over 16 months.
- Analysis of recorded clinical data, diagnostic tests, and medications administered during ER visits.
Main Results:
- Most acute asthma episodes were associated with infection, with a mean symptom duration of 41 hours.
- Key assessments like pulsus paradoxus, lung function, and blood gas values were rarely documented.
- Underuse of bronchodilators and systemic corticosteroids was observed, with only 4% receiving steroids; anticholinergic therapy was not used.
- Hospitalization occurred in 26% of visits, and one death was recorded.
Conclusions:
- Inconsistent asthma severity assessment and underutilization of essential medications (bronchodilators, corticosteroids) in the ER are significant concerns.
- Improved adherence to evidence-based guidelines for asthma assessment and treatment could potentially reduce hospitalization rates and improve outcomes for children with acute asthma.
Abstract:
Because inadequate assessment and inappropriate treatment of acute asthma have been implicated as contributing factors in morbidity and even deaths, the management of acute asthma, as practiced in an emergency room, were reviewed. The study population comprised 1,864 children (mean age 5.6 years; 65% boys) who attended the emergency room with acute asthma on 3,358 occasions during a 16-month period. Visits occurred more commonly in winter and usually in the evenings; 93% were self-referred and the mean duration of symptoms was 41 hours. Most acute episodes were associated with infection. Although chest auscultation, heart rate, and respiratory rate were recorded during the majority of visits, evidence that pulsus paradoxus had been measured could be found for only 1% of visits. Results of lung function and blood gas values were rarely recorded, but chest radiographs were obtained in 18% of visits. Drugs used in the emergency room included beta 2-agonists (93% of visits), theophylline (16%), and systemic steroids (4%), but no child received anticholinergic therapy. In 26% of patient visits, admission to hospital occurred; one patient died. The erratic fashion in which asthma severity appears to have been assessed and the failure to document whether lung function had been measured are causes for concern. The surprisingly high hospitalization rate may have been avoided if bronchodilators and corticosteroids had not been underused in the emergency room.