Current therapeutic practice in the management of acute severe asthma

In a prospective study we have documented the treatment administered to patients before and during attacks of acute severe asthma, including cases managed at home by the general practitioner and those treated in hospital. In the course of 1 year, 261 consecutive episodes were studied. Five patients required artificial ventilation but there were no fatalities. In 28 patients (11.8%) no regular maintenance therapy was being taken before the index attack, and in 72 (30.3%) no regular treatment with a beta 2-adrenergic bronchodilator. Childhood asthmatics were receiving less maintenance therapy than adults, with the exception of cromoglycate. An increased dose of a beta 2-adrenergic bronchodilator was taken prior to medical consultation in 64.7% as the attack developed, but an increased dose of oral steroids in only 19.3%. The general practitioners gave intravenous steroids in 53 cases (61.6%), but rarely combined this with a bronchodilator. However, when a combination of a bronchodilator and intravenous steroids was given, there was a significant reduction in the need for hospital admission. In hospital the majority of patients received intravenous steroids as well as a nebulized beta 2-adrenergic bronchodilator and an intravenous xanthine bronchodilator, but one-third were not given oxygen. Sedatives were rarely used. Differing treatment patterns emerged when contrasting childhood with adult episodes, whether managed inside or outside hospital. Comparisons are made between the treatment observed in practice and that currently recommended for optimal treatment, and the implications are discussed.