Factors Associated With Relapse After Emergency Department Treatment for Acute Asthma,☆☆,

Presented in part at the American College of Emergency Physicians Research Forum, San Diego, March 1994.
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Abstract

Study objective: The rate of relapse after emergency department treatment for acute asthma is high. Most studies on this subject were performed before the recent recommendations for routine use of corticosteroids and followed the patients for 10 or fewer days. We sought to evaluate relapse following ED treatment for acute asthma over a longer period, focusing particularly on the relationship between steroid use and outpatient follow-up visits. Design: A prospective study in which we followed patients for 21 days after discharge to determine their relapse rate (unscheduled return for asthma treatment) and compliance with scheduled outpatient appointments. Setting: University-affiliated county hospital ED. Participants: One hundred four adult asthmatic patients discharged from our ED after treatment under a standardized protocol. Results: Follow-up was performed for 91 patients (88%). There was no difference in the posttreatment forced expiratory volume at 1 second between those who relapsed (55.2%) and those who did not (57.8%; NS). Twenty-three patients (25.3%) relapsed within 3 weeks of discharge. Ninety-one percent of relapses occurred before the patients saw their primary care physician. Those who relapsed had a history of previous ED visits and hospitalizations. There was no difference in theophylline levels or history of cigarette use. Patients who relapsed within 3 days had higher eosinophil counts. Conclusion: Even with routine use of oral corticosteroids, a high percentage of patients relapse after ED treatment for acute asthma. Patients who relapse have a greater number of recent ED visits and so should be targeted for more aggressive management of their asthma. [Emerman CL, Cydulka RK: Factors associated with relapse after emergency department treatment for acute asthma. Ann Emerg Med July 1995;26:6-11.]

Section snippets

INTRODUCTION

Patients who experience relief of dyspnea after emergency department treatment may relapse after discharge. Several investigators have devised criteria to distinguish patients who can be discharged safely from those who are likely to continue to have symptoms of asthma. Early studies focused on changes in pulmonary function during ED treatment for asthma, specifying the degree of improvement in pulmonary function needed to discharge the patient successfully.1, 2 Some investigators have failed

MATERIALS AND METHODS

Our study was conducted in the ED of MetroHealth Medical Center— a large, urban, county-owned, university-affiliated ED—from February 1992 through June 1993. Patients were included in the study if they presented to the ED with acute asthma manifested as dyspnea, cough, or wheezing and a 1-second initial forced expiratory volume (FEV1) less than 70% of the predicted normal value. Adult patients between the ages of 18 and 50 years were eligible for the study if they had history of asthma.

RESULTS

One hundred forty-five patients were enrolled initially in the study; 104 were discharged from the ED, and 41 were admitted to the hospital. Follow-up data were available for 91 patients (88%). There was no significant difference between patients who were followed and those who were lost to follow-up in age, pretreatment and posttreatment FEV1, gender, or medication use. The 27 male and 64 female patients had a mean age of 35.7±13.1 years. Of the 91 patients, 28.9% were cigarette smokers and

DISCUSSION

Identifying patients at risk for relapse and devising methods for minimizing the risk of relapse have been the subjects of many studies. Early investigators focused on using spirometric criteria to identify patients at risk for relapse. Nowak et al1 studied 59 patients discharged from the ED after standardized therapy that did not include corticosteroids and found that those discharged with subsequent persistent dyspnea had a lower FEV1 (1.19±.65 L) than patients discharged successfully

CONCLUSION

Despite oral corticosteroid therapy, 25% of patients treated in the ED for asthma relapsed within 3 weeks. Pulmonary function testing was not useful in identifying patients at risk for relapse. Those who relapsed were characterized by history of frequent ED visits. Patients who relapsed early were characterized by eosinophilia. The timing of relapse does not seem to correlate with the termination of corticosteroid therapy. The patients at highest risk of relapse may benefit from more aggressive

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From the Department of Emergency Medicine, MetroHealth Medical Center, Department of Surgery, Case Western Researve University, Cleveland, Ohio.

☆☆

Address for reprints: Charles L Emerman, MD, FACEP, Department of Emergency Medicine, S1-203, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, Ohio 44109

Reprint no. 47/1/65119

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