Monitoring
Criteria for discharge from the hospital are subjective. However, documentation of normal oxygen saturations and lack of respiratory distress are critical factors in deciding whether to discharge a patient. Guidelines from the British Thoracic Society (BTS) advise that patients in the accident and emergency department who have a peak flow >75% of their best/predicted one hour after initial treatment may be discharged but that admission may be appropriate if they meet any of the following criteria: still significantly symptomatic, adherence concerns, lives alone/socially isolated, psychological problems, physical disability or learning difficulties, previous near-fatal asthma attack, asthma attack occurred despite adequate dose of oral corticosteroid prior to presentation, presentation at night, pregnant.[13] There is evidence that peak flow <75% best/predicted and diurnal variability of peak flow >25% on discharge may be associated with increased risk of early relapse and readmission.[13] The BTS advises that no individual physiological parameter can be used to make the hospital discharge decision but that patients should have clinical signs compatible with management at home, be on reducing amounts of beta-2 agonist treatment (ideally no more than 4 hourly) and be taking drugs that can be continued safely at home.[13] The Global Initiative for Asthma (GINA) advises that the decision to admit or discharge should be based on clinical status, lung function, response to treatment, history of exacerbations and risk factors, and ability to self-manage at home (e.g., social circumstances, available support and resources).[1] Availability of timely follow-up may impact ability to discharge.[1] See Management recommendations.
Patients with severe asthma exacerbations may have labile airway obstruction for several days after an acute exacerbation. Nocturnal symptoms and deterioration may also be common. The decision to re-admit a patient to hospital is based on clinical judgment. See Management recommendations.
Before discharge, management should be optimised, inhaler skills and adherence reviewed, and follow-up arranged.[1][13] BTS guidelines recommend that asthma education provided to patients prior to discharge should include how to record and monitor their peak flow, and they should be provided with a written personalised asthma action plan based on symptoms and peak flow readings.[13] Patients discharged from the accident and emergency department with a written asthma action plan and peak flow meter have better outcomes than those discharged without these.[1] Patients should be followed up by their general practitioner within 2 working days after an exacerbation (regardless of whether it was managed in hospital or in primary care).[13] Patients managed in hospital should also be referred to an asthma liaison nurse or chest clinic.[13] Hospitalised patients should have follow-up with a hospital specialist asthma nurse or respiratory physician approximately 1 month after admission.[13] Follow-up should identify potential reasons for the asthma attack with a focus on future prevention, and should further assess the patient’s symptom control and optimise their asthma management, including medications, inhaler technique, and written asthma action plan.[1][13] GINA advises that patients should be reviewed regularly after an exacerbation until symptoms are controlled and they achieve or better their personal best lung function.[1] GINA also recommends that modifiable risk factors and comorbidities should be addressed (utilising non-pharmacological strategies where appropriate) to reduce the patient’s risk of future exacerbations (as patients who have had an exacerbation are at increased risk of a further one within the next year).[1] See Management recommendations.
BTS guidelines advise that patients who have a near-fatal asthma attack should remain under the supervision of a specialist indefinitely, and that patients admitted with a severe asthma attack should have specialist respiratory follow-up for at least a year following their admission.[13] GINA recommends referring the patient for expert advice after an exacerbation if they required ICU treatment or have already had an exacerbation in the last year, and advise that referral should be considered if the exacerbation was severe and/or the patient was hospitalised, or if the patient has repeatedly attended acute care.[1] Specialist follow-up after an exacerbation is associated with reduced further accident and emergency department visits or hospitalisations.[1] GINA also recommends considering referral for expert advice if the patient has any risk factors for asthma-related death (including suspected or confirmed anaphylaxis), or if it is suspected that the exacerbation was triggered by aspirin or a non-steroidal anti-inflammatory drug (NSAID).[1]
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