Monitoring
Criteria for discharge from the hospital are subjective. Documentation of normal oxygen saturations and lack of respiratory distress are critical factors in deciding whether to discharge a patient. GINA advises 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]
The peak flow measurement may aid in the clinical decision for hospitalization, with a peak flow <40% of normal value predicting hospitalization.[1][53] Patients with a peak flow >70% of normal value can be safely treated at home (GINA mentions a slightly lower threshold for discharge of posttreatment peak flow >60% best or predicted).[1][53] Clinical status (including being able to lie flat) and lung function an hour after initiating treatment appear to predict a need for admission more reliably than status on arrival, according to retrospective analyses.[1] Other factors associated with greater likelihood of needing admission include: female sex, older age, nonwhite race, >8 beta-2 agonist puffs in preceding 24 hours, severity of the exacerbation (e.g., resus or rapid medical intervention required on arrival), history of severe exacerbations, history of unplanned healthcare visits requiring oral corticosteroids.[1]
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 readmit a patient to the hospital is based on clinical judgment.
Before discharge, management should be optimized, inhaler skills and adherence reviewed, and follow-up arranged.[1] Patients discharged from the emergency department with a written asthma action plan and peak flow meter have better outcomes than those discharged without these.[1] Patients who needed treatment in primary care or acute care (e.g., emergency department, hospital) should be followed up by a primary physician or pulmonologist within 2-7 days after the exacerbation to further assess their symptom control and optimize their asthma management, including medications, inhaler technique, and written asthma action plan.[1] Modifiable risk factors and comorbidities should also be addressed (utilizing nonpharmacologic 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] Patients should be reviewed regularly after an exacerbation until symptoms are controlled and they achieve or better their personal best lung function.[1]
GINA recommends referring the patient for expert advice 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 hospitalized, or if the patient has repeatedly attended acute care.[1] Specialist follow-up after an exacerbation is associated with reduced further emergency department visits or hospitalizations.[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 nonsteroidal anti-inflammatory drugs (NSAIDs).[1]
How to use a peak flow meter to obtain a peak expiratory flow rate measurement.
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