+ ImprovIng care through evIdence

GUIDELINES UpDatE

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PAGE
PAGE

for the On The

22 | Guideline
British Guideline
Management
ManagementOf
OfAcute
Asthma:
And
Chronic
Pain
In
A National Clinical
Sickle
Cell
Disease.
Guideline.
American
Pain Society.
Scottish Intercollegiate
Guidelines Network

PAGE
PAGE

Management of Sickle
44 || The
Expert
Panel Report 3:
Cell Disease. National
Guidelines For The DiagInstitutes of Health, National
nosisLung
And and
Management
Heart
Blood
Of
Asthma.
Institute.
National Heart, Lung, and
Blood Institute

PAGE

8 | Intubation and Mechanical Ventilation Of The

Asthmatic Patient In
Respiratory Failure.
Journal Of Emergency
Medicine

Noninvasive Ventilation.
Journal Of Emergency
Medicine
PAGE

11 | Editorial Comment

Editors Note: To read more about this publication and the background and methodologies for
practice guideline development, go to:
http://www.ebmedicine.net/introduction

Current
Current Guidelines
Guidelines For
For
Management
Of Asthma
Sickle Cell Disease:
In
The Emergency
Management
Of AcuteDepartment
Complications

In this issue of EM Practice Guidelines Update, 4 guidelines that address

this issue of
EM Practice
Guidelines
Update,
2 guidelines
the In
management
of asthma
are reviewed.
Asthma
is the most
common
In populachronic
addressing
disease of
thechildhood,
management
affecting
of 22
sickle
million
cellAmericans.
disease 1(SCD)
are
tions
with less access
to care
poorer adherence
to therapy,
asthma
reviewed.
As a result
of and
numerous
SCD-related
complications,
2
The National
Asthma Education
and Premorbidity
the rise.
patients has
withbeen
SCDonhave
significantly
diminished
life expectancy.
vention Programs (NAEPP) Expert Panel Report (EPR) produced its first
Although most patients will be followed by subspecialty hemaguidelines in 1991; since then, the number of asthma deaths has declined,
tologists,
SCD isprevalence
fundamentally
disease
of emergencies.
despite
increasing
of the adisease.
In addition,
fewer patients
Emergency
clinicians
should betofamiliar
with the
recommendawho
have asthma
report limitations
their activities,
and
an increasing
proportion
of people
with asthma
formalcomplications,
patient education.
Nonetions around
management
of receive
acute SCD
because
theless,
hospitalization
rates
for
asthma
have
remained
relatively
stable
failure to appreciate the nuances of care in these brittle patients
over the last decade.1 The most recent NAEPP guideline has expanded to
may place them at risk for short-term morbidity and mortality. The
include a dedicated section on managing exacerbations of asthma. Emermethodology
these
practice
guidelines
varies
greatlyfrom
gency
cliniciansof
must
rapidly
identify
and manage
asthma
exacerbations of
evidencebased
to
expert
opinionand
thus
must
be applied
toare
all severity. The recommendations from the 4 guidelines reviewed
here
drawn
from the
source material
to focus
onpragmatism.
emergency department-based
emergency
practice
with caution
and
asthma assessment, treatment, disposition, advanced airway and ventilator management, and patient education.

Practice Guideline Impact

Guideline Impact
Practice
In the management
of acute SCD pain crises, bolus normal

Relapse
prevented through
objective
assessment
of severity
saline ismay
notbe
recommended
unless
the patient
is hypovolemof exacerbation, identification of psychosocial risk factors that may limit
ic. In euvolemic
patients,
intravenous
hydration should not
adherence
and access
to care,
and patient education.

exceed 1.5 times maintenance with D5 NS.

Intubation does not treat and may exacerbate bronchospasm. A trial of

In the management
ofappropriate
acute SCD
pain crises,
specificrespirarecnoninvasive
ventilation in
patients
with impending
tory
failure may preclude
the need
for to
intubation.
ommendations
exist with
regard
opiate choice and adju-

Authors

February 2010
December 2009
Volume
Volume 2,
1, Number
Number 2
2

Editor-In-Chief
Edward
R. Melnick, MD

Staff Physician, North Shore University Hospital, Department

Reuben
J.Medicine;
Strayer,
MD
of
Emergency
Manhasset,
NY

Assistant Professor of Emergency Medicine,

Jennifer
A. Cottral,
BS
Mount Sinai
School of
Medicine, New York, NY

Academic Associate, North Shore University Hospital Department

of Emergency Medicine; Manhasset, NY

Editorial Board

Andy Jagoda, MD, FACEP

Editor-In-Chief
Professor and Chair, Department of Emergency Medicine
Reuben
J. Strayer,
MD
Mount Sinai
School of
Medicine, New York, NY
Assistant Professor of Emergency Medicine, Mount Sinai
Erik Kulstad, MD, MS
School of Medicine, New York, NY

Research Director, Advocate Christ Medical Center

Department of Emergency Medicine, Oak Lawn, IL
Editorial
Eddy S. Board
Lang, MDCM, CCFP (EM), CSPQ

Associate Professor, McGill University, SMBD Jewish General

Andy Jagoda, MD, FACEP
Hospital, Montreal, Canada
Professor and Chair, Department of Emergency Medicine
Lewis
S. School
Nelson,
MD New York, NY
Mount
Sinai
of Medicine,

Director, Fellowship in Medical Toxicology, New York City Poison

Erik Kulstad, MD, MS
Control Center, Associate Professor, Department of Emergency
Research Director, Department of Emergency Medicine, Advocate Christ
Medicine, NYU Medical Center, New York, NY
Medical Center, Oak Lawn, IL

Gregory
M. Press,
RDMS
Eddy
S. Lang,
MDCM,MD,
CCFP
(EM), CSPQ
Assistant Professor, Director of Emergency Ultrasound, Emergency
Associate Professor, McGill University, SMBD Jewish General Hospital,
Ultrasound
Fellowship
Director,
Department of Emergency Medicine,
Montreal, Canada
University of Texas at Houston Medical School, Houston, TX
Lewis S. Nelson, MD

Maia Rutman,
MD
Director,
Fellowship in
Medical Toxicology, New York City Poison Control
Medical
Director,
Pediatric
Emergency
Services,Medicine,
DartmouthCenter,
Associate
Professor,
Department
of Emergency
NYU Medical
Hitchcock
Medical
Center;
Assistant Professor of Pediatric
Center, New York, NY
Emergency Medicine, Dartmouth Medical School, Lebanon, NH
Gregory M. Press, MD, RDMS

Scott M.
Silvers,
MDof Emergency Ultrasound, Emergency Ultrasound
Assistant
Professor,
Director
Chair, Department
of Emergency
Medicine
Fellowship
Director, Department
of Emergency
Medicine, University of Texas at
Mayo Clinic,
Jacksonville,
FL TX
Houston
Medical
School, Houston,
ScottRutman,
Weingart,
Maia
MD MD FACEP
Assistant
Professor,
Department
Emergency
Medicine, Elmhurst
Medical
Director,
Pediatric
Emergency of
Services,
Dartmouth-Hitchcock
Medical
Hospital
Center,Professor
Mount Sinai
School
of Medicine,
NewDartmouth
York, NY
Center;
Assistant
of Pediatric
Emergency
Medicine,
Medical School, Lebanon, NH

Prior to beginning this activity, see Physician CME Information on

page 9.

Scott M. Silvers, MD

Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL

vant medications.

Scott Weingart, MD, FACEP

identify candidates for outpatient treatment.

Prior toguideline
beginningdevelopment,
this activity, seehttp://www.ebmedicine.net/
Physician CME Information on page 13.

The pathophysiology of obstructive airway disease presents special

considerations in the prevention and treatment of ventilator-associated
In patients with SCD and suspected infection, criteria exist to
complications such as hypoxemia, hypotension, and cardiac arrest.

Separate algorithms exist for the diagnosis and treatment of

stroke in adults and children with SCD.

Assistant Professor, Department of Emergency Medicine, Elmhurst Hospital

Center,Editors
Mount Sinai
School
of Medicine,
New York,
Note:
To read
more about
this NY
publication

and the background and methodologies for practice

content.php?action=showPage&pid=107&cat_id=16

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Current Guidelines For Management Of Asthma In The Emergency Department

British Guideline On The Management Of Asthma: A National

Clinical Guideline; Revised June 20093
Scottish Intercollegiate Guidelines Network, British Thoracic Society
Link to full report and quick reference guide: http://www.sign.ac.uk/guidelines/fulltext/101/index.html

he Scottish Intercollegiate Guidelines Network (SIGN) and the

British Thoracic Society (BTS) jointly coordinated the development of this document, first published in 2003. The most recent
revision was published in June 2009. The guidelines were created by
multidisciplinary groups of practicing clinicians in Britain using a standard methodology based on a systematic review of the evidence.

Patients with a peak flow greater than 75% best or predicted 1 hour
after initial treatment may be discharged from the ED unless they
meet any of the following criteria, when admission may be appropriate. (Recommendation Level C):
Still have significant symptoms
Concerns about compliance
Living alone/socially isolated
Psychological problems
Physical disability or learning difficulties
Previous near-fatal or brittle asthma
Exacerbation despite adequate dose steroid tablets prepresentation
Presentation at night
Pregnancy

An explicit strategy guided the literature search and review, and the
levels of evidence were assessed according to predefined criteria
and ranked on a 4-point scale utilizing a +/- system (1++ being the
highest level, and 4 being the lowest, expert opinion). Recommendations were also graded (A, B, C, D) for strength of evidence, not
importance. All members of the guideline development group made
financial disclosuresdetails are available on request from SIGN.
Note: The following quoted excerpts retain original British medical terminology. Where appropriate, standard American terminology is given
alongside [in brackets].

Treatment Of Acute Asthma In Adults

Give supplementary oxygen to all hypoxemic patients with acute
severe asthma to maintain SpO2 level of 94% to 98%. Lack of pul
se oximetry should not prevent the use of oxygen. (Recommendation Level C)
Nebulized 2-agonist bronchodilators should preferably be driven
by oxygen. (Recommendation Level A)
In hospital, ambulance, and primary care, nebulized 2-agonist
bronchodilators should preferably be driven by oxygen. (Recommendation Level A)
In severe asthma that is poorly responsive to an initial bolus dose
of 2-agonist, consider continuous nebulization with an appropriate
nebulizer. (Recommendation Level A)
Give steroids in adequate doses in all cases of acute asthma.
(Recommendation Level A)

Management Of Acute Asthma

Healthcare professionals must be aware that patients with severe
asthma and 1 or more adverse psychosocial factors are at risk of
death. (Recommendation Level B)
Acute Asthma In Adults - Criteria For Admission
Admit Patients with any feature of a life-threatening or near-fatal
attack. (Recommendation Level B)
Admit Patients with any feature of a severe attack persisting after
initial treatment. (Recommendation Level B)

EM Practice Guidelines Update 2010

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Current Guidelines For Management Of Asthma In The Emergency Department

Add nebulized ipratroprium bromide 0.5 mg 4-6 hourly [every 4 to

6 hours] to 2-agonist treatment for patients with acute, severe, or
life-threatening asthma or those with a poor initial response to 2agonist therapy. (Recommendation Level B)
Consider giving a single dose of IV magnesium sulfate for patients
with:
Acute severe asthma who have not had a good initial response to
inhaled bronchodilator therapy. (Recommendation Level B)
Life-threatening or near-fatal asthma. (Recommendation Level B)
Routine prescription of antibiotics is not indicated for acute asthma.
(Recommendation Level B)
Heliox is not recommended for use in acute asthma outside a
clinical trial setting. (Recommendation Level B)
All patients transferred to intensive care units should be accompanied by a doctor suitably equipped and skilled to intubate, if necessary. (Recommendation Level C)

pMDI [MDI] + spacer is the preferred option in mild to moderate

asthma. (Recommendation Level A)
Individualize drug dosing according to severity and adjust according
to the patients response. (Recommendation Level B)
If symptoms are refractory to initial 2-agonist treatment, add ipratropium bromide (250 mcg/dose mixed with the nebulized 2-agonist
solution). (Recommendation Level A)
Give prednisolone early in the treatment of acute asthma attacks.
(Recommendation Level A)
Second-Line Treatment Of Acute Asthma In Children Aged Over 2
Years
Consider early addition of a single bolus dose of intravenous salbutamol (15 mcg/kg over 10 minutes) in severe cases where the
patient has not responded to initial inhaled therapy. (Recommendation Level B)
Aminophylline is not recommended in children with mild to moderate
acute asthma. (Recommendation Level A)

Acute Asthma In Children Aged Over 2 Years

Consider intensive inpatient treatment for children with SpO2 < 92%
in air [on room air] after initial bronchodilator treatment. (Recommendation Level B)

Treatment Of Acute Asthma In Children Aged Less Than 2 Years

For mild to moderate acute asthma, a pMDI [MDI] + spacer is the
optimal drug delivery device. (Recommendation Level A)
Oral 2-agonists are not recommended for acute asthma in infants.
(Recommendation Level B)
Consider steroid tablets in infants early in the management of severe episodes of acute asthma in the hospital setting. (Recommendation Level B)
Consider inhaled ipratropium bromide in combination with an inhaled
2-agonist for more severe symptoms. (Recommendation Level
B)

Initial Treatment Of Acute Asthma In Children Aged Over 2 Years

The use of structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge is
recommended. (Recommendation Level D)
Inhaled 2-agonists are the first-line treatment for acute asthma.
(Recommendation Level A)

EM Practice Guidelines Update 2010

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Current Guidelines For Management Of Asthma In The Emergency Department

Expert Panel Report 3: Guidelines For The Diagnosis And Management

Of Asthma.1
National Institutes of Health; National Heart, Lung, and Blood Institute; NIH Publication No. 02-2117. Revised August 2007.
Link to full report: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Link to summary report: http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

his document was developed from 2004-2007 by an expert

panel commissioned by the National Asthma Education and
Prevention Program (NAEPP), coordinated and funded by the
National Heart, Lung, and Blood Institute (NHLBI) of the National
Institutes of Health of the U.S. Department of Health and Human
Services. It is an update to the original clinical practice guidelines that
were created in 1991 and revised in 1997 and 2002. The composition of the panel in terms of the medical specialties represented is not
reported. Financial disclosures are listed in detail in the full report.

in the ED. The Journal of Emergency Medicine recently published a

document summarizing recommendations on managing asthma exacerbations in the ED. Only recommendations pertinent to emergency medicine are abstracted here. Figure 1, Management of Asthma
Exacerbations: Emergency Department And Hospital-Based Care, is
adapted from the original NHLBI guideline. (See Figure 1, page 7.)
Key Points
Management of asthma exacerbations requiring urgent medical care
(eg, in the urgent care setting or emergency department) includes:
Oxygen to relieve hypoxemia in moderate or severe exacerbations.
(EPR-2 1997)
Short-acting 2-agonist (SABA) to relieve airflow obstruction, with
addition of inhaled ipratropium bromide in severe exacerbations.
Systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations, or for patients who fail to respond
promptly and completely to a SABA. (Evidence Category A)
Consideration of adjunct treatments, such as intravenous (IV) magnesium sulfate or heliox, in severe exacerbations unresponsive to
the initial treatments listed above. (Evidence Category B)
Monitoring response to therapy with serial measurements of lung
function. (Evidence Category B)
Preventing relapse of the exacerbation or recurrence of another exacerbation by providing all of the following (Evidence Category B):
Referral to followup asthma care within 1 to 4 weeks
An ED asthma discharge plan with instructions for medications
prescribed at discharge and for increasing medications or seeking
medical care if asthma worsens
Review of inhaler techniques whenever possible
Consideration of initiating inhaled corticosteroids (ICSs)

The panel conducted a literature search, prepared evidentiary tables

according to which recommendations were graded, and arranged for
an external review. The level of evidence was ranked specified according to predefined criteria and categorized into 1 of 4 categories:
A, B, C, and D. The strength of a recommendation was indicated as
strong when a certain clinical practice is recommended and less
strong when a certain clinical practice should be considered or may
be considered. The Evidence Categories are described as follows:
Evidence Category A: Randomized controlled trials (RCTs),
rich body of data
Evidence Category B: RCTs, limited body of data
Evidence Category C: Nonrandomized trials and observational
studies
Evidence Category D: Panel consensus judgment
This is a comprehensive guideline for the diagnosis and management
of asthma in patients of all ages and in all clinical settings. The target
audience is the primary care physician; however, the 2007 revision
includes an expanded section on managing exacerbations of asthma
EM Practice Guidelines Update 2010

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Current Guidelines For Management Of Asthma In The Emergency Department

Intramuscular depot injections of corticosteroids may be considered

as an alternative to oral corticosteroids for patients who are at high
risk of nonadherence. (Evidence Category D)
Give supplemental doses of oral corticosteroids to patients who
take them regularly, even if the exacerbation is mild. (Evidence
Category D)
High doses of an ICS may be considered in the ED, although current evidence is insufficient to permit conclusions about using ICSs
rather than oral systemic corticosteroids in the ED. (Evidence
Category B)
The Expert Panel does not recommend the following treatments:
Methylxanthines (Evidence Category A)
Antibiotics, except as needed for comorbid conditions
(Evidence Category B)
Aggressive hydration is not recommended for older children and
adults, but may be indicated for some infants and young children
(Evidence Category D)
Chest physical therapy is not generally recommended (Evidence
Category D)
Mucolytics (Evidence Category C)
Sedation is not generally recommended (Evidence Category D)

Assessment
Obtain objective lung function measurements.
FEV1 or PEF values provide important information about the level
of airflow obstruction both initially and in response to treatment.
Because low PEF values cannot distinguish between poor effort,
restrictive ventilatory disorders (eg, neuromuscular weakness,
pneumonia), and obstructive ventilatory disorders (eg, asthma),
FEV1 measurements are preferable if they are readily available.
(Evidence Category D)
In the initial assessment of a life-threatening asthma exacerbation,
FEV1 or PEF are not indicated. (Evidence Category D)
Very severe exacerbations may preclude performance of a maximal expiratory maneuver and, in such cases, the clinical presentation should suffice for clinical assessment and prompt initiation of
therapy. (Evidence Category D)
In less severe exacerbations, in the office or ED, FEV1 or PEF
should be obtained on arrival and 30 to 60 minutes after initial treatment. (Evidence Category B)
In the hospital, FEV1 or PEF should be measured on admission
and 15 to 20 minutes after bronchodilator therapy during the acute
phase and at least daily thereafter until discharge. (Evidence Category C)
Any FEV1 or PEF value < 25% of predicted that improves by
< 10% after treatment, or values that fluctuate widely are potential
indications for ICU admission and close monitoring for respiratory
failure. (Evidence Category C)

Repeat Assessment
The Expert Panel recommends that repeat assessment of patients
who have severe exacerbations be made after the initial dose of a
SABA and that repeat assessment of all patients be made after 3
doses of a SABA (60 to 90 minutes after initiating treatment). (Evidence Category A)

Treatment
Give systemic corticosteroids to patients who have moderate or
severe exacerbations and patients who do not respond completely
to initial SABA therapy. (Evidence Category A)
Oral administration of prednisone has been shown to have effects
equivalent to those of intravenous methylprednisolone. (Evidence
Category A)
Give a 5- to 10-day course following ED discharge to prevent early
relapse. (EPR-2 1997)

EM Practice Guidelines Update 2010

Hospitalization
The Expert Panel recommends that the decision to hospitalize a
patient be based on duration and severity of symptoms, severity of
airflow obstruction, response to ED treatment, course and severity
of prior exacerbations, medication use at the time of the exacerbation, access to medical care and medications, adequacy of support
and home conditions, and presence of psychiatric illness. (Evidence
Category C)

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Current Guidelines For Management Of Asthma In The Emergency Department

Patient Discharge
The Expert Panel recommends that clinicians, before patients
discharge from the ED, provide patients with necessary medications and education on how to use them, a referral for a followup
appointment, and instruction in an ED asthma discharge plan for
recognizing and managing relapse of the exacerbation or recurrence of airflow obstruction. (Evidence Category B)
Emphasize the need for continual, regular care in an outpatient
setting, and refer the patient for a follow-up asthma care appointment (either primary care provider or asthma specialist) within 1
to 4 weeks. If appropriate, consider referral to an asthma selfmanagement education program. (Evidence Category B)
Review discharge medications with the patient and provide patient education on correct use of an inhaler. (Evidence Category
B)
Give the patient an ED asthma discharge plan with instruction
for medications prescribed at discharge and for increasing medications or seeking medical care if asthma should worsen. (Evidence Category B)
Consider issuing a peak flow meter and giving appropriate education on how to measure and record PEF to patients who have
difficulty perceiving airflow obstruction or symptoms of worsening
asthma. (Evidence Category D)

Impending Respiratory Failure

The Expert Panel recommends that intubation not be delayed
once it is deemed necessary; exactly when to intubate is based
on clinical judgment. (Evidence Category D)
Other adjunct therapies to avoid intubation include IV 2-agonists,
IV leukotriene receptor antagonists (LTRAs), and noninvasive
ventilation; however, insufficient data are available to make
recommendations regarding these possible adjunct therapies.
(Evidence Category D)
The Expert Panel Recommends The Following Actions
Regarding Intubation
Patients who present with apnea or coma should be intubated immediately. (EPR-2 1997)
There are no other absolute indications for endotracheal intubation, but persistent or increasing hypercapnia, exhaustion, and
depression of mental status strongly suggest the need for ventilatory support. (Evidence Category D)
Intubate semi-electively, before the crisis of respiratory arrest,
because intubation is difficult in patients who have asthma. (EPR2 1997)
Intubation should be performed by a physician who has extensive
experience in intubation and airway management. (EPR-2 1997)
Permissive hypercapnia or controlled hypoventilation is the
recommended ventilator strategy. (Evidence Category C)

EM Practice Guidelines Update 2010

Source: U.S. Department of Health and Human Services; National

Institutes of Health; National Heart, Lung, and Blood Institute.

ebmedicine.net February 2010

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Current Guidelines For Management Of Asthma In The Emergency Department

Current Guidelines for Sickle Cell Disease: Management Of Acute Complications

Figure 1. Management Of Asthma Exacerbations: Emergency Department And Hospital-Based Care

Initial Assessment: Brief history, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate), PEF or FEV1, oxygen saturation, and other tests as indicated.
FEV1 or PEF 40% (mild to moderate)

Oxygen to achieve SaO2 90%

Inhaled SABA by nebulizer or MDI with valved holding chamber, up to 3 doses in first hour

Oral systemic corticosteroids if no immediate response or if

patient recently took oral systemic corticosteroids

FEV1 or PEF < 40% (severe)

Oxygen to achieve SaO2 90%

High-dose inhaled SABA plus ipratropium by nebulizer or

MDI plus valved holding chamber, every 20 minutes or continuously for 1 hour

Oral systemic corticosteroids

Impending or actual respiratory arrest

Intubation and mechanical ventilation with 100% oxygen

Nebulized SABA and ipratropium

Intravenous corticosteroids

Consider adjunct therapies

Repeat Assessment: Symptoms, physical examination, PEF, O2 saturation, other tests as needed

Admit to hospital intensive care (see box below)

Moderate exacerbation: FEV1 or PEF 40-69% predicted/personal

best
Physical exam: moderate symptoms

Inhaled SABA every 60 minutes

Oral systemic corticosteroid

Continue treatment 13 hours, provided there is improvement; make admit decision in < 4 hours

Severe exacerbation: FEV1 or PEF < 40% predicted personal best

Physical exam: severe symptoms at rest, accessory muscle use, chest reaction
History: high-risk patient; no improvement after initial treatment

Oxygen

Nebulized SABA + ipratropium, hourly or continuous

Oral systemic corticosteroids

Consider adjunct therapies

Good response

FEV1 or PEF 70%

Response sustained 60 minutes after last treatment

No distress

Physical exam: normal

Incomplete response

FEV1 or PEF 4069%

Mild-to-moderate symptoms

Discharge home

Continue treatment with inhaled SABA.

Continue course of oral systemic corticosteroid.

Consider initiation of an ICS.

Patient education
n
Review medications, including inhaler technique.
n
Review/initiate action plan.
n
Recommend close medical followup.

Admit to hospital ward

Oxygen

Inhaled SABA

Systemic (oral or intravenous) corticosteroid

Consider adjunct therapies

Monitor vital signs, FEV1 or PEF, SaO2

Key: FEV1, forced expiratory volume in 1 second; ICS, inhaled corticosteroid; MDI, metered dose inhaler; PCO2, partial pressure carbon dioxide;

PEF, peak expiratory flow; SABA, short-acting b2-agonist; SaO2, oxygen

saturation

Source: U.S. Department of Health and Human Services; National

Institutes of Health; National Heart, Lung, and Blood Institute.

EM
PracticeGuidelines
GuidelinesUpdate
Update2010
2009
EM
Practice

Poor response

FEV1 or PEF < 40%

PCO2 42 mm Hg

Physical exam: symptoms severe, drowsiness, confusion

Individualized decision re: hospitalization (see text)

Improve
Discharge home

Continue treatment with inhaled SABAs

Continue course of oral systemic corticosteroid

Continue on ICS. For those not on long-term control therapy,

consider initiation of an ICS

Patient education (eg, review medications, including inhaler

27

Admit to hospital intensive care

Oxygen

Inhaled SABA hourly or continuously

Intravenous corticosteroid

Consider adjunct therapies

Possible intubation and mechanical ventilation

Improve
technique and, whenever possible, environmental control
measures; review/initiate action plan; recommend close medical
followup)
Before discharge, schedule followup appointment with primary
care provider and/or asthma specialist in 14 weeks

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Current Guidelines For Management Of Asthma In The Emergency Department

Intubation And Mechanical Ventilation Of The Asthmatic Patient.5

Journal of Emergency Medicine. 2009:37:S23-34.

Noninvasive Ventilation6

Journal of Emergency Medicine. 2009:S18-S22.

Link to these: http://www.jem-journal.com/ (login and payment required)

Criteria For Intubation (Evidence Category D)

Clinical indications
Cardiac arrest
Respiratory arrest
Altered mental status
Progressive exhaustion
Silent chest
Laboratory indications
Severe hypoxia with maximal oxygen delivery
Failure to reverse severe respiratory acidosis despite intensive
therapy
pH < 7.2, carbon dioxide pressure increasing by more than 5 mm
Hg/h or greater than 55 to 70 mm Hg, or oxygen pressure of less
than 60 mm Hg

hese 2 documents were developed in 2008-2009 by a multidisciplinary group from the American Academy of Allergy, Asthma,
and Immunology; the American Academy of Emergency Medicine; and the American Thoracic Society, with the purposes of creating a Joint Task Force Report on the management of severe asthma
exacerbations. The group reviewed the National Asthma Education and Prevention Program Expert Panel Report (EPR-2) and, by
consensus, identified 11 areas with knowledge gaps in management
in follow-up. The group addressed 4 topics from the list; the most
recent EPR revision (EPR-3) discusses the remaining issues.4 A
systematic literature review was conducted for each of the 4 topics.
Of these topics, the reviews on intubation and mechanical ventilation5
and noninvasive ventilation6 are reviewed here. Financial disclosures
are provided in a third summary article.7 The Joint Task Force Report was co-published in 3 journals: Journal of Emergency Medicine,
Journal of Allergy and Clinical Immunology, and Proceedings of the
American Thoracic Society.

Intubation Technique (Evidence Category D)

There are 4 choices of technique, each with its own benefits and risks:
Nasotracheal intubation
Awake orotracheal intubation
Orotracheal intubation with sedation
Orotracheal intubation with sedation and neuromuscular blockade
In general, orotracheal intubation with sedation and neuromuscular
blockade are preferred for asthmatic patients in critical respiratory
distress.
The use of ketamine and propofol might be preferred over other
sedative agents. Pretreatment with bronchodilators might reduce
airway bronchospasm associated with tracheal intubation in patients with nonacute asthma requiring intubation. Patients with
acute asthma almost invariably would have received bronchodilation before intubation unless presenting in arrest or near arrest.

The level of evidence was assessed according to predefined criteria

and categorized into 1 of 4 groups (A, B, C, D), and are the same as
used by the EPR-3 Expert Panel (see NHLBI guideline summary beginning on page 4). Recommendations were also graded for strength
of evidence, delineated by the value strong or conditional.
Following is a summary of recommendations, from Intubation and Mechanical Ventilation Of The Asthmatic Patient, all
of which are strong.

EM Practice Guidelines Update 2010

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Current Guidelines For Management Of Asthma In The Emergency Department

Recommendations For Appropriate Ventilator Settings (Evidence

Category D)
Control of hyperinflation and auto-positive end-expiratory pressure
(auto-PEEP)
Reduction of respiratory rate might help control hyperinflation.
Reduction of tidal volume might help control hyperinflation.
An initial set-up of 80 L/min with a decelerating waveform configuration might be appropriate in adults.
Shortening of inspiration with a square wave pattern and an inspiratory flow rate of 60 L/min allows greater time for exhalation in
each respiratory cycle and might help control hyperinflation.
Auto-PEEP and plateau pressure (Pplat) should be followed during mechanical ventilation.
Hypercapnia is preferable to hyperinflation.
Hypercapnia should not be used in the presence of increased
intracranial pressure.
An acceptable level of hypercapnia and acidosis is a pH as low
as 7.15 and a PaCO2 of up to 80 mm Hg.

Prevention And Treatment Of Complications (Evidence Category D)

Hypoxemia
Exclude right mainstem intubation (21 cm at incisors).
Exclude pneumothorax and place pleural drain.
Tube obstruction (kinking, biting of tube, or plugging).
Exclude pneumonia and other lung disease.
Hypotension
Consider pneumothorax early, but first perform a trial of apnea or
hypopnea to decrease intrathoracic pressure unless there is unequivocal evidence of pneumothorax, such as tracheal shift with
unilateral breath sounds or subcutaneous emphysema.
Tension pneumothorax is a clinical diagnosis. If a lung examination suggests this complication, proceed with a needle thoracostomy followed by a chest tube thoracostomy.
Fluids.
Measure auto-PEEP and pPlat and apply reduction measures.
Exclude other causes, such as myocardial infarction and sepsis.
Cardiac arrest
A trial of apnea or hypopnea for no more than 30 to 60 seconds
with external compressions and volume challenge is therapeutic
for lung hyperinflation as a cause of cardiac arrest.
Consider tension pneumothorax early. If lung examination suggests this complication, proceed with a needle thoracostomy
followed by a careful chest tube thoracostomy.

Management In The Postintubation Period (Evidence Category D)

Verify endotracheal tube placement with a carbon dioxide detector,
adequate oximeter readings, and chest radiography. Chest radiography will determine the depth of intubation but not esophageal
intubation with the patient breathing around the tube.
Postintubation sedation should be provided with a benzodiazepine.

Medical Management Of The Intubated Asthmatic Patient

Continued treatment with inhaled bronchodilators, such as nebulized albuterol or albuterol administered with an MDI. (Evidence
Category B)
Systemic corticosteroid treatment, such as 40 mg of methylprednisolone every 6 hours. (Evidence Category B)
No routine use of heliox once the patient is intubated. (Evidence
Category D)

EM Practice Guidelines Update 2010

Reprinted from Journal of Emergency Medicine, Volume 37, Schatz

M, Kazzi AA, Brenner B, et al, Intubation and Mechanical Ventilation
Of The Asthmatic Patient In Respiratory Failure, pages S32-S33,
2009, with permission from Elsevier.

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Current Guidelines For Management Of Asthma In The Emergency Department

Pending additional data, specific settings should follow the protocol

set forth in the article by Soroksky et al.7 (Evidence Category D)*
Settings should be individualized and guided by careful evaluation of
clinical response.

Following is a summary of recommendations from "Noninvasive Ventilation" (all conditional):

A trial of noninvasive positive pressure ventilation (NPPV) before
intubation and mechanical ventilation should be considered in selected patients with acute asthma and respiratory failure (Evidence
Category B).
These would include patients who can tolerate and cooperate with
this therapy. NPPV should only be used in these patients provided
that the respiratory therapists, nurses, and physicians who are responsible for their care are very familiar with this technology and the
patients are in an area where they can be constantly observed and
monitored and can receive immediate intubation, if needed. (Recommendation Level Conditional)

EM Practice Guidelines Update 2010

*The protocol called for an initial expiratory pressure of 3 cm H2O that

was increased by 1 cm H2O every 15 minutes to a maximum pressure
of 5 cm H2O. The initial inspiratory pressure was set at 8 cm H2O and
increased by 2 cm H2O every 15 minutes to a maximum pressure of
15 cm H2O or until the respiratory rate was less than 25 breaths/min,
whichever came rst.

Reprinted from Journal of Emergency Medicine, Volume 37, Nowak

R, Corbridge T, Brenner B,Noninvasive Ventilation, pages S18-S22,
2009, with permission from Elsevier.

10

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Current Guidelines For Management Of Asthma In The Emergency Department

Editorial Comment
The Joint Task Force Report coordinated by the American Academy
of Allergy, Asthma, and Immunology; the American Academy of Emergency Medicine; and the American Thoracic Society released clinical
guidelines in 2009 addressing knowledge gaps in the NAEPP Expert
Panel Report. These guidelines are the first major clinical guidelines
to address the use of noninvasive ventilation, intubation, and mechanical ventilation in the asthmatic patient. The emergency clinician
now has a comprehensive set of recommendations to guide the management of asthma in the emergency department ED.

Intubation: Intubation does not treat bronchospasm, and in fact, can

worsen bronchospasm, in addition to subjecting patients to a variety
of ventilator-associated complications. The emergency clinicians
goal in treating patients presenting with severe asthma is preventing
intubation. Patients with severe asthma should receive IV magnesium and be considered for an IV -agonist such as terbutaline or
epinephrine. Although high-quality evidence supporting the use of
noninvasive ventilation (NIV) in asthma is limited, a trial of NIV may
prevent intubation in cooperative patients with severe asthma where
intubation is a consideration but not immediately indicated. Weak evidence also exists for the use of dissociative-dose IV ketamine as part
of a strategy to prevent intubation of severe asthmatics.11,12

For mild and moderate asthma exacerbations, thoughtful discharge

planning is perhaps the most important element of the ED evaluation.
Institution of an asthma action plan, arrangement of follow-up with
primary or specialist providers, and prescription of appropriate abortive and preventative therapies improve quality of life and reduce ED
presentations.

Management Of The Ventilated Asthma Patient: The pathophysiology of obstructive airway disease presents special considerations in
the prevention and treatment of ventilator-associated complications
such as hypoxemia, hypotension, and cardiac arrest. Breath-stacking
due to air trapping in already hyperinflated lungs not only increases
the risk of barotrauma and pneumothorax, but may also decrease venous return, causing hypotension and cardiac arrest. For this reason,
a trial of apnea or hypopnea to decrease intrathoracic pressure is the
best initial strategy when treating an intubated asthma patient with
hypotension or cardiac arrest unless there are objective physical findings to suggest tension pneumothorax. This is best accomplished by
disconnecting the intubated asthmatic who acutely decompensates
from the ventilator circuit. If tension pneumothorax exists, the emergency clinician should proceed with needle thoracostomy followed
by chest tube thoracostomy, or finger thoracostomy followed by tube
thoracostomy if a rush of air is felt.13,14 To prevent these complications, hypercapnea is generally preferable to hyperinflation. This
should be obtained with permissive hypercapnea reduction of autoPEEP obtained via:
A decreased respiratory rate (10 breaths/min)
A reduced tidal volume (7-8 ml/kg of ideal body weight)
An increased inspiratory flow rate (60 L/min of constant flow or 80 to
90 L/min of decelerating flow), allowing greater time for exhalation
Close monitoring of plateau pressures4

Steroid Use: The EPR-3 and BTS/SIGN groups have different

recommendations with regard to steroid use: EPR-3 limits its recommendations in the ED to systemic steroids in moderate and severe
exacerbations and in patients who do not respond to SABA only,
whereas the BTS/SIGN recommend steroids in adequate doses in all
cases of acute asthma. The emergency clinician should have a low
threshold for using systemic steroids given the low risk of this treatment and its potential to prevent relapse. To improve compliance and
convenience, evidence supports the use of single-dose oral or intramuscular dexamethasone as an alternative to a short course of oral
prednisone or prednisolone.9,10
Objective Testing: Both the EPR-3 and SIGN guidelines recommend the use of peak flow or FEV1 measurements in the assessment
of asthma exacerbation severity. While they are limited by patient
effort and must not blind the provider to the larger clinical picture (eg,
psychosocial risk factors, severity of prior exacerbations), results of objective testing are valuable in guiding therapy and disposition decisions.

EM Practice Guidelines Update 2010

11

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Current Guidelines For Management Of Asthma In The Emergency Department

References
1.

2.

3.

emergency department: summary of the National Asthma Education and Prevention

Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. J Emerg Med. 2009 Aug;37:S6-S17. (Review)

US Department of Health and Human Services, National Institutes of Health,

National Heart Lung and Blood Institute. Expert Panel Report 3: Guidelines for the
diagnosis and management of asthma, Full Report 2007. NIH Publication No. 074051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Third edition, revised
August 2007. Accessed December 30, 2009. (Clinical Guideline)
Kattan M, Mitchell H, Eggleston P, et al. Characteristics of inner-city children with
asthma: the National Cooperative Inner-City Asthma Study. Pediatr Pulmonol.
1997;24:253-262. (Prospective; 1528 patients)
British Thoracic Society and Scottish Intercollegiate Guidelines Network. British
Guideline on the Management of Asthma: A National Clinical Guideline. Third edition, revised June 2009. http://www.sign.ac.uk/pdf/sign101.pdf. Accessed December
30, 2009. (Clinical Guideline)

4.

Schatz M, Kazzi AA, Brenner B, et al. Recommendations for the management and
follow-up of asthma exacerbations. Introduction. J Emerg Med. 2009;37:S1-S5.
(Review)

5.

Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the

asthmatic patient in respiratory failure. J Emerg Med. 2009;37:S23-S34. (Clinical
Guideline)

6.

Nowak R, Corbridge T, Brenner B. Noninvasive ventilation. J Emerg Med.

2009;37:S18-S22. (Clinical Guideline)

7.

Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exacerbations in the

Soroksky A, Stav D, Shpirer I. A pilot prospective, randomized, placebo-controlled

trial of bilevel positive airway pressure in acute asthmatic attack. Chest.
2003;123:1018-1025. (Prospective, randomized; 30 patients)

9.

Altamimi S, Robertson G, Jastaniah W, et al. Single-dose oral dexamethasone in the

emergency management of children with exacerbations of mild to moderate asthma.
Pediatric Emergency Care. 2006;22:786-793.

10. Gordon S, Tompkins T, Dayan P. Randomized trial of single dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Pediatric
Emergency Care. 2007;23:521-527.
11. Denmark TK, Crane HA, Brown L. Ketamine to avoid mechanical ventilation in
severe pediatric asthma. J Emerg Med. 2006;30(2):163-166.
12. Shlamovitz GZ, Hawthorne T. Intravenous ketamine in a dissociating dose as a temporizing measure to avoid mechanical ventilation in adult patient with severe asthma
exacerbation. J Emerg Med. 2008 Oct 13. [Epub ahead of print]
13. Deakin CD, Davies G, Wilson A. Simple thoracostomy avoids chest drain insertion in
prehospital trauma. J Trauma. 1995;39(2):373374.
14. Weingart S. EMCrit Podcast 16 Coding Asthmatic, DOPES, & Finger Thoracostomy. 13 Dec 2009. http://blog.emcrit.org/podcasts/finger-thoracostomy/

Opinions expressed are not necessarily those of this publication. Mention of products

To write a letter to the editor, email Reuben Strayer, MD, Editor-In-Chief, at:
strayermd@ebmedicine.net

or services does not constitute endorsement. This publication is intended as a general

guide and is intended to supplement, rather than substitute, for professional judgment.

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Current
Guidelines
For And
Management
Of Externa
Asthma In
In The
The ED:
Emergency
Department
Benign Paroxysmal
Positional
Vertigo
Acute Otitis
Current Guidelines

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Subscribe to Emergency Medicine Practice and youll receive EM Practice Guidelines Update at no additional charge! Plus, you
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An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed
based on strength of evidence.

Years

Evidence-B
ased Appro
ach
To Diagnos
is
Of Aneurys And Management
ma
Hemorrhag l Subarachnoid
e In The Em
ergency
Departmen
t

Improving Patien

t Care

July 2009

Authors

Volume 11,

Lisa E. Thoma

Number 7

s, MD
Department
of Emerge
Hospital &
ncy
Massachusetts Medicine, Brigham
& Women
Jonathan
General Hospita
s
Edlow, MD
l, Boston,
Vice Chair,
MA
Department
Beth Israel
of Emerge
Deaconess
ncy
Medicine,
Medical Center;Medicine
Harvard Medica
Associate
l School,
Joshua N.
Boston, MA Professor of
Goldstein,
Instructor
MD, PhD,
in Surgery
FAAEM
(Emergency
School, Departm
Medicine),
General Hospita ent of Emergency
Harvard Medica
Medicine,
l, Boston,
Massachusetts l
MA
Peer Review
ers

You walk into

a crowded
Your first patien
evening shift
in the emerg
her head, compl t is a middle-aged
woman lying ency department (ED).
with her hands
about a subara aining of the wors
t heada
noncontrast chnoid hemorrhage (SAH che of her life. You clutching
head compu
are worried
E. Bradshaw
says that her
ted tomography ). You treat her pain
Bunney,
Associate
MD, FACEP
and order
headache is
Professor,
(CT), which
a
kids. Does
Residency
Emergency
is negative.
Director, Departm
Medicine,
she really needbetter and that she needs
She now
Chicago,
University
ent of
to stay for
IL
to go home
of Illinois
at Chicago
an LP, which a lumbar puncture
to pick up
Neal Little,
,
(LP)?
her
is also negati
need any additi
MD, FACEP
Adjunct Clinical
ve. Can she She eventually agrees
onal worku
Assistant
Medicine,
go home now?
p?
Professor,
While you
University
Department
are
Does she
of Michiga
thinking about
of Emerge
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migraine arrive
CME Objecti
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School, Ann
this,
ves
Arbor, MI
lasted 12 hours s complaining of sudde another patient with
Upon comple
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histor
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of this article,
y of
et, severe heada
1. Describ
SAH? After . Is this headache her
you should
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che
be able to:
usual migra
further histor
discuss the classic presentation
ine or could that has
and you obtain
of an SAH
wide spectru
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Describ
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ed,
e the diagnos
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some clearin a CT, which is norma you are concerned about be an
tic approac
having an
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SAH.
g
l.
3. Identify
suspected
it may have of red blood cells (RBC You perform an LP, which an SAH
the major
of
limitations
been a traum
modalities.
s) from tube
shows
in interpre
pondering
ting the diagnos
1 to tube 4,
4. Discuss
this, the lab atic tap, but how can
general principle
tic
you be sure? and you think
the ED.
calls to say
diagnosis of
s of acute
SAH manage
there is xanth
Just as you
5. Identify
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ment in
common
are
ochromia.
should you
calling for
pitfalls in
You
neurosurgic
do in the ED
the diagnos
is of SAH.
al consultation make the
to treat this
Date of original
patient?
, what else
release: July
Date of most
1, 2009
recent

Editor-in-Ch

Andy Jagoda, ief

MD, FACEP
Professor
and Chair,
Department
of Emergen
cy
Sinai School Medicine, Mount
of Medicine
Director, Mount
; Medical
Sinai Hospital,
York, NY
New

Editorial

Chattano
oga, TN
Michael A.
Gibbs,
Chief, Departm MD, FACEP
ent of Emergen
Medicine,
cy
Maine Medical
Portland,
Center,
ME

Charles V.
Pollack, Jr.,
FACEP
MA, MD,
Chairman,
Department
Emergency
of
Medicine

Termination review: April 27,

2009
date: July
1, 2012
Medium:
Prior to beginni
Print and
online
ng this activity,
see Physic
Information
ian CME
on page 27.

University
Medical Center,
Nashville
, TN

Internationa

Steven A.
, Pennsylv
Hospital,
Godwin,
Universit
ania Jenny Walker,
Board
l Editors
MD, FACEP
MD, MPH,
Health System, y of Pennsylv
Assistant
William J.
Assistant
MSW
Professor
ania
Peter Camero
Brady, MD
Philadelp
Professo
and Emergen
Medicine
hia, PA
n, MD
Professor
Family Medicine r; Division Chief,
Residenc
cy Michael S. Radeos,
Chair, Emergen
of
y Director,
University
, Departm
and MedicineEmergency Medicine
of Commun
cy Medicine
MD, MPH
Assistant
of Florida
ent
Monash Universit
ity and Preventiv
,
Professor
HSC,
Jacksonv
Emergency Vice Chair of
Medicine,
of Emergen
y; Alfred Hospital,
Medicine,
ille, FL
Melbourn
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Medicine,
Mount Sinai
cy
Weill
e, Australia
of Virginia
University
Center, New
Medical
Gregory
Cornell UniversitMedical College
School of
L. Henry,
York, NY
Amin Antoine
of
Medicine,
Charlotte
y, New York,
MD, FACEP
CEO, Medical
sville, VA
Kazzi, MD,
Ron M. Walls,
NY.
Robert L.
Associate
FAAEM
Rogers,
MD
Assessment, Practice Risk
Professor
Peter DeBlieux
Professo
FAAEM, FACP MD, FACEP,
and Vice
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r and Chair,
, MD
of Emergen Inc.; Clinical Professo
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