Reassessment of asthma management in an accident and emergency department

Management of Acute Asthmatic Attacks in a Local Emergency Department before and after the Introduction of Guidelines

Introduction

Objective assessment and management of acute asthma is often sub-optimal in busy emergency departments. This study examined the effect of the introduction of guidelines on asthma management in the emergency department.

Materials & Methods

All patients (>2 years old) presented to the emergency department for acute asthmatic attacks over a period of 1 year were included. Guidelines for the management of acute asthma were introduced after the first quarter of the study year. Analysis was made to compare the assessment, treatment and discharge planning of patients presenting with acute asthma to the emergency department before and after the introduction of the guidelines.

Results

After the introduction of the guidelines, there was a significant increase in the measurement of peak expiratory flow rate (PEF) and oxygen saturation as part of patient assessment for asthma severity. Such an improvement did not result in a change in hospital admission rate. There was a significant increase in the proportion of patients discharged with a course of oral corticosteroids, a significant reduction in the use of oral bronchodilators in the younger age group and antibiotics in the older age group.

Conclusions

The introduction of guidelines for the management of acute asthma and education of the clinicians in the emergency department has resulted in improvement in the overall management and discharge planning for asthma patients.

Do the residents in the emergency department appropriately manage patients with acute asthma attack? A study of self-criticism

The objective of this study was to investigate the management of patients with asthma attack admitted to the emergency department (ED) in terms of compliance with international guidelines. The records of patients with asthma who were admitted to a university-based ED between December 2001 and December 2002 were evaluated. A total of 72 cases with available data were evaluated retrospectively. Twenty-six patients (36.1%) were admitted more than once during the study period. The number of multiple admissions ranged from 2 (15 patients, 20.0%) to 11 (2 patients, 2.8%). Peak expiratory flow (PEF) measurements were recorded in 17 patients (23.6%) on presentation. Pulse and respiratory rates were recorded in 70 (97.0%) and 67 patients (93.0%), respectively. Thirty-four patients (47.2%) underwent chest x-ray; results were normal in most patients. Salbutamol was the most commonly used drug as first-line therapy. Ipratropium bromide (inhaled) and systemic corticosteroids were added to the salbutamol in 47 (65.2%), 42 (58.4%), and 32 patients (44%), respectively. Pulmonologists were consulted in only 7 cases (9.7%). Thirty patients (43.4%) were prescribed corticosteroids on discharge. The role of functional parameters in determining asthma severity and monitoring treatment effects should be emphasized in clinical practice. Finally, more prevalent use of management guidelines will help determine their usefulness.

Standardized protocol improves asthma management in emergency department

This study assessed, 30 months after its initiation, the impact of a standardized asthma management program designed to facilitate the implementation of asthma management guidelines in a tertiary teaching hospital adult emergency department. The program was initiated in a stepwise manner: first, a retrospective baseline audit; followed by generation of local guidelines; validation of these guidelines by all staff involved; distribution of the guidelines; a second practice audit; use of these results to further improve the program; feedback to the staff; twice-yearly information meetings; and a new audit 2 years later. The main results were a significant improvement in history taking (p < 0.001), increased use of serial airflow measurements (p < 0.001), increased steroid use (p < 0.001), and better documentation of follow-up arrangements (p < 0.01). Several tests of questionable value were no longer prescribed routinely. The improvements persisted after 2.5 years. In contrast, there was no improvement in the proportion of medical files that contained records of discharge prescriptions for outpatients. Implementation of locally agreed guidelines resulted in a marked improvement in several aspects of asthma management in an emergency department; the program must be pursued to maintain and further improve quality of care.

Trends in emergency department asthma care in metropolitan Chicago: results from the Chicago Asthma Surveillance Initiative

STUDY OBJECTIVE

The purpose of this study was to assess trends in emergency department (ED) asthma care in a single large community and to address how these trends meet expectations of national guidelines for asthma care.

DESIGN AND SETTING

This study is based on a repeated cross-sectional, self-administered survey of ED directors (or designees) in the Chicago area.

PARTICIPANTS

Fifty-one EDs that responded to both the 1996-1997 and 2000 surveys comprise the database for this study.

RESULTS

Areas of significant improvement from 1996-1997 to 2000 include reduction in the use of theophylline (10.1% vs 3.1%, p < 0.0001), increased use of systemic steroid prescriptions at discharge (57.7% vs 77.2%, p < 0.0001), decreased use of arterial blood gas (ABG) analyses as part of the initial patient assessment (10.2% vs 4.5%, p = 0.02) and to document improvement after treatments (18.8% vs 8.9%, p = 0.03) and increased use of pulse oximetry as part of the initial patient assessment (95.1% vs 98.1%, p = 0.05). Areas of significant worsening of asthma care from 1996-1997 to 2000 include reduction in the use of ABG analyses in the assessment of severe cases (71.5% vs 47.5%, p < 0.0001), decreased use of instructions to inform patients what to do in the event of inability to attend their follow-up appointment (94.4% vs 38.9%, p = 0.0004), and decreased use of peak expiratory flow rate measurements to document improvement after treatments (82.7% vs 78.6%, p = 0.04).

CONCLUSIONS

From 1996-1997 to 2000, ED asthma care in metropolitan Chicago has improved in some areas and worsened in others. However, most aspects of asthma care have continued to fall short of national asthma guidelines. The lack of overall improvement with the current widespread knowledge of national guidelines suggests that a dissemination strategy of medical education by itself is not sufficient to improve ED asthma care.

Background severity of asthma in children discharged from the emergency department

OBJECTIVE

Attendance at an Emergency Department (ED) with an acute attack of asthma may be indicative of undertreatment of persistent disease. However, many presentations are in children with infrequent episodic asthma. The aim of this study was to characterize the pattern of asthma of children discharged from ED to determine whether there was potential to improve underlying disease control.

METHODOLOGY

This was a cohort study. Three hundred and ten parental caretakers of 1 to 15-year-old children, attended and discharged from an ED with asthma, completed an asthma control questionnaire, an asthma knowledge questionnaire and a caregiver's quality of life questionnaire. Background severity of asthma was classified and medication history was assessed. Also included were those with their first attack of asthma.

RESULTS

One hundred and thirty-two (43%) children had infrequent episodic asthma, 105 (34%) frequent episodic, 40 (13%) persistent asthma and 33 (11%) first attack asthma. Thirty-nine per cent of children were not receiving preventer therapy and this seemed appropriate; 14% of children with frequent episodic and persistent asthma were not receiving appropriate preventer therapy; and a further 34% had frequent symptoms despite receiving preventer therapy.

CONCLUSIONS

We observed deficiencies in use of preventer medications, use of written asthma management plans and lack of parental knowledge in some children with established asthma who presented to an ED. There was also a large number of children who did not have frequent background symptoms or who presented with their first episode.

Accident and emergency departments are still failing to assess asthma severity

OBJECTIVES

To quantify the documentation of vital signs in children attending accident and emergency (A&E) for asthma and to assess whether indicators of severity were used appropriately.

METHODS

Records of all children aged 3 to 14 attending A&E for the treatment of asthma in four London hospitals over a three month period were examined for documentation of heart rate, respiratory rate, peak expiratory flow rate, oxygen saturation, and fraction of inspired oxygen. The relation between severity indicators and whether the child was admitted or not was examined.

RESULTS

There were 255 attendances in 229 children. Heart rate, respiratory rate, and oxygen saturation were recorded on most attendances (94.5%, 85.5%, and 96.8%) but fraction of inspired oxygen and peak flow were recorded in few children (48.6% and 48.5%). Heart rate and respiratory rate were higher and oxygen saturation lower in children who were admitted compared with those who were not.

CONCLUSIONS

Assessment of airways obstruction is inadequate in children but when measured may be used appropriately to guide admission. There is a need for interventions to improve assessment of children attending A&E for asthma.

The socio-economics of asthma

Is it healthy to be wealthy? The answer to this simple but provocative question can be found in a wide variety of published studies, which evaluate the socio-economic equity of healthcare and the socio-economic impact of diseases. Studies have focused on avoidable mortality, race and ethnicity, environment and access to healthcare services, and many found supporting facts of the above thesis, mostly based on cardiovascular diseases. But what about asthma? Additional factors such as risk behaviours e.g. smoking, excessive use of beta-agonists or general non-compliance with asthma medication have been investigated and found to be contributing to adverse health outcomes. Prevalence and incidence of asthma is higher in people with high socio-economic status (SES), but disease severity and premature mortality is more than twice as common in populations with low SES. The key to reduce the large socio-economic impact is, therefore, to improve the management of patients with more severe diseases. Because those patients are found more often in low SES groups, new approaches such as community disease management programmes, probably provided by a multi-disciplinary care team, have to be established. Current financial incentives within the largely sectored healthcare system are counterproductive. Furthermore, a better co-ordination of the goals of public healthcare experts with those providing individual 'clinical' healthcare is needed. Clearly communicated healthcare goals are needed to create common incentives and shared visions. Cornerstones of the new disease management efforts are co-ordinated care, high quality innovative medicines and a well-educated patient. This might help improve the implementation of current asthma management knowledge into practice.

Beyond administrative data: characterizing cardiorespiratory disease episodes among patients visiting the emergency department

We attempted to address deficiencies in administrative health service data during a study of cardiorespiratory emergency department visits. From 1994-1996, we obtained data on 9,264 visits and conducted 1,772 follow-up interviews. The median interval between symptoms and visit ranged from 0.8 days (95% CI 0-1.7) for cardiac conditions to 4.0 days for chronic obstructive pulmonary disease (COPD) (95% CI 2.7-5.3) and respiratory infections (95% CI 3.5-4.5). Infection was the most common trigger of respiratory visits. Although most had improved at follow-up, symptoms persisted following the visit for a mean of 4.5 days (95% CI 3.8-5.4) for cardiac conditions to 8.4 days (95% CI 7.2-9.5) for COPD. Among adults aged < 70, the mean number of reduced activity days per episode ranged from 4.7 (95% CI 3.9-5.4) for asthma to 6.6 (95% CI 5.9-7.4) for respiratory infections. Our data assist in interpreting epidemiological studies based on administrative data, and illustrate the broad impacts of cardiorespiratory disease episodes.

Asthma care practices in Chicago-area emergency departments. Chicago Asthma Surveillance Initiative Project Team

INTRODUCTION

Emergency departments (EDs) represent an important source of asthma care, yet there are few studies detailing how ED asthma practices vary and to what extent EDs meet expectations of national asthma guidelines. The purpose of this study is to characterize ED care for persons with asthma in a single large community.

METHODS

During 1996 and 1997, a cross-sectional, self-administered survey to characterize asthma care practices was conducted among medical directors of the 89 EDs serving the Chicago metropolitan area (six counties). The survey topic areas included asthma-specific demographics and selected utilization statistics; assessment practices; treatment practices; discharge and follow-up activities; and familiarity with, attitudes toward, and utilization of guidelines/ protocols.

RESULTS

Sixty-four EDs completed surveys, for a response rate of 71.9%. Ninety-four percent of the respondents were ED medical directors. As part of assessment, peak flow measurements, while common, were used less frequently than pulse oximetry. The average (+/- SE) estimated length of stay for asthma care was 3.0 +/- 0.1 h, and average disposition time (ie, the decision to admit) was 2.5 +/- 0.2 h. Systemic steroids (either i.v. or p.o.) were estimated to be given to 73.2 +/- 3.9% of patients during their ED visits. Systemic steroids were prescribed for 55.9 +/- 3.5% of patients at time of discharge. Only 57.0 +/- 5.4% of patients were estimated to have received any type of written asthma educational materials. Approximately 25% of patients were reported to have been given a detailed follow-up appointment at the time of discharge.

CONCLUSION

The results reveal that the medical directors reported many of the Chicago-area EDs as providing asthma care that is consistent with key aspects of national guidelines. However, in certain critical areas of care, the EDs demonstrate a high degree of variation, often with the community falling short of guideline recommendations. By identifying these variations in asthma care, it is now possible to target specific goals for community-wide asthma quality improvement among the EDs in the Chicago metropolitan area.

Prehospital treatment of acute asthma in a rural state

BACKGROUND

Acute asthma exacerbations can be life threatening and are recognizable to emergency medical service (EMS) personnel; however, the therapies and medications which these emergency service personnel can use to treat exacerbations are limited. Several studies have demonstrated the effective use of beta2-agonist therapy in the treatment of patients complaining of wheezing or dyspnea, yet few EMS personnel can administer them.

OBJECTIVE

The purpose of this study was to determine what therapeutic interventions emergency personnel around the state of New Mexico could use when responding to a call for a severe asthma exacerbation.

METHODS

Questionnaires were distributed over a period of three years, 1992-1994, to all Emergency Service Agencies in New Mexico.

RESULTS

Eighty percent of the emergency medical personnel administer oxygen to patients experiencing acute asthma exacerbations. Seventeen percent of EMS personnel administer epinephrine, 4% administer steroids, and only 23% administer beta2 agonists. Only in more populated areas were EMS personnel allowed to administer beta2 agonists, and those personnel had to have at least intermediate-level training. Most emergency response teams in the state consisted of EMT Basics and provided only basic life support services. In rural New Mexico, transport to a hospital can often take over one hour, which left EMS crews feeling helpless.

CONCLUSIONS

We conclude that due to the rural nature of New Mexico, EMS personnel should be trained in the use of beta2 agonists and allowed to administer them to patients with acute asthma exacerbations. In addition, standard protocols for the pre-hospital management of acute asthma exacerbations should be instituted.

Management of acute asthma in Canada: an assessment of emergency physician behaviour

The study objective was to assess Canadian emergency physicians for their management preferences and their compliance with recently developed guidelines for treatment of acute asthma in adults. The design was a cross-sectional survey sent to members of the Canadian Association of Emergency Physicians (CAEP) and to the emergency department (ED) directors of all Canadian hospitals with more than 25 beds in November 1992. ED directors who had not responded were sent a second survey in January 1993. The response rates for the survey were 60.1% (362/602) for ED directors and 53.4% (302/586) for CAEP members. Respondents were more likely to be from larger hospitals and to have completed some training beyond general practice level (CCFP, CCFP-EM, ABEM, FRCPC). There were wide variations among respondents in the use of objective measurements of asthma severity (forced expiratory volume in 1 s [FEV1] and peak expiratory flow rates [PEFR]), dosing of bronchodilators, and utilization of systemic corticosteroids. Forty-six percent of respondents used the FEV1 "occasionally" (22.3%) or "never" (23.8%), and 26.7% used PEFR "occasionally" (15.8%) or "never" (10.9%) in asthma management. Ninety-seven percent used nebulized beta agonist "always" (71.3%) or "often" (25.6%), but only 48.5% used the metered dose inhaler (MDI) "always" (11%) or "often" (37.5%). More than a quarter of respondents (27.2%) used doses of beta agonists that were less than those recommended (> every 30-60 min). Oral corticosteroids were prescribed at discharge only "occasionally" (51.1%), "seldom" (18.9%), or "never" (6.5%) in 76.6% of physicians. Physicians with more training were more likely to assess and treat patients according to current asthma treatment guidelines. The survey shows that many Canadian emergency physicians did not follow published recommendations for the care of patients with acute asthma. This finding was especially so with regard to objective evaluation of airflow, aggressive use of beta-agonists, the use of corticosteroids, and in making appropriate arrangements for patient discharge and follow-up.

A national census of those attending UK accident and emergency departments with asthma. The UK National Asthma Task Force

OBJECTIVE

To obtain a representative national picture of the type of people with asthma attending accident and emergency (A&E) departments in the UK, the reasons why they attend, and to determine the proportion admitted to hospital.

DESIGN

A national census involving questionnaires.

SETTING

100 A&E departments throughout the UK.

SUBJECTS

All those with asthma attending because of asthma during a one week period in September 1994.

RESULTS

Details were obtained about 1292 attendances. About half of all attendances were by adults and half by children, and 87.8% were previously diagnosed asthmatics; 18.8% of adult attenders were unemployed. Perceived severity of asthma was the reason for attendance in 65.5%, but 11.5% reported non-availability, or perceived non-availability, of the general practitioner (GP) as the reason for attending. One fifth of adults had been kept awake by their asthma for over three nights before attendance. 425 of the 1292 attenders (32.9%) had been admitted to hospital in the previous 12 months and 316 (24.5%) had attended the A&E department in the previous three months. Only 24.6% of attenders had had contact with their general practitioner in the previous 24 h. 61.6% of under-5 attenders (n = 341) were admitted to hospital; the figures for those aged 5-15 and 15+ years and above were 265 (41.4%) and 665 (38.7%).

CONCLUSIONS

Many people with asthma attend A&E departments without first having seen their GP. In many adult cases the asthma, while severe, is not acute, but a high proportion of both adults and children are admitted to hospital. Many of these attendances and admissions are repeat attendances. To enhance the quality of care provided to those with asthma may require easier access to primary care, enhanced patient education, or enhanced health professional education. Further study is needed of a variety of potential interventions.

Death from asthma: rare but real

Asthma mortality has been increasing over the past 15 years. Since the incidence of fatal asthma is rare, death is perceived as an unexpected outcome. This paper reviews the nature of asthma, and the circumstances and characteristics of patients with fatal asthma attacks. In light of these features, the emergency care of acute asthma is discussed. Recommendations for improvement of prehospital and hospital care are made. Despite optimum therapy and management, death is sometimes unavoidable.

Survey of asthma practice among emergency physicians

PURPOSE

The National Asthma Education and Prevention Program (NAEPP) published guidelines for asthma management in 1991. The purpose of this study is to assess the concordance between emergency physicians' practice and the guidelines.

DESIGN

Survey mailed to emergency physicians. Non-respondents were mailed a second copy of the survey.

PARTICIPANTS

Eight hundred randomly selected active members of the American College of Emergency Physicians.

INTERVENTIONS

None.

MEASUREMENTS

Participants were asked questions regarding training, current asthma practices, and sources of information on asthma management.

RESULTS

Eight hundred questionnaires were mailed, of which 416 (52%) were returned. Sixty-four percent of respondents administer beta-agonists consistent with the NAEPP guidelines. Seventy-five percent of respondents administer corticosteroids in similar accord, while 75% prescribed outpatient corticosteroids in concordance with those recommendations. Forty-seven percent report measuring pretreatment pulmonary function more than half the time and only 38% report checking pulmonary function prior to disposition more than half the time.

CONCLUSIONS

Most emergency physicians surveyed use beta-agonists and steroids at least as often as recommended. A minority of emergency physicians reported utilizing pulmonary function testing in the manner recommended by the NAEPP.

Oxygen saturation in adults with acute asthma

Avoidable deaths from asthma continue. Some of these result from the difficulty in determining the severity of an acute asthma attack at the initial assessment. This study evaluated the relation of pulse oximetry with other markers of severity in 46 patients attending an accident and emergency (A&E) department with acute asthma. Neither oxygen saturation nor peak flow correlated with length of admission or with other "retrospective" markers of severity. Attempts to collect follow up data (for example, peak flow charts) from patients discharged from the A&E department failed. It proved impossible to determine whether pulse oximetry predicts which adults can be discharged.

Emergency department resource use by patients with migraine and asthma in a health maintenance organization

OBJECTIVE

To identify and compare the resources consumed by patients with symptoms of asthma or migraine who presented to the Walk-In Emergency Department (WIED).

DESIGN

Chart review.

SETTING

WIED, Group Health Cooperative of Puget Sound, Seattle, WA.

PATIENTS

Identified via WIED records as having visited the WIED between October 1991 and February 1992 for migraine or asthma.

MAIN OUTCOME MEASURES

Time spent in the WIED, medications administered during visit and prescribed at discharge, diagnostic procedures performed, referrals, and hospitalizations.

RESULTS

Of 16,755 WIED visits during the study period, 323 (1.9%) were migraine related and 159 (1.0%) were asthma related. Ninety percent of the asthma patients and 62% of the migraine patients reported having self-medicated prior to going to the WIED; 89% of the migraine patients received additional medication at the WIED versus 57% of the patients with asthma. Fifty-four (35.5%) of the migraine patients and 7 (4.6%) of the asthma patients had more than 1 WIED visit during the study period.

CONCLUSIONS

Patients with asthma and migraine present striking contrasts in the types of resources used during WIED visits. This descriptive research highlights the need for further evaluation of the appropriateness of the healthcare services provided.

Managing asthma in accident and emergency departments: an assessment in non teaching hospitals

BACKGROUND

The management and follow-up of asthma patients presenting at Accident and Emergency (A&E) departments have mostly been studied in children's hospitals or specialised teaching hospitals.

AIMS

To study the adequacy of assessment, treatment and follow-up of patients presenting at A&E departments in non-teaching hospitals. To compare the assessment and management of asthma in A&E departments among hospitals in a health region.

METHODS

A twenty-five per cent sample of presentations to A&E departments in all public hospitals in the Illawarra for one year was selected for a case note audit. Information on demographics, assessment, management and referral was extracted from the A&E case notes and medical records of cases with documentation of a final diagnosis of asthma. Chi square and Fischer's Exact tests were used for comparisons among hospitals.

RESULTS

Of 359 presentations with a final diagnosis of asthma, 88% were self referred and only 5% were first presentations. Objective measures of airways obstruction was not documented in 34% of admissions and 48% of nonadmissions. There was no documented follow-up in 28% of cases. The assessment and management of asthma in A&E was significantly poorer in smaller hospitals.

CONCLUSION

Evidence of high use of A&E as a primary care facility by asthma patients was found in the study. There is a need to implement protocols to optimise assessment and treatment of asthma in smaller hospitals.

A prospective audit of asthma management following emergency asthma treatment at a teaching hospital

OBJECTIVE

To audit the assessment and treatment of acute asthma and the subsequent application of the Australian Asthma Management Plan.

DESIGN

Prospective audit of case notes with follow-up telephone questionnaire and clinical assessment at 8-12 weeks after discharge.

SETTING

Tertiary-level teaching hospital.

MAIN OUTCOME MEASURES

Comparison with published guidelines for acute and ongoing asthma management.

RESULTS

Asthma severity was objectively assessed in the Primary and Emergency Care Department, with lung function performed in 95% of acute presentations. Clinical history and examination were documented completely in 28% of presentations. Corticosteroids were underused and there was inappropriate use of ipratropium bromide. At 8-12 weeks follow-up most patients were symptomatic with limited activity due to asthma (46%) and impaired lung function (66%). One-third of patients were undertreated. Asthma management skills were seriously inadequate: only 20% of patients were performing peak flow monitoring, and only 21% recalled receiving specific instructions for the management of future exacerbations. Inhaler technique was inadequate in one-third of patients and asthma knowledge was poor. These deficits were more frequent in patients not admitted to hospital.

CONCLUSION

This audit identified suboptimal assessment and treatment of acute asthma, and deficits in the implementation of the Australian Asthma Management Plan following discharge. Patients in this audit were undertreated and not provided with the skills to manage future attacks of asthma.

A retrospective comparative study of in-hospital management of acute severe asthma: 1984 vs 1989

Recent controversies examining the management of acute asthma prompted us to investigate whether there had been any significant changes in our management practices. We therefore audited the charts of all patients admitted to a large tertiary-care university-affiliated hospital with a primary diagnosis of acute asthma during the years of 1984 and 1989. A total of 67 patients' charts were reviewed (39 in 1984 and 28 in 1989). The mean age and initial flow rates (FEV1 or peak expiratory flow rate [PEFR]) were similar. In the emergency room, chest radiographs and arterial blood gas analyses were done more frequently than objective measures of flow. Fifty-one percent (20/39) of the patients had no measurement of flow in the emergency room in 1984 and 39 percent (11/28) in 1989 (p > 0.05). In both years, approximately 20 percent of the patients had no record of flow rates during their hospitalization (21 percent [8/39] in 1984 and 18 percent [5/28] in 1989). More studies of the blood were ordered in 1989, including hepatic enzyme and electrolyte measurements for no clear reasons. The clinical utility of chest radiographs was negligible. While the vast majority of patients received systemic corticosteroids in both years (85 percent [33/39] in 1984 and 96 percent [27/28] in 1989), 23 percent (9/39) and 18 percent (5/28) were discharged without oral steroid therapy in 1984 and 1989, respectively (p > 0.05). There was a significant decline in the use of aminophylline (95 percent [37/39] to 54 percent [15/28]; p < 0.05) and an increase in the use of ipratropium bromide (15 percent [6/39] to 75 percent [21/28]; p < 0.05) in 1989. Theophylline levels were less likely to be measured in 1989, and the majority of levels in both years were either subtherapeutic or toxic. No patients were discharged with peak flow meters or recorded action plans, although follow-up arrangements were recorded in 87 percent (34/39) and 96 percent (27/28) of the patients in 1984 and 1989. We conclude that while improvements in in-hospital management of asthma were noted in 1989, suboptimal management practices are still common.

National asthma attack audit 1991-2. General Practitioners in Asthma Group

OBJECTIVE

To describe the frequency and characteristics of asthma attacks in the United Kingdom and to compare actual management with recommended guidelines for the management of attacks.

DESIGN

Correspondence survey.

SETTING

218 general practices in the United Kingdom.

SUBJECTS

1775 patients of all ages who had a total of 1805 asthma attacks over three months.

MAIN OUTCOME MEASURES

Patient characteristics, place of management of attacks, comparison of actual management with recommended guidelines.

RESULTS

Of the 1805 attacks, 300 occurred in boys aged 0-9, 144 in girls aged 0-9, and 118 in women aged 20-29. The estimated frequency of attacks in the community was 14.3 per 1000 patients per year. 1546 (86%) patients with attacks were managed within general practice, 225 (12%) were admitted to hospital, and 34 (2%) were discharged from an accident and emergency department. Two patients died. On initial presentation, 248 (14%) patients were "not breathless," 900 (50%) were "moderately breathless," 535 (30%) were "breathless and distressed," 68 (4%) were "too breathless to talk," and 2 were "moribund." Recording of clinical data was variable. Underuse of nebulised bronchodilators and systemic steroid was apparent in all grades of clinical severity. Contrary to current guidelines for asthma management, "step up" in maintenance therapy after an attack was often not practised.

CONCLUSION

Reported management was at variance with recommended guidelines. This has major implications for the design and distribution of future guidelines.