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British Guideline on the MAnAGeMent of AsthMA
8.2 ACute exACerBAtions
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People with asthma who experience deterioration in symptom control leading to an acute
exacerbation can access a wide variety of sources of care. Few studies have looked at the
relative merits of one type of service compared to another. Exceptions include a UK study
showing a better outcome for patients managed by a specialist respiratory ward compared to a
general medical ward, and a US study showing more favourable outcome in patients managed
by specialist allergists compared to generalists. 669,670
C Manage hospital inpatients with asthma in specialist rather than general units.
; All services involved in the care of acute asthma should be staffed by appropriately
trained personnel and have access to all the equipment needed to manage acute
asthma.
Audit the percentage of inpatients receiving care from specialist asthma nurse or chest
physician.
Models of care addressing access such as NHS Direct/NHS 24 produce similar outcomes to
routine general practice, but have high referral rates and are unlikely to promote the continuity
of care required for longer term management. 671
A structured clinical assessment and a standardised recording system are associated with
favourable outcome in acute exacerbations. 672 Audit of the management of patients with acute
asthma attacks is associated with improved concordance with recommended guidelines and
in turn improved clinical outcome and reduced exacerbation rate. 673-675
There is no evidence that the publication of guidelines per se improves care: clinicians need to
link best practice to the management of individual patients. This effect is apparent in hospital and
general practice care. 447 Certain actions, for example early prescription of oral corticosteroids
for acute exacerbations of asthma, reduce hospitalisation and relapse rates. Clinicians should
refer to relevant chapters in this guideline for advice.
B Clinicians in primary and secondary care should treat asthma according to recommended
guidelines.
Audit the percentage of patients treated according to key guideline recommendations.
Using acute asthma management protocols and clinical pathways can be beneficial and
cost effective. Sub-optimal control of asthma leading to exacerbation is more expensive to
manage than well controlled asthma. 630 Early discharge schemes from hospital and emergency
departments may be cost effective. 445,676
The safety of telephone help lines has not been established. ‘Direct dial’ emergency admission
schemes may be of benefit to a small group of patients with severe or ‘brittle’ asthma but there is
insufficient evidence to justify their widespread introduction. 677 Admission criteria are discussed
elsewhere (see section 6.2.6).
Criteria for and timing of discharge from hospital and emergency departments has been
studied. The key event in recovery appears to be improved symptoms and peak flow rather
than a complete return to normality. Discharge when improvement is apparent may be as
safe as discharge when full stability is achieved. Asthma specialist nurse education of adults
and school-age (but not pre-school) children at or shortly after hospital attendance improves
symptom control, self management and re-attendance rates .678-683
Making an appointment for review in primary care prior to discharge improves follow-up rates
(but not outcomes). 684 Review within 30 days after hospital attendance with acute asthma is
associated with reduced risk of further acute episodes. 685 There is most evidence of benefit when
follow up is provided by specialist nurses. various types of follow up after an acute exacerbation
have been evaluated including GP care, hospital outpatient, and telephone follow up. 680,686 There
would appear to be little difference in outcome depending on place or personnel involved in
follow up (see section 6.6). 676
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