Postacute care and discharge following an episode of acute asthma

Patients who had any feature of acute life-threatening asthma, or any feature of acute severe asthma that persisted after initial treatment, should be admitted to hospital.

Note: No single physiological measurement can define whether a patient is safe for discharge.

No single factor or physiological measurement can define the extent of ongoing care required, or whether the patient is safe for discharge. Consider the patient’s:

response to therapy during the episode of acute asthma
ongoing frequency of short-acting beta₂ agonist (SABA) requirement—do not discharge a patient who still requires SABA more than every 4 hours
ability to lie flat without dyspnoea
history of exacerbations
current circumstances such as the time of day, distance from medical help, access to phone, and home environment
treatment adherence
comorbidities
risk factors for potentially fatal asthma (see Risk factors for potentially fatal asthma).

In addition to the above, consider spirometry or peak expiratory flow (PEF) findings (these can often be performed after 1 hour of management); a low forced expiratory volume in 1 second (FEV₁) or PEF may indicate a need for hospital admission.

Patients with severe asthma and adverse psychosocial factors are at increased risk of asthma-related death (see Risk factors for potentially fatal asthma).

Note: Patients with severe asthma and adverse psychosocial factors are at increased risk of asthma-related death.

The National Asthma Council website includes links to asthma discharge plans for adults and children.

Reviews required before discharging a patient after an episode of acute asthma outlines reviews that should be completed before discharge.

Figure 1. Reviews required before discharging a patient after an episode of acute asthma

Once the episode of acute asthma has resolved, review the patient’s:

inhaler technique
adherence to prescribed asthma therapy
asthma triggers; discuss avoidance measures if necessary
preventer therapy and dose; adjust therapy if necessary (see Maintenance management for asthma in adults and adolescents or Maintenance management of asthma in children)
written asthma action plan (see Written asthma action plans for adults or Written asthma action plans for children); educate the patient about the action plan.

On discharge, ensure therapy can be continued at home (eg switch nebulised therapy to pMDI with spacer). Continue oral corticosteroids for a total treatment course of 5 to 10 days for adults, or 3 days for children.

Many children presenting with acute asthma may only ever have one such episode. However, a small number of children are at risk of recurrent, potentially fatal acute asthma. Consider whether regular preventer therapy is required. Base assessment on both the pattern of asthma symptoms between exacerbations, and the severity of symptoms during the exacerbation. See Maintenance management of asthma in children.

Any adult or adolescent with an episode of acute asthma severe enough to require emergency-department care, and who is not already using an inhaled corticosteroid (ICS), should be started on ICS therapy to reduce the risk of another episode. See Maintenance management of asthma in adults and adolescents.