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                         Managing acute mild asthma in
       the emergency department
                                                                 acute mild asthma
                                                                      Why is this important?                             departments and patients often re-present
                                                                                                                         with further deterioration over the next 12
                                                                      Asthma is a common condition that continues
                                                                                                                         months [3–5].
                                                                      to increase in Australia and globally. The
                                                                      prevalence of asthma in Australia is among the     The initial assessment of the severity of an
                                                                      highest in the world, with over two million        asthma episode is critical in acute management.
                                                                      people affected [1].                               A recent multi-centre Australian study has
                                                                                                                         shown that most acute asthma presentations to
                                                                      Despite the condition becoming more common,
                                                                                                                         Australian emergency departments are mild to
                                                                      the number of people dying from asthma in
                                                                                                                         moderate (95.5 per cent in children and 90.5 per
                                                                      Australia has fallen [1,2]. This is likely to be
                                                                                                                         cent in adults) [6]. In the management of severe
                                                                      due in part to the promotion of ‘best-practice’
                                                                                                                         acute asthma, which makes up only six per cent
                                                                      care, better self-management and preventive
                                                                                                                         of cases, the addition of ipratropium bromide to
                                                                      care by government, health care professionals
                                                                                                                         the standard drugs used improves health
                                                                      and organisations such as the National
                                                                                                                         outcomes with no significant additional side
                                                                      Asthma Council [2].
                                                                                                                         effects [7]. However, it is an expensive
                                                                      Nonetheless, any patient with asthma may           treatment and there is little evidence to support
                                                                      experience an acute deterioration requiring        its use in cases of moderate severity, and it is
                                                                      medical intervention, either by a general          not recommended in the management of mild
                                                                      practitioner or at a hospital emergency            acute asthma [1].
                                                                      department. Indeed, asthma makes up a large
                                                                      proportion of presentations to emergency


     NATIONAL INSTITUTE OF CLINICAL STUDIES Evidence–Practice Gaps Report Volume 2 2005
There is substantial evidence that ipratropium bromide is of limited usefulness in acute
episodes of mild to moderate asthma.
                                                                                                                                                               19

Severity of asthma in presentations to   Best available evidence                               ipratropium bromide was of no additional
emergency departments 2000–2001                                                                benefit in children with mild to moderate
                                         Numerous clinical practice guidelines
                                                                                               asthma. Multiple doses of ipratropium bromide,
                                         recommend that, along with oxygen, cortico-
                                                                                               whilst safe, only had sufficient evidence to
                                         steroids and beta2-agonists, multiple doses of
                                                                                               support its use in school-aged children with
                                         ipratropium bromide be used in the
                                                                                               acute severe asthma.
                                         management of patients with severe and life
                                         threatening asthma attacks, or those with a           Another evidence-based review [11] found
                                         poor initial response to beta2-agonist therapy        that multiple doses of ipratropium bromide are
                                         [1,8,9]. Australian guidelines indicate that          indicated in the emergency management of
                                         ipratropium bromide use is optional in the            children and adults with severe asthma. There
                                         management of moderate acute asthma, and              was no apparent benefit of adding single doses
                                         recommend against its use in patients with mild       of ipratropium bromide to those with mild to
                                         acute asthma [1,9].                                   moderate asthma.

                                         These recommendations are broadly in line with
                                         the findings of two published systematic
                                         literature reviews. The reviews, however, do
                                         not support the use of ipratropium bromide in
   Mild                                  the management of moderate or mild attacks.
   Moderate                              A Cochrane systematic review [10] of acute
   Severe                                asthma in children looked at 13 trials of
Source: Kelly AM et al (2003)            ipratropium bromide. A single dose of

                                                                          Evidence–Practice Gaps Report Volume 2 2005 NATIONAL INSTITUTE OF CLINICAL STUDIES
20
                         Managing acute mild asthma in
       the emergency department
                                                                 acute mild asthma
        Current practice                                              Implications                                     bromide in accordance with best available
                                                                                                                       evidence would provide cost savings
        The Snapshot of acute asthma study [6] was a                  • There is substantial evidence that
                                                                                                                       without detrimental effects to patients,
        prospective, observational study involving 38                   ipratropium bromide is of limited usefulness
                                                                                                                       and minimise the (albeit) small effect of
        emergency departments in Australia. The study                   in acute episodes of mild to moderate
                                                                                                                       medication reactions.
        collected data on presentations for asthma for a                asthma. Given that most presentations to
        two-week period in 2000 and the same period                     the emergency department are mild to
        in 2001. There were 1,340 presentations in the                  moderate in severity, many patients may
        total 28-day period with a complete data set for                therefore receive an expensive therapy with
        840 children and 421 adults.                                    little evidence for its efficacy.
        In children, nearly 38 per cent of patients                   • In practice, the formal assessment of
        presenting with mild asthma and 66 per cent                     asthma severity is not always done as part
        of those presenting with moderate asthma                        of routine procedure, which may lead to the
        received ipratropium bromide. In adults, the                    over-treatment of many patients with less
        figures were 64 per cent and 83 per cent                        severe attacks.
        respectively.                                                 • Whilst it is easy to focus on increasing the
                                                                        use of effective treatments when evidence
                                                                        suggests they are not being used, it is
                                                                        equally important that we do not continue to
                                                                        use treatments when there is no evidence to
                                                                        support their application. Using ipratropium


     NATIONAL INSTITUTE OF CLINICAL STUDIES Evidence–Practice Gaps Report Volume 2 2005
                                                                                                                                                                                                    21

References                                                      8   Scottish Intercollegiate Guidelines Network (SIGN), British
                                                                    Thoracic Society (2004) British guideline on the
1   National Asthma Council (2002) Asthma Management                management of asthma. A national clinical guideline. SIGN
    Handbook 2002. National Asthma Council, Melbourne               Pub. No.63. Scottish Intercollegiate Guidelines Network
2   Douglass JA, O’Hehir RE (2003) Emergency treatment of           (SIGN), British Thoracic Society, Edinburgh, Scotland
    asthma: how are we doing? Intern Med J 33: 401–403          9   Therapeutic Guidelines Limited 2000. Respiratory, Version 2,
3   Australian Centre for Asthma Monitoring (2003) Asthma in        ETG Complete. Available at: http://www.etg.hcn.net.au/.
    Australia 2003. AIHW Asthma Series 1. AIHW Cat. No. ACM         Accessed 8 March, 2005
    1. AIHW, Canberra                                           10 Plotnick LH, Ducharme FM (2004) Combined inhaled
4   Marks GB et al (2000) Use of ‘preventer’ medications and       anticholinergics and beta2-agonists for initial treatment of
    written asthma management plans among adults with              acute asthma in children. Cochrane Database Syst Rev:
    asthma in New South Wales. NSW Health Department               CD000060
    Asthma Data Working Group. Med J Aust 173: 407–410          11 Rodrigo GJ, Rodrigo C (2002) The role of anticholinergics in
5   Goeman DP et al (2004) Back for more: a qualitative study      acute asthma treatment: an evidence-based evaluation.
    of emergency department reattendance for asthma.               Chest 121: 1977–1987
    Med J Aust 180: 113–117
6   Kelly AM, Powell C, Kerr D (2003) Snapshot of acute
    asthma: treatment and outcome of patients with acute
    asthma treated in Australian emergency departments.
    Intern Med J 33: 406–413
7   Stoodley RG, Aaron SD, Dales RE (1999) The role of
    ipratropium bromide in the emergency management of
    acute asthma exacerbation: a metaanalysis of randomized
    clinical trials. Ann Emerg Med 34: 8–18



                                                                                                               Evidence–Practice Gaps Report Volume 2 2005 NATIONAL INSTITUTE OF CLINICAL STUDIES

				
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