When can a patient with an asthma exacerbation be discharged?

From the Guidelines

Patients with asthma exacerbation can be discharged when their FEV1 or PEF results are 70% or more of predicted value or personal best and symptoms are minimal or absent. This is based on the guidelines from the National Asthma Education and Prevention Program Expert Panel Report 3, as stated in the study published in the Journal of Allergy and Clinical Immunology in 2009 1.

Discharge Criteria

The following criteria should be met before discharging a patient with asthma exacerbation:

• FEV1 or PEF results are 70% or more of predicted value or personal best
• Symptoms are minimal or absent
• Patient has a good response to bronchodilator therapy with minimal rebound symptoms
• Patient has appropriate medications, including a short-acting beta-agonist for rescue use and an inhaled corticosteroid for ongoing control
• Patient has been prescribed a short course of oral corticosteroids, typically for 3 to 10 days, as recommended by the Expert Panel 1

Patient Education and Follow-up

Before discharge, the patient should:

• Demonstrate proper inhaler technique
• Understand their asthma action plan, including when to seek medical attention if symptoms worsen
• Be scheduled for a follow-up appointment with their primary care provider or asthma specialist within 1-4 weeks, as recommended by the guidelines 1
• Receive a written plan for managing recurrence of airflow obstruction, as suggested by the Expert Panel 1 By meeting these criteria, patients with asthma exacerbation can be safely discharged and continue their treatment at home with a low risk of immediate relapse.

From the FDA Drug Label

The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.

The FDA drug label does not answer the question.

From the Research

Discharge Criteria for Asthma Exacerbation

• Patients can be discharged from the hospital once they have responded clinically to intensive anti-asthma treatment, despite incomplete resolution of symptoms, signs, and peak expiratory flow rates (PEFR) 2.
• The decision to discharge a patient with asthma exacerbation from the emergency department (ED) can be based on the following guidelines:
  • Patients with a PEFR of < 20% and who do not respond to inhalant therapy, with PEFR values persisting at < 40% of predicted, will require 4 or more days to resolve and should be admitted to the hospital 3.
  • Patients with a PEFR between 40% and 70% of predicted after initial inhalant therapy may well be responsive to steroids in the ED, but an ED will adequately need to care for the patient for 5 to 12 hours while waiting for the onset of action of glucocorticoids 3.
  • Patients with a PEFR of > or = 70% have a 14% relapse rate after discharge without glucocorticoids 3.
• Other factors to consider when deciding to discharge a patient with asthma exacerbation include:
  • History of previous endotracheal intubation 3.
  • Pulse rate and accessory muscle use 3.
  • Presence of complicating diseases, such as pneumonia or barotrauma 3.
  • Patient's access to medications and ability to use them correctly 3.
  • Patient's understanding of their condition and ability to manage it 3.

Risk Factors for Relapse

• A history of previous exacerbations, including emergency room visits, is a significant risk factor for subsequent treatment failure and asthma exacerbations 4.
• Reduced pulmonary function, as measured by forced expiratory volume in one second (FEV1), is also a risk factor for treatment failure 4.
• Age of asthma onset and duration of asthma are not significant risk factors for treatment failure 4.
• Environmental tobacco smoke exposure does not appear to increase the risk of treatment failure or exacerbations 4.