What discharge advice should be given to asthma patients?

Discharge Advice for Asthma Patients

All asthma patients must be discharged with a comprehensive medication regimen including oral corticosteroids (prednisolone 30-60 mg daily for 3-10 days), inhaled corticosteroids at higher doses than pre-admission, inhaled short-acting beta-agonists for as-needed use, a peak flow meter with written self-management plan, and scheduled follow-up within one week. 1

Discharge Readiness Criteria

Before discharge, patients must meet specific clinical stability markers:

• Peak expiratory flow (PEF) must be >75% of predicted or personal best value 2, 3
• Diurnal PEF variability must be <25% 2, 3
• No nocturnal symptoms should be present 2, 3
• Patient must have been on discharge medications for at least 24 hours 1, 3
• Nebulizers should be replaced by standard inhaler devices 24-48 hours before discharge (unless home nebulizer is required) 2, 3

If these criteria are not met, the patient should be evaluated by a respiratory physician before discharge. 2

Mandatory Discharge Medications

Oral Corticosteroids

• Prescribe prednisolone 30-60 mg daily for adults (typically 40-60 mg in single or divided doses) for 3-10 days 1
• For children, prescribe 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1
• Critical warning: Never stop prednisolone abruptly or reduce the dose if asthma is worsening 4
• For patients at high risk of non-adherence, consider intramuscular depot corticosteroid injections 1

Inhaled Corticosteroids (ICS)

• Prescribe ICS at a higher dosage than before admission 2, 1
• ICS treatment must be started at least 48 hours before discharge 2, 3
• For mild-to-moderate asthma, use low-dose ICS 1
• For severe asthma, consider moderate-dose ICS or ICS/LABA combination 1

Short-Acting Beta-Agonists (SABAs)

• Prescribe inhaled SABAs (albuterol) for as-needed symptom relief 1
• Typical dosing: 2-4 puffs every 4-6 hours as needed, or 4-8 puffs every 1-4 hours for more severe cases 1

Additional Medications (If Required)

• Consider oral theophylline, long-acting beta-agonists, or inhaled ipratropium based on asthma severity 2, 4
• If prescribing oral xanthines, monitor blood theophylline concentrations 2, 3

Peak Flow Meter and Self-Management Plan

Every patient must receive a peak flow meter and comprehensive training on its use before discharge. 2, 1

Written Self-Management Plan Must Include:

• Specific PEF values at which to increase treatment 2, 1
• When to call their doctor 2, 1
• When to return to the hospital or emergency department 2, 1
• Duration of oral corticosteroid course 1
• Dosing schedule for all medications 1

Failing to provide a written self-management plan significantly increases risk of relapse. 3

Inhaler Technique Verification

• Check and document proper inhaler technique before discharge 2, 3
• If technique is inadequate, provide alternative inhaler devices 2
• Not checking inhaler technique can result in medication delivery issues and treatment failure 1, 3

Patient Education Components

Medication Understanding

• Explain that ICS and oral corticosteroids treat airway inflammation, not just symptoms 5
• Use airway models or colored pictures to demonstrate inflammation 5
• Advise patients to rinse mouth with water without swallowing after ICS inhalation to reduce risk of oral candidiasis 6
• Emphasize that SABA is for acute symptom relief only, not for prevention 6

Warning Signs Requiring Immediate Medical Attention

• Decreasing effectiveness of short-acting beta-agonists 6
• Need for more inhalations than usual of rescue inhalers 6
• Worsening shortness of breath, increased wheezing, or chest tightness 4
• Significant decrease in lung function or PEF values 6

Critical Safety Information

• Never stop asthma therapy without physician guidance, as symptoms may recur 6
• Do not use additional long-acting beta-agonists beyond what is prescribed 6
• Patients on immunosuppressant doses should avoid exposure to chickenpox or measles 6

Investigation of Precipitating Factors

Before discharge, review the circumstances that led to admission: 2, 4

• Was there an avoidable precipitating cause or allergen exposure? 2
• Was the patient complying with regular treatment, and if not, why not? 2
• Did the patient or relatives react appropriately to worsening asthma? 2
• Was there a period of sudden deterioration before the acute attack? 2

Follow-Up Arrangements

Mandatory follow-up schedule must be arranged before discharge:

• Primary care physician visit within 1 week of discharge 2, 1, 3
• Respiratory physician appointment within 4 weeks (1 month) 2, 1, 3

Common Pitfalls to Avoid

• Inadequate duration or dosing of systemic corticosteroids increases relapse risk 1, 3
• Discharging patients before they have been on medications for 24 hours 1, 3
• Failing to increase ICS dose above pre-admission levels 2, 1
• Not providing written action plan (significantly increases relapse risk) 1, 3
• Overlooking follow-up arrangements leads to gaps in care continuity 3
• Prescribing antibiotics unless bacterial infection is documented 2
• Any sedation is contraindicated in asthma patients 4