What is the recommended treatment and management plan for patients discharged with reactive airway disease?

Discharge Advice for Reactive Airway Disease

All patients with reactive airway disease (asthma) must be discharged on a three-medication regimen: oral corticosteroids (prednisolone 30-60 mg daily for 3-10 days), inhaled corticosteroids at higher doses than pre-admission, and inhaled short-acting beta-agonists for as-needed use. 1, 2

Essential Discharge Medications

Oral Corticosteroids

• Prescribe prednisolone 30-60 mg daily for adults for 3-10 days (typically 5-7 days for most patients) 3, 1, 2
• For children: 1-2 mg/kg/day with a maximum of 60 mg daily for 3-10 days 1
• Never stop prednisolone abruptly or reduce the dose if asthma symptoms are worsening 4
• For patients at high risk of non-adherence, consider intramuscular depot corticosteroid injections 1

Inhaled Corticosteroids (ICS)

• Increase ICS to a higher dosage than before admission—this is mandatory, not optional 3, 1, 2
• ICS treatment must be started at least 48 hours before discharge 3, 4, 2
• Standard dosing should be 200-250 mcg of fluticasone propionate equivalent daily, which achieves 80-90% of maximum therapeutic benefit 1

Bronchodilators

• Prescribe inhaled short-acting beta-agonists (albuterol) for as-needed use, typically 2-4 puffs every 4-6 hours as needed 1
• For severe asthma, consider 4-8 puffs every 1-4 hours as needed 1
• Add oral theophylline, long-acting beta-agonists, or inhaled ipratropium if required based on severity 3, 4

Pre-Discharge Requirements

Clinical Stability Criteria

Patients must meet ALL of the following before discharge:

• Peak expiratory flow (PEF) >75% of predicted or personal best value 3, 2
• Diurnal PEF variability <25% 3, 2
• No nocturnal symptoms 3, 2
• If these criteria are not met, the patient must be seen by a respiratory physician before discharge 3

Medication Transition

• Patients must be on discharge medications for at least 24 hours before leaving the hospital 3, 1, 2
• Replace nebulizers with standard inhaler devices 24-48 hours before discharge unless a home nebulizer is required 3, 4, 2
• Verify and document proper inhaler technique—this is critical as inadequate technique leads to treatment failure 3, 1, 2

Peak Flow Meter and Self-Management Plan

Peak Flow Monitoring

• Every patient must receive a peak flow meter and comprehensive training on its use 3, 2
• Teach patients specific PEF values at which to increase treatment, call their doctor, or return to the emergency department 3, 2

Written Action Plan

• Provide a written self-management plan—failure to do this significantly increases relapse risk 3, 1, 2
• The plan must include:
  • When to increase treatment based on PEF values 3, 2
  • When to call their doctor 3, 2
  • When to return to the hospital 3, 2

Follow-Up Arrangements

Mandatory follow-up schedule:

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

Investigation of Precipitating Factors

Before discharge, review:

• Was there an avoidable precipitating cause or allergen exposure? 3, 4, 2
• Was the patient complying with regular treatment, and if not, why not? 3, 4
• Did the patient react appropriately to worsening asthma? 3, 4
• Was medical management appropriate? 3

Critical Pitfalls to Avoid

Medication Errors

• Inadequate duration or dosing of systemic corticosteroids increases relapse risk—do not prescribe less than 3 days 1, 2
• Discharging patients before they have been on medications for 24 hours increases relapse risk 1, 2
• Failing to increase ICS dose above pre-admission levels leads to treatment failure 2

Documentation Failures

• Not checking inhaler technique before discharge results in medication delivery issues 1
• Not providing a written action plan significantly increases relapse risk 1, 2

Safety Concerns

• Never prescribe sedatives—they are contraindicated in asthma 3, 4
• Ensure patients understand warning signs: worsening shortness of breath, increased wheezing, or decreased effectiveness of rescue inhalers warrant immediate return to the emergency department 4