What is the recommended management plan for an adult patient with a history of asthma and possibly other atopic diseases being discharged after an acute exacerbation of bronchial asthma?

Management on Discharge of a Patient with Acute Exacerbation of Bronchial Asthma

Patients being discharged after an acute asthma exacerbation must receive oral corticosteroids (prednisolone 30-60 mg daily for 5-7 days), increased-dose inhaled corticosteroids started at least 48 hours before discharge, a peak flow meter with written action plan, verified inhaler technique, and scheduled follow-up within 1 week—all after being clinically stable on discharge medications for at least 24 hours. 1, 2

Pre-Discharge Clinical Stability Requirements

Before discharge can be considered, patients must meet specific objective criteria to reduce relapse risk:

• Peak expiratory flow (PEF) must be >75% of predicted or personal best value 3, 1, 2
• PEF diurnal variability must be <25% 3, 1, 2
• Patient must be stable on discharge medications for at least 24 hours 3, 1, 2
• Nebulizers should be replaced with standard metered-dose inhalers 24-48 hours before discharge unless home nebulizer therapy is specifically required 1, 2

Mandatory Discharge Medications

Oral Corticosteroids

All discharged patients require systemic corticosteroids to prevent relapse:

• Adults: Prednisolone 30-60 mg daily for 3-10 days (typically 5-7 days for most patients) 1
• Children: Prednisolone 1-2 mg/kg/day (maximum 60 mg daily) for 3-10 days 1
• For patients at high risk of non-adherence, consider intramuscular depot corticosteroid injection as an alternative 1
• Critical pitfall: Never taper oral corticosteroids over this short course—abrupt cessation after 5-7 days is appropriate and does not require tapering 1

Inhaled Corticosteroids (ICS)

ICS dosing must be increased above pre-admission levels:

• ICS must be started at least 48 hours before discharge to ensure tolerance and proper technique 1, 2
• Increase to a higher dose than the patient was using before admission—this is mandatory, not optional 1, 2
• Standard dosing: 200-250 mcg fluticasone propionate equivalent daily or higher 1
• Failing to increase ICS dose above pre-admission levels is a common cause of treatment failure and readmission 1, 2

Bronchodilators

• Prescribe short-acting beta-agonists (albuterol/salbutamol) for as-needed use: 2-4 puffs every 4-6 hours as needed 1
• Continue or initiate ICS/long-acting beta-agonist (LABA) combination therapy for maintenance 3

Inhaler Technique Verification

Proper inhaler technique must be verified and documented before discharge:

• Directly observe and document the patient demonstrating correct inhaler technique 3, 1, 2
• Inadequate technique is a major cause of treatment failure and readmission 1, 2
• Re-educate and re-check if technique is suboptimal 1, 2

Peak Flow Meter and Self-Management Plan

Every patient must receive both a peak flow meter and written action plan:

Peak Flow Meter

• Provide a peak flow meter to every discharged patient 3, 1, 2
• Train patients on proper technique and interpretation 1, 2
• Teach specific PEF values at which to increase treatment, call their physician, or return to the emergency department 1, 2

Written Self-Management Plan

A written action plan must include:

• Specific PEF values or symptom triggers for escalating treatment 1, 2
• When to call their primary care physician 1, 2
• When to return to the emergency department or hospital 1, 2
• Failure to provide a written action plan significantly increases relapse risk 1, 2

Mandatory Follow-Up Arrangements

Follow-up must be scheduled before discharge, not left to the patient:

• Primary care physician visit within 1 week of discharge 3, 1, 2
• Respiratory specialist or asthma clinic appointment within 4 weeks 3, 1, 2
• Pre-scheduled appointments (rather than instructions to "call for an appointment") significantly improve follow-up rates from 42% to 65% 4

Investigation of Precipitating Factors

Before discharge, review circumstances that led to admission:

• Identify avoidable precipitating causes or allergen exposures 1, 2
• Assess patient compliance with regular maintenance therapy 1, 2
• Evaluate the patient's response to worsening symptoms and whether they followed their previous action plan 1, 2
• Address any barriers to medication adherence, as hospital admission alone does not reliably improve long-term adherence 5

Vaccination Considerations

Pneumococcal vaccination should be administered before discharge:

• All asthma patients should receive pneumococcal vaccination, as asthma is a high-risk condition warranting vaccination at any age 6
• Adults with asthma should receive the 23-valent pneumococcal polysaccharide vaccine 6
• Immunocompromised patients should receive both 13-valent conjugate and 23-valent polysaccharide vaccines 6
• Vaccination should not delay discharge if other clinical stability criteria are met 6

Critical Pitfalls to Avoid

Common errors that increase readmission risk:

• Discharging before 24 hours of stability on discharge medications 1, 2
• Inadequate duration or dosing of oral corticosteroids (less than 5 days or insufficient dose) 1, 2
• Failing to increase ICS dose above pre-admission levels 1, 2
• Not verifying and documenting proper inhaler technique 1, 2
• Discharging without a written self-management plan 1, 2
• Not providing a peak flow meter with training 1, 2
• Leaving follow-up scheduling to the patient rather than providing pre-scheduled appointments 4

Special Considerations for Discharge Timing

Lower the threshold for extended observation or admission if:

• Attack occurred in the afternoon or evening 3
• Recent nocturnal symptoms or previous severe attacks 3
• Recent hospital admission within the past year 3
• Poor social circumstances or inability to assess own condition 3
• Patient or family concern about managing at home 3