What is the recommended outpatient discharge management for an adult after emergency department treatment of an acute asthma exacerbation?

Outpatient Discharge Management for Acute Asthma Exacerbation

All patients discharged from the emergency department after an acute asthma exacerbation should receive a 5-10 day course of oral corticosteroids (prednisone 40-60 mg daily for adults), initiation or continuation of inhaled corticosteroids, a written asthma action plan, verified inhaler technique, and a scheduled follow-up appointment within one week. 1

Systemic Corticosteroids at Discharge

Prescribe oral prednisone 40-60 mg daily for 5-10 days without tapering for adults with moderate-to-severe exacerbations. 1 This reduces relapse rates by approximately two-thirds, with as few as 13 patients needing treatment to prevent one relapse requiring additional care. 2

Adult Dosing

• Prednisone 40-60 mg once daily (or divided into two doses) for 5-10 days 1
• Continue until peak expiratory flow reaches ≥70% of predicted or personal best 1
• No tapering required for courses <7-10 days, especially if patient is on inhaled corticosteroids 1

Pediatric Dosing

• Prednisone or prednisolone 1-2 mg/kg/day in two divided doses (maximum 60 mg/day) for 3-10 days 1
• Calculate dose using ideal body weight in overweight children to avoid excessive exposure 1

Alternative for Non-Adherent Patients

• Consider intramuscular depot corticosteroid injection (e.g., methylprednisolone) for patients at high risk of non-adherence, as this may be as effective as oral therapy in preventing relapse 1, 3, 2

Inhaled Corticosteroids at Discharge

Initiate or increase inhaled corticosteroids at discharge in all patients, as ED visits typically result from inadequate long-term asthma control. 1

• Patients already on inhaled corticosteroids should continue them while taking systemic corticosteroids 1
• Consider initiating inhaled corticosteroids in patients not already receiving them (conditional recommendation) 1
• Start at higher doses than pre-admission levels 4
• Ensure patient has been stable on discharge medications for at least 24 hours before leaving 3

Bronchodilator Therapy

• Prescribe short-acting beta-agonist (albuterol) metered-dose inhaler for as-needed symptom relief 3
• Typical dosing: 2-4 puffs every 4-6 hours as needed, adjusting based on symptom severity 3
• For severe exacerbations: 4-8 puffs every 1-4 hours as needed initially 3

Patient Education and Inhaler Technique

Verify correct inhaler technique before discharge—this is a core component of preventing relapse. 4

• Demonstrate all steps of metered-dose inhaler use with spacer device 4
• Have patient demonstrate technique back to you 4
• Failing to verify inhaler technique is a common pitfall that results in medication delivery failure 4, 3

Written Asthma Action Plan

Provide a written discharge plan—verbal instructions alone are insufficient. 1, 4

The plan must include:

• Medication names, doses, and duration 1
• Instructions for monitoring symptoms and peak flow 1
• Specific thresholds for when to increase treatment 1, 4
• When to call their physician 1, 4
• When to return to the emergency department 1, 4
• Peak flow meter prescription with instructions on target values 3

Follow-Up Arrangements

Schedule outpatient follow-up before discharge—this dramatically increases the likelihood that patients will obtain appropriate ongoing care. 1, 4

• Primary care follow-up within 1 week of discharge 4, 3
• Respiratory specialist follow-up within 4 weeks 4, 3
• Failing to schedule follow-up before discharge is a critical error, as ED visits often result from inadequate long-term management 1

Discharge Criteria

Patients can be discharged if: 1

• FEV₁ or peak expiratory flow ≥70% of predicted or personal best
• Symptoms are minimal or absent
• Stable for 30-60 minutes after most recent bronchodilator dose
• Peak flow >75% of predicted with diurnal variability <25% 3

Critical Pitfalls to Avoid

• Discharging without a written action plan—verbal instructions are not enough 4
• Not prescribing adequate corticosteroid duration (<3 days is insufficient to prevent relapse) 4
• Failing to schedule follow-up before discharge—dramatically reduces adherence to ongoing care 4
• Not verifying inhaler technique—leads to medication delivery failure 4, 3
• Inadequate systemic corticosteroid dosing or duration—increases relapse risk 3
• Overlooking the need to initiate or increase inhaled corticosteroids—ED visits signal inadequate chronic control 1