Ep 192 ED Adult Asthma Management Strategies For Improved Prognosis – A Stepwise Approach

Welcome to Part 1 of our two-part podcast series on Adult Asthma Exacerbations. Given this past summers' increase in the number and size of forest fires leading to increased asthma presentations to the ED, we are joined by Dr. Leeor Sommer from North York General Hospital and Dr. Sameer Mal, an ED-Intensivist and Transport Physician from London, Ontario to discuss the most important aspects of ED asthma care. Together, we'll explore a systematic approach to managing patients presenting to the ED with asthma exacerbations. Our discussion will emphasize the critical role of a thorough history and physical examination in effectively stratifying patient risk and guiding treatment/disposition decisions. Additionally, we'll examine the importance of providing comprehensive discharge medications and instructions to mitigate both mortality and morbidity associated with asthma exacerbations. We answer questions such as: which patients, if any, require peak expiratory flow measurements in the ED? Why is it so important to add steroid MDI therapy to oral steroid therapy in patients being discharged from the ED after an asthma exacerbation? What are the most predictive variables to risk stratify patients with asthma exacerbations to help guide treatment and disposition? and many more. Stay tuned for Part 2, where we'll delve deep into the management of the crashing asthmatic.

Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul

Written Summary and blog post by Kate Dillon, edited by Anton Helman March, 2024.

Cite this podcast as: Helman, A. Mal, S. Sommer, L. Episode 192 Asthma Management Strategies for Improved Prognosis - A Stepwise Approach. Emergency Medicine Cases. March, 2024. https://emergencymedicinecases.com/emergency-asthma-management-strategies. Accessed May 30, 2024

Résumés EM Cases5 Simple Steps to managing asthma exacerbations in the ED

Step 1: Consider the asthma differential diagnosis carefully 

"Not all that wheezes is asthma, and asthma does not always present with a wheeze.”

While the diagnosis of asthma is often straightforward, especially in patients with a history of exacerbations and repeat ED visits, it is crucial to consider several other conditions in patients presenting to the ED with wheezing, including:

* Heart Failure ("cardiac asthma")

* Pulmonary embolism

* Pneumonia

* Pneumothorax

* Foreign body aspiration

* Bronchiolitis

* Anaphylaxis

* Stridor (primarily inspiratory, but can be expiratory, potentially mistaken for wheezing)

In cases where wheezing is absent, particularly in patients suspected of having an asthma exacerbation, be mindful that patients may exhibit a silent chest—a sign of a severe/life-threatening exacerbation where patients are unable to generate sufficient airflow to produce an audible wheeze.

Utilize adjuncts such as PoCUS and chest X-ray to help refine your differential diagnosis in conjunction with a thorough history and physical examination. Guard against diagnostic premature closure that might lead you to exclusively consider asthma upon hearing the term 'wheeze'.

Step 2: Risk stratification based on history

Effective risk stratification of patients presenting to the ED with asthma exacerbations, grounded in a comprehensive assessment of their medical history and physical examination findings, is pivotal in directing appropriate management and disposition decisions.