Who Relapses After Emergency Room Visit For Asthma?

Brian H. Rowe, MD, MSc, CCFP(EM), FCCP Tier I Canada Research Chair in Evidence-based Emergency Medicine Scientific Director, Emergency Strategic Clinical Network Professor, Department of Emergency Medicine University of AlbertaMedicalResearch.com Interview with:
Brian H. Rowe, MD, MSc, CCFP(EM), FCCP
Tier I Canada Research Chair in Evidence-based Emergency Medicine
Scientific Director, Emergency Strategic Clinical Network
Professor, Department of Emergency Medicine
University of Alberta

Medical Research: What is the background for this study? What are the main findings?

Dr. Rowe​: The study was designed to evaluate non-pharmacological issues associated with relapse following discharge from the emergency department with acute asthma. Many years of high-quality research have shown that systemic and inhaled corticosteroids (ICS) in combination are required to reduce relapse. In this study all patients received systemic corticosteroids and the majority received inhaled corticosteroids (either as mono-therapy or in combination with long-acting beta-agonists​ {LABA}).

This study ​ design permitted us to evaluate other factors associated with relapse as a guide for clinicians to use in planning discharge.

The main findings include identifying the key factors independently associated with relapse: female sex (OR = 1.9; 95% confidence interval [CI]: 1.2, 3.0), symptom duration of > 24 hours prior to emergency department visit (OR = 1.7; 95% CI: 1.3, 2.3), ever using oral corticosteroids (OR = 1.5; 95% CI: 1.1, 2.0), current use of an ICS/LABA combination product (OR = 1.9; 95% CI: 1.1, 3.2), and owning a spacer device (OR = 1.6; 95% CI: 1.3, 1.9).


Medical Research:
What should clinicians and patients take away from your report?

Dr. Rowe​: Emergency clinicians should reflect upon the fact that every effort should be made to reduce relapses after emergency department discharge. This includes ensuring patients are appropriately selected for discharge, receive systemic  and inhaled corticosteroids at discharge, and receive follow-up from a qualified and interested primary care provider in a semi-urgent fashion.  Moreover, physicians should categorize patients into low, moderate and high risk of relapse and adjust their management accordingly.  For example, a woman with recent emergency department visits on an ICS/LABA combination has a particularly high risk of relapse and perhaps prolonged observation or rapid clinic evaluation should be arranged.  Conversely, a male with stable asthma over many years only receiving salbutamol as needed, who experiences a flair-up can be easily managed and followed up without urgency (yet, still requires a follow-up within the guideline recommended period).  ​

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Rowe​: Future research should be conducted to validate this rule in other settings. In addition, additional work is required to determine the non-pharmacological gaps in care and how we can reduce them to improve outcomes for patients with asthma.

​Citation:

Rates and Correlates of Relapse Following Emergency Department Discharge for Acute Asthma: A Canadian 20-Site Prospective Cohort Study

Brian H. Rowe, MD, MSc; Cristina Villa-Roel, MD, MSc; Sumit R. Majumdar, MD, MPH; Riyad B. Abu-Laban, MD, MHSc; Shawn D. Aaron, MD, MSc; Ian G. Stiell, MD, MSc; Jeffrey Johnson, PhD; Ambikaipakan Senthilselvan, PhD; for the AIR Investigators

Chest. 2014. doi:10.1378/chest.14-0843