Chest
Volume 125, Issue 3, March 2004, Pages 1081-1102
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Acute Asthma in Adults: A Review

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All patients with asthma are at risk of having exacerbations. Hospitalizations and emergency department (ED) visits account for a large proportion of the health-care cost burden of asthma, and avoidance or proper management of acute asthma (AA) episodes represent an area with the potential for large reductions in health-care costs. The severity of exacerbations may range from mild to life threatening, and mortality is most often associated with failure to appreciate the severity of the exacerbation, resulting in inadequate emergency treatment and delay in referring to hospital. This review describes the epidemiology, costs, pathophysiology, mortality, and management of adult AA in the ED and in the ICU.

Section snippets

Epidemiology and Costs

AA is a common medical emergency faced by ED and intensive care specialists. In the United States, asthma represents the 11th most frequent ED diagnosis nationwide, and adolescents and young adults are the most likely age groups to visit the ED for treatment.11 Women visit the ED and are hospitalized for AA twice as often as men.1213 Previous data suggested that 40% of these hospitalizations occur during the premenstrual phase of the cycle.14 Men are less likely than women to report severe

Pathophysiology

Different triggers cause asthma exacerbations by inducing airway inflammation or provoking acute bronchospasm or both. Triggers vary from person to person and from time to time. Exposure to indoor and outdoor allergens, air pollutants, respiratory tract infections (primarily viral), exercise, weather changes, foods, additives, drugs, and extreme emotional expressions are the main triggers identified clinically. Other factors that may cause exacerbations are rhinitis, bacterial sinusitis,

Fatal Asthma

In many countries, asthma mortality increased from the 1960s to the second half of the 1980s, but reached a plateau and has subsequently declined.5455565758 This recent downward trend may reflect better management of this condition in primary care. Asthma has a low mortality rate compared with other lung diseases, but mortality does occur, typically in patients with poorly controlled disease whose condition gradually deteriorates over a period of days or even weeks before the fatal attack.596061

Assessment

AA is a medical emergency that must be diagnosed and treated urgently. The assessment of an asthma exacerbation constitutes a process with two different dimensions: (1) a static assessment to determine the severity of attack, and (2) a dynamic assessment to evaluate the response to treatment. Overall, it requires an analysis of several factors.8283

ICU Management

Many patients admitted to the ICU with AA simply require additional time for the therapies instituted in the ED to be continued and for respiratory function to improve. These patients often require a relatively brief period of time in the ICU; when improvement is clear, they can be discharged to the regular ward. Since it is not clear on ICU admission which patients will pursue such a course, the benefit of the ICU is largely one of careful observation and rapid response to those patients who

Summary

AA is a common medical emergency faced by ED and intensive care physicians. Properly managed, there should be a very low mortality rate; but death does occur, typically in patients with poorly controlled disease whose condition gradually deteriorates over a period of days or even weeks before the fatal event. This observation suggests many patients have a window of opportunity for recognition and reversal of this period of deterioration. The assessment of an asthma exacerbation constitutes a

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