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A Prospective Evaluation of the 1-Hour Decision Point for Admission Versus Discharge in Acute Asthma

Division of Pulmonary, Allergy and Critical Care Medicine, wilsom01{at}ummhc.org

Richard S. Irwin, MD

Division of Pulmonary, Allergy and Critical Care Medicine

Ann E. Connolly, MS, ACNP

Division of Pulmonary, Allergy and Critical Care Medicine

Christopher Linden, MD

Department of Emergency Medicine

Mariann M. Manno, MD

Department of Pediatrics; the University of Massachusetts Medical School, Worcester

The Acute Asthma Study Group

Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV ₁ alone as an outcome predictor yielded suboptimal performance. FEV ₁ at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better ( P = .0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV ₁ reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.

Key Words: asthma • pharmacotherapy • therapy • decision analysis • practice guidelines • projections and predictions

Journal of Intensive Care Medicine, Vol. 18, No. 5, 275-285 (2003)
DOI: 10.1177/0885066603256044


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