Recurrent Emergency Department visits for asthma in children: an opportunity for asthma care improvement?

Acute asthma is a common reason for visiting the emergency department (ED) in every country. It has been estimated that in the United States alone, asthma exacerbations account for almost two million ED visits per year¹. Approximately 10–20 % of these patients require hospital admission and a further 10-20% will relapse within the subsequent two weeks². The outcome depends mainly on the risk factors associated to the patients (young age, severity of the disease, trigger exposure and the other factors which characterize the patient's asthma phenotype), and on the treatment prescribed in the ED and at the discharge, which consists mainly in β2 agonists and systemic corticosteroids³.

There are, therefore, two different aspects that we have to consider when evaluating the accesses to ED for asthma exacerbations: the first are the risk factors of the patient for requiring the ED visit and the other is the management of these visits at the ED, which are also often a unique opportunity for an educational approach to the patient. In this issue of Allergologia et Immunopathologia, Rodriguez-Martinez and co-workers evaluated the risk factors associated to recurrent visits to the ED for asthma in a paediatric population in Bogota, Colombia⁴. Several risk factors for ED access have been previously identified, such as younger and adolescent age, duration of symptoms, previous asthma hospitalization, high use of β2-agonists, social disparities, parents' underestimation of the child's asthma, exposure to allergens and other triggers, low compliance to the prescribed therapy and the lack of a plan when symptoms are worsening. In said paper, the authors evaluated the characteristics of patients requiring repeated visits at the ED for their asthma⁴. Recurrent ED visits were associated not only to the severity being enough to go to the hospital but also to an important lack of parental knowledge regarding the treatment of the disease. Parents of children requiring ED visits were more prone to consider that asthma medications should be used only when the children are symptomatic and less prone to consider that asthma exacerbations can be avoided if asthma is treated during the asymptomatic periods⁴.

Several guidelines have been published for asthma diagnosis and management^5–8, which have been translated into different languages and widely distributed to physicians. After the production of the first guidelines it was soon clear that there was a need to improve adherence to guidelines, since no greater improvement in asthma diagnosis and treatment was observed⁹. Therefore recurrent ED visits represent a challenge to the implementation of clinical guidelines by improving overall care and by the use of clinical pathways to provide health personnel and patients with successful educational interventions. It has been previously observed that parents frequently underestimate the severity of their child's asthma¹⁰ and that parental expectations of asthma control are lower than those outlined in the guidelines^11,12. The same is true for physicians who, irrespective of their training (asthma specialist, asthma speciality fellows, general medicine faculty, internal medicine fellow, family medicine residents) generally fail in estimating disease severity¹³. Moreover, it has been observed that symptoms alone do not entirely reflect disease severity and that multiple variables including lung function and drug consumption need to be considered in the classification of disease severity, and therefore control¹⁴.

To avoid the high rates of re-admission of children with acute asthma, several actions can be established based on asthma guidelines. For instance, a nurse-led service based on BTS/SIGN guidelines for asthma management was proven effective by reducing the salbutamol inhaler treatment, by assessing the need for regular preventer treatment and of “step up” asthma control measures at home¹⁵. The use of written action-plan can significantly reduce acute care visits per child, leading to consequent less missed school, less nocturnal awakening and an improved symptom score¹⁶. Therefore, the ED visit can be an opportunity for a more precise patient evaluation, for parental improvement of knowledge of the disease, by access to pre-printed information on the disease and by access to a paediatrician's office for further consultation¹⁷. All these strategies, which contribute to improving the management of asthma in children, are associated with important reductions in return-visit rates¹⁷.

In conclusion, an educational programme by all physicians involved in the care of the paediatric patient with asthma intended to reduce the recurrent ED visits for asthma is mandatory and should consider explaining the chronic nature of the disease; the effect of the regular preventer treatment and of the importance of long-term therapy.