A RETROSPECTIVE COMPARATIVE-STUDY OF IN-HOSPITAL MANAGEMENT OF ACUTE SEVERE ASTHMA - 1984 VS 1989

Recent controversies examining the management of acute asthma prompted us to investigate whether there had been any significant changes in o ur management practices. We therefore audited the charts of all patien ts admitted to a large tertiary-care university-affiliated hospital wi th a primary diagnosis of acute asthma during the years of 1984 and 19 89. A total of 67 patients charts were reviewed (39 in 1984 and 28 in 1989). The mean age and initial flow rates (FEV1 or peak expiratory fl ow rate [PEFR]) were similar. In the emergency room, chest radiographs and arterial blood gas analyses were done more frequently than object ive measures of flow. Fifty-one percent (20/39) of the patients had no measurement of flow in the emergency room in 1984 and 39 percent (11/ 28) in 1989 (p>0.05). In both years, approximately 20 percent of the p atients had no record of flow rates during their hospitalization (21 p ercent [8/39] in 1984 and 18 percent [5/28] in 1989). More studies of the blood were ordered in 1989, including hepatic enzyme and electroly te measurements for no clear reasons. The clinical utility of chest ra diographs was negligible. While the vast majority of patients received systemic corticosteroids in both years (85 percent [33/39] in 1984 an d 96 percent [27/28] in 1989), 23 percent (9/39) and 18 percent (5/28) were discharged without oral steroid therapy in 1984 and 1989, respec tively (p>0.05). There was a significant decline in the use of aminoph ylline (95 percent [37/39] to 54 percent [15/28]; p<0.05) and an incre ase in the use of ipratropium bromide (15 percent [6/39] to 75 percent [21/28]; p<0.05) in 1989. Theophylline levels were less likely to be measured in 1989, and the majority of levels in both years were either subtherapeutic or toxic. No patients were discharged with peak flow m eters or recorded action plans, although follow-up arrangements were r ecorded in 87 percent (34/39) and 96 percent (27/28) of the patients i n 1984 and 1989. We conclude that while improvements in in-hospital ma nagement of asthma were noted in 1989, suboptimal management practices are still common.