Clinical pathway improves outcomes in asthma exacerbations

Investigators studied the effect of implementing a clinical pathway for the emergency care of children and adolescents with asthma, using evidence-based clinical practice guidelines. The prospective trial was conducted in children from 1–18 years of age who were treated for acute exacerbations of asthma in a tertiary care pediatric emergency department in Vancouver, B.C. Investigators collected data for 267 patients in two categories: children who came to the emergency department for an asthma exacerbation before implementation of the clinical pathway (control group), and those who came for care after its implementation (intervention group).

The intervention called for using a severity-adjusted plan-of-care flowchart, which indicated treatment and suggested actions of nurses and doctors during the first eight hours in the emergency department. In the intervention group, patients with a mild exacerbation received at least one dose of 5-mg nebulized salbutamol (albuterol). Those with a moderate or severe exacerbation received at least three consecutive doses of nebulized salbutamol, each with a 500-mg dose of nebulized ipratropium bromide (Atrovent) and oral corticosteroids. In the control group, timing and selection of treatment were left to the discretion of the doctor, and included nebulized β₂-adrenergic agonists with or without oral corticosteroids. About half the children in both the intervention and control groups had a moderate or severe exacerbation.

The rate of hospital admission (in children with a moderate to severe asthma exacerbation) was more than 50% lower in the intervention group (13.5%) than in the control group (27.5%)-with no increase in a return for emergency care. Implementation of the clinical pathway also resulted in more prompt administration of salbutamol, and an increase in the proportion of children with moderate to severe asthma who received corticosteroids. According to study data, about seven patients would need to be managed under the clinical pathway to prevent one hospitalization (Norton SP et al: Arch Dis Child 2007;92:60).

The care path implemented here didn't include anything drastic: early initiation of nebulized salbutamol, inclusion of nebulized ipratropium, and liberal and early dosing with oral steroids. However, use of these interventions with less delay and more consistency seems to have worked to improve outcomes in asthmatics treated in the emergency department. This may be worth a try.