Perhaps the most important aspect of ED management of non-life-threatening asthma exacerbations is providing evidence-based discharge instructions and appropriate prescription medications. A common pitfall in the management of asthma exacerbations is neglecting to prescribe an inhaled corticosteroid in addition to a beta agonist on discharge from the ED. Inhaled corticosteroids are seldom prescribed on discharge from the ED, in one study at a rate as low as 6 percent.¹⁷ Inhaled steroids used as a controller therapy improve lung function and symptom control, while also reducing airway inflammation, the risk of exacerbation, the need for repeat ED visits, and the total exposure to systemic steroids.¹⁸ Even patients who are provided a prescription for a short course of oral corticosteroids additionally require one for inhaled corticosteroids, which should be used for at least three to six weeks after ED discharge. In a randomized controlled trial, the addition of high-dose inhaled corticosteroids to a course of oral corticosteroids at discharge was associated with a lower risk of relapse of the asthma exacerbation at 21 days than the use of oral corticosteroids alone.¹⁹ Inhaler technique should ideally be taught before discharge home. Poor inhaler technique is associated with poor asthma control and increased ED visits, so teaching patients proper MDI plus spacer technique before discharge from the ED may prevent bounce backs.²⁰ Asthma care plans have been shown to decrease bounce backs, as well. Patient education should include the role of each medication and the avoidance of allergens, irritants, and workplace exposures.²¹ Robust evidence supports the role of written asthma action plans that detail how to prevent and manage future exacerbations, and every ED should provide online and/or paper access to such plans.^22,23 Written action plans should include when to increase therapy, how to increase it, how long to increase it, and when to seek medical care.

The simple principles outlined here of risk stratification, treatment, and discharge instructions will keep our patients with asthma healthy and prevent frequent ED visits, morbidity, and mortality.

A special thanks to Dr. Leeor Sommer and Dr. Sameer Mal for their expert contributions to the EM Cases podcast that inspired this article.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website (www.emergencymedicinecases.com).