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Rapid-Onset Asthma Attack^*

A Prospective Cohort Study About Characteristics and Response to Emergency Department Treatment

^* From the Departamento de Emergencia (Dr. G. J. Rodrigo), Hospital Central de las FF.AA.; and Unidad de Cuidado Intensivo (Dr. C. Rodrigo), Asociación Española 1^a de Socorros Mutuos, Montevideo, Uruguay.

Correspondence to: Gustavo J. Rodrigo, MD, Departamento de Emergencia, Hospital Central de las FF.AA., Av. 8 de Octubre 3020, Montevideo 11600, Uruguay; e-mail: gurodrig{at}adinet.com.uy

Study objectives: (1) To determine the frequency of rapid-onset asthma attacks (ROAAs) and slow-onset asthma attacks (SOAAs) in adult patients with acute, severe disease (18 to 50 years old), who presented to an emergency department (ED); and (2) to establish whether ROAA patients differ from SOAA patients in terms of clinical and spirometric characteristics; and (3) in terms of the response of treatment.

Subjects and methods: Four hundred three patients (with peak expiratory flow [PEF] or FEV₁ of < 50% of predicted value) with acute exacerbations of asthma were enrolled in the trial using a prospective cohort study. Asthma attacks were classified as an ROAA (< 6 h of symptoms) or an SOAA ( 6 h). All patients were treated with albuterol, four puffs at 10-min intervals (100 µg per actuation), delivered by metered-dose inhaler with a spacer device during 3 h.

Results: On the basis of previously determined criteria, 11.3% of patients were classified as having a ROAA. Male patients comprised 53.6% of the ROAA group (p = 0.03). In ROAA patients, the exacerbation was less likely to be attributed to respiratory tract infection (p = 0.001) and more likely to have no identifiable cause (p = 0.0001). Also, ROAA patients had lower pulmonary function (FEV₁) at presentation (mean difference, - 0.13; 95% confidence interval [CI], - 0.22 to - 0.04 L; p = 0.04) than SOAA patients. At the end of treatment, ROAA patients had an overall 48.0 L/min (95% CI, 14.1 to 81.8 L/min) greater improvement in PEF and a 0.31 L (95% CI, 0.08 to 0.54 L) greater improvement in FEV₁ than SOAA patients. Also, ROAA patients presented with less accessory muscle use (p < 0.05) and higher oxygen saturation (p = 0.005). Finally, SOAA patients showed an increased incidence of hospital admission (relative risk, 3.89; 95% CI, 1.01 to 15.0).

Conclusions: Data from this study support the notion that ROAAs constitute a distinct but uncommon acute asthma ED presentation, with a predominance of male patients. Upper respiratory tract infection was not believed to be a significant trigger factor in these patients, and ROAA patients had rapid deterioration of their conditions followed by a more rapid response to treatment and a lower hospital admission rate than SOAA patients. Thus, we have identified a subgroup of patients who appear to have common characteristics with patients with sudden-onset near-fatal/fatal asthma.

Key Words: acute severe asthma • near-fatal asthma • sudden-onset asthma

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