Asthma and COPD Symposium

Course Pre-Test

Case Presentation

Dad: age 39

Asthma since childhood Hx of ezcema, day & night time symptoms weekly Hospitalized for asthma, ED visit 8 yrs ago, Smoker (20 pk/yr), FEV1- 60-80%. Allergies: Cat, trees, grass, weeds, cockroach. Meds:(Non compliant) Fluticasone/salmeterol MDI, Albuterol MDI, TMC ream (Primatene mist before research study enrollment.

Son 1  Age 13 yrs

Hx of asthma since infancy, SOB c exercise, No nocturnal sxms, Hx of eczema, No hosp. No ED visits or missed school days in 9 mos. Allergies: Cat, Dust mite, Trees, Grass, Weeds, Mold, Fish, crab. Meds: Albuterol MDI, TMC cream

Daughter 1 Age 11 yrs

Hx of asthma since 4 yrs, SOB c exercise, Occ. nocturnal sxms, Hx of eczema, No hosp. ED visit age 4, Missed 1 sch. days in 9 mos.  Allergies: Cockroach, Dustmite, Trees, Grass, Weeds, Mold, Mouse, Watermelon, Bananas. Meds:

Albuterol MDI, Fluticasone nasal, Cetirizine, .TMC cream

Daughter 2 9 yrs

Hx of asthma since 2 yrs, SOB c exercise, nocturnal sxms 4 times/wk, Hx of eczema, No hosp, No ED visits, Missed 3-4 sch. days in 9 mos. Allergies: Cockroach, Dustmite, Trees, Grass, Weeds, Mold, Mouse, Fish, Orange. Meds: Albuterol MDI

Fluticasone nasal, Cetirizine, TMC cream.

Son 2  Age 5 yrs

Hx of asthma since 4 yrs. No nocturnal or day time scms, Hx of eczema, No hosp, 1 ED visit c URI, No missed school days in 9 mos.  Allergies: Cat, Dog, Dust mite, Trees, Grass, Weeds, Mold, Mouse, Salmon, Turkey, Chicken. Meds: Albuterol MDI, TMC cream.

Please answer the next 4 questions using the data from the Case Presentation above:

Emergency Department Treatment of Acute Asthma: Closing the Gaps
a. Moderate, intermittent, mild
b. Moderate, intermittent, intermittent
c. Moderate, mild, moderate
d. Moderate, moderate, intermittent
e. Severe, moderate, intermittent

a) Dad
b) Daughters
c) Sons
d) Son 2 and Daughter 1
e) Son 2

a. Dad
b. Sons
c. Daughters
d. Daughter 1 and Son 1
e. Dad and Daughter 2
f. All family members

a) No response to 3 doses of an inhaled short-acting β-agonist within 1-2 hr
b) Tachypnea
c) Unable to speak or drink or is breathless
d) Transient fall of oxygen saturation
e) Subcostal retractions (infants & children)

a. Immunodeficiency
b. Prematurity (< 37 weeks gestational age)
c. Age < 12 weeks
d. Malnutrition
e. Asthma

a. NIPPV causes an overall decrease in mortality
b. NIPPV causes an increased rate in the need to intubate
c. NIPPV results in an improvement in respiratory status within the first hour
d. NIPPV can be used to reverse respiratory acidosis
e. None of the above

a. Tachypnea > 35 breaths /minute
b. Somnolence
c. Severe acidosis
d. Respiratory arrest
e. All of the above

a. Steroid use causes an increase in mortality
b. Steroid use results in increased duration of hospitalization
c. Steroid treatment is only useful in chronic care of COPD and is not indicated in acute exacerbations
d. Steroid treatment results in significantly fewer treatment failures
e. None of the above is true

a. < 25%
b. 25-30%
c. 30-40%
d. 40-50%
e. >50%

a. Yes definitely
b. No

Leave this field empty

Asthma is one of the most common chronic medical conditions in the U.S. It affects 16 million adults and 6.1 million children and results in two million visits to emergency departments, 70,000 hospitalizations, and 5,000 deaths annually. The burden of asthma disproportionately affects persons of lower socioeconomic status. Because asthma can neither be prevented nor cured, it is imperative that Emergency Medicine and Primary Care physicians posses current evidence based information on the diagnosis, acute treatment and management of asthma. Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients.

Chronic obstructive pulmonary disease (COPD) represents a huge part of the health and economic burden of this country and the Emergency Department (ED) patient population.  COPD is the fourth leading cause of death in the United States. It affects more than 10 million people in the United States, and accounts for over 1 million ED visits per year.

Although African Americans have lower COPD mortality and prevalence rates than Whites, they tend to have higher rates of hospitalization and emergency room visits due to COPD. There is evidence that even though African American COPD patients started smoking later in life and smoked fewer total pack-years than White patients, their rates of airflow limitation were identical, with African Americans presenting similar disease severity at an early age.

Given that there is no clear standard of care for COPD exacerbations and management varies widely and  given the prevalence of this disease in the United States and in the ED patient population, it is paramount that the ED physicians have a full understanding of this disease and is knowledgeable of and confidently practice the most current evidence based treatment modalities for COPD exacerbations.

Care transition refers to the actions of healthcare providers designed to ensure the coordination and continuity of healthcare during the movement between health care practitioners and settings (e.g. hospital, emergency department, nursing home, assisted living facility, skilled nursing facility, primary care physician, or specialist) as their condition and care needs change during the course of a chronic or acute illness (e.g. asthma/acute exacerbation). During such transitions, patients with complex medical needs are at greater risk for poorer outcomes due to medication errors and other errors of communication among involved healthcare providers and between providers and patients/family caregivers. Adverse patient outcomes include continuation or recurrence of symptoms, temporary or permanent disability and even death. Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency department or being readmitted to the hospital. As healthcare expenditure rise at an unsustainable rate there is increasing focus by patients, providers, policymakers and payers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations.


Data from the Pre- and Post 2009 Asthma and COPD program participants’ outcomes survey, national asthma studies and literature searches point to the following gaps:

1. Therapeutic non-adherence and psychosocial factors are major contributing factors to repeat asthma visits to the Emergency Department.

2. Home Discharge – continue treatment with inhaled SABA, oral systemic corticosteroid, initiation of a ICS and patient/caregiver education was the major guideline recommendation for treatment of asthma not always performed by emergency medicine physicians.

3. Arterial blood gas testing was the major guideline recommendation for treatment of COPD not always performed in their practice environment.

4. Despite the availability of guidelines, PCPs often manage COPD in a manner that is discordant with recommendations.

Program Objectives

At the conclusion of this symposium, the participant will provide better patient care through an increased ability to:

Recognize predictors of asthma relapse and treatment – response factors after being discharged from the ED following treatment for asthma exacerbation

  • Analyze why therapeutic non-adherence and psychosocial factors are believed to be major contributing factors to repeat asthma visits to the Emergency Department and develop mechanisms to change this behavior
  • Analyze current treatment guidelines on home discharge- Home Discharge – continue treatment with inhaled SABA, oral systemic corticosteroid, initiation of a ICS and patient/caregiver education to treat acute exacerbations of Asthma and develop methods to incorporate them  in their practice environments
  • Develop and use outreach tools for patients to encourage medication adherence, smoking cessation and delineation of specific criteria to ensure that patients are keeping their outpatient clinical referrals
  • Analyze the role of noninvasive ventilation in the COPD patient and apply this knowledge in their practice environments
  • Analyze why Arterial blood gas testing is the major guideline recommendation for treatment of COPD not always performed in their practice environment, and develop measures incorporate this in the treatment of their patients
  • Delineate the following: 1) the landscape drivers necessitating that a more coordinated approach toward care transition be developed and implemented 2) factors that may contribute to less than optimal transition of care for patients with chronic illnesses (e.g. asthma) discharged from the Emergency Department and 3) strategies and programs that have been deemed successful in improving outcomes for patients with asthma discharged from the Emergency Department.


Joseph A. Tyndall, M.D., MPH

Joseph A. Tyndall, M.D., MPH Dr. Joseph (Adrian) Tyndall is Chief of Emergency Services and Medical Director of the Emergency Department at Shands at the University of Florida, is Associate professor and Chairman of the Department of Emergency Medicine at the University of Florida College of Medicine in Gainesville and a ...
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Cynthia Price, M.D.

Cynthia Price, M.D. Dr Price is Assistant Residency Program Director of Emergency Medicine at University of Connecticut. She completed her undergraduate studies at Abilene Christian University in Texas and went back to the University of Arizona for her Medical Degree. She then went on to Emory University in Atlanta ...
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Kelvin J. Holloway, M.D., MBA

Kelvin J. Holloway, M.D., MBA Kelvin J. Holloway is an Associate Professor in the Department of Pediatrics at Morehouse School of Medicine, and Deputy Senior Vice President/Deputy Chief of Staff of Medical Affairs at Grady Health System.
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Melody C. Carter, M.D.

Melody C. Carter, M.D. Dr. Carter received her M.D. from Tulane University Medical School and completed her pediatric residency training at Emory University in Atlanta. She started her career in general pediatrics in an inner-city clinic.
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