Acute Asthma: Admission Chest Radiography in Hospitalized Adult Patients

doi:10.1378/chest.100.1.14

Chest

Volume 100, Issue 1, July 1991, Pages 14-16

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The utility of admission chest radiography has been controversial in the management of adult patients admitted to the hospital with acute asthma. We reviewed the impact of admission chest radiography on in-hospital management of 54 adult patients with acute asthma. Each patient was admitted after a failed 12-h course of bronchodilator therapy in the emergency ward. Major radiographic abnormalities were found in 20 (34 percent) of 58 occasions. These abnormalities included focal parenchymal opacities, IIM, enlarged cardiac silhouette, pulmonary vascular congestion, new solitary pulmonary nodule and pneumothorax. Subsequent antibiotic use correlated with radiographic focal opacities or IIM, even in afebrile patients, but did not correlate with elevated blood leukocyte count. Based on the evidence of in-hospital alteration of management independent of elevated blood leukocyte count and body temperature, we recommend that chest radiographs be obtained for all adult patients admitted because of acute asthma.

Section snippets

Materials and Methods

During a 10-week period (March through May, 1987), 54 adult (age >18 years) patients were admitted (58 of 59 consecutive admissions, excluding 1 patient for whom no admission CXR was obtained) to the hospital from the emergency ward of an urban university medical center with the clinical impression of acute asthma (as defined by criteria formulated by the American Thoracic Society).⁷ Each patient presented with acute shortness of breath, the auscultatory finding of diffuse wheezes, and a

Results

The 58 consecutive admissions in which admission CXR was obtained occurred in 54 patients (35 women and 19 men) with a mean age of 52 years (range: 19 to 96 years). A standard CXR (posteroanterior and left lateral, erect position) was obtained on 55 (95 percent) of the 58 occasions. An antero-posterior CXR was obtained (supine position) in three patients with acute respiratory failure. Major abnormalities on the admission CXR were noted in 20 (34 percent) of the 58 examinations (Table 1). A

Discussion

The present study demonstrates two major findings. First, the incidence of major abnormalities (34 percent) on admission CXR was considerably higher than has been described in previous studies of asthmatic patients in the emergency ward, in which rates of 1 to 9 percent have been reported.1, 2, 3, 4, 5, 6 Second, immediate management was affected for the 22 percent of admission CXR with a focal pulmonary opacity (12 percent of the examinations) or IIM (10 percent of the examinations), in that

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There are more references available in the full text version of this article.

Cited by (53)

GEMA 5.3. Spanish Guideline on the Management of Asthma
2023, Open Respiratory Archives
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide.
Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists.
Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.
Su objetivo es prevenir y mejorar la situación clínica de las personas con asma, aumentando el conocimiento de los profesionales sanitarios involucrados en su cuidado. Su propósito es convertir la evidencia científica en recomendaciones prácticas sencillas y fáciles de seguir. Por lo tanto, no se trata de una monografía que reúna todo el conocimiento científico sobre la enfermedad, sino más bien de un documento conciso con lo esencial, diseñado para ser aplicado rápidamente en la práctica clínica de rutina. Las recomendaciones son necesariamente multidisciplinares, están desarrolladas para ser útiles y una herramienta indispensable para médicos de diferentes especialidades, así como para profesionales de enfermería y farmacia.
Seguramente, los aspectos más destacados de la guía son las recomendaciones para: establecer el diagnóstico del asma utilizando un algoritmo secuencial basado en pruebas diagnósticas objetivas; el seguimiento de los pacientes, preferentemente basado en la estrategia de lograr y mantener el control de la enfermedad; el tratamiento según el nivel de gravedad del asma utilizando seis escalones, desde la menor hasta la mayor necesidad de medicamentos, y el algoritmo de tratamiento basado en fenotipos para la indicación de biológicos en pacientes con asma grave no controlada. A esto se suma ahora una novedad para su fácil uso y seguimiento a través de una aplicación informática basada en la inteligencia artificial conversacional de tipo chatbot (ia-GEMA).
What not to do in the therapeutic management of bronchial asthma. Delphi consensus recommendations for physicians who treat asthma
2021, Atencion Primaria
El asma es una de las enfermedades más prevalentes en España y, a pesar de los grandes avances diagnósticos y terapéuticos, los resultados en salud indican que hasta el 80% de los pacientes no tendrían su asma bien controlada. Aunque las causas de esta situación son diversas, existen algunas prácticas entre los profesionales que atienden el asma que no contribuyen a la mejora de los resultados en salud de esta enfermedad. Nuestro grupo de trabajo ha elaborado este documento para recordar una serie de pautas básicas, alineadas con las guías actuales y la literatura reciente, y consensuadas mediante metodología Delphi por un panel experto multidisciplinar. Estas recomendaciones sobre qué no se debe hacer en el manejo del asma en el adulto quedan articuladas en 4 ámbitos: el diagnóstico, el seguimiento, el tratamiento y la prevención de exacerbaciones.
Asthma is one of the most prevalent diseases in Spain, yet despite the great diagnostic and therapeutic advances made in this field, health outcomes suggest that up to 80% of patients do not have their asthma well controlled. Although the causes of this situation are diverse, there are some practices among the professionals who treat asthma that are not conducive to improving health outcomes in this disease. Our working group has prepared this document in order to remind clinicians of a series of basic guidelines, aligned with current guidelines and recent literature, and agreed by a multidisciplinary expert panel using Delphi methodology. These recommendations about what not to do in the management of asthma in the adult patient are structured into four areas: diagnosis, monitoring, treatment and prevention of exacerbations.
Evaluation and management of the critically ill adult asthmatic in the emergency department setting
2021, American Journal of Emergency Medicine
Citation Excerpt :
The trend in pCO2, along with the trend in clinical examination may demonstrate response to therapy, or more ominously the failure to respond, particularly in those severe enough to require treatment with non-invasive ventilation. While chest radiographs are typically unrevealing in mild or moderate acute exacerbations [60,73-77], they should be obtained in patients with severe exacerbation or patients with significant respiratory distress, fever, chest pain, hypoxemia, or if there is concern for an alternate etiology for patient symptoms (e.g., pleural effusion, heart failure, pneumonia, pneumothorax) [17]. In patients with undifferentiated shortness of breath, point-of-care ultrasound (POCUS) can provide valuable information with regard to alternate etiologies and potential causes of the exacerbation [78-82].
Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management.
This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma.
It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission.
This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.
ACR Appropriateness Criteria <sup>®</sup> Acute Respiratory Illness in Immunocompetent Patients
2018, Journal of the American College of Radiology
Citation Excerpt :
Findley and Sahn [37] recommended chest radiographs only when PNA or pneumothorax is suspected. White et al [39] found significant chest radiograph abnormalities in 34% of adults whose asthma exacerbation warranted hospital admission. Although our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of patients with a high pretest probability of PNA presenting with an acute asthma exacerbation, patients who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening may warrant a CT if the chest radiograph is negative or equivocal.
Acute respiratory illness, defined as cough, sputum production, chest pain, and/or dyspnea (with or without fever), is a major public health issue, accounting for millions of doctor office and emergency department visits every year. While most cases are due to self-limited viral infections, a significant number of cases are due to more serious respiratory infections where delay in diagnosis can lead to morbidity and mortality. Imaging plays a key role in the initial diagnosis and management of acute respiratory illness. This study reviews the current literature concerning the appropriate role of imaging in the diagnosis and management of the immunocompetent adult patient initially presenting with acute respiratory illness.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Imaging procedures and bronchial thermoplasty for asthma assessment and intervention
2018, Personalizing Asthma Management for the Clinician
Newer imaging techniques such quantitative computed tomography chest, hyperpolarized gas magnetic resonance imaging, positron emission tomography, endobronchial ultrasound, and optical coherence tomography are currently being developed to assess structural changes, such as airway remodeling, and functional changes, such as air trapping and ventilation defects, in asthma. The application of these imaging tools in asthma has the potential to advance our management of the disease. We now recognize the key pathophysiologic processes in asthma are heterogeneous throughout the airway and lung. These imaging tools will help clinicians assess asthma phenotypes such as remodeling due to chronic airflow obstruction, monitor disease progression, and evaluate response to asthma therapies. Emerging asthma therapies, such as bronchial thermoplasty, have started to utilize these imaging modalities to assess response and target treatment. In the future, clinicians will have a new imaging armamentarium to optimally manage their asthma patients.
Imaging Procedures and Bronchial Thermoplasty for Asthma Assessment and Intervention
2017, Personalizing Asthma Management for the Clinician
Newer imaging techniques such quantitative computed tomography chest, hyperpolarized gas magnetic resonance imaging, positron emission tomography, endobronchial ultrasound, and optical coherence tomography are currently being developed to assess structural changes, such as airway remodeling, and functional changes, such as air trapping and ventilation defects, in asthma. The application of these imaging tools in asthma has the potential to advance our management of the disease. We now recognize the key pathophysiologic processes in asthma are heterogeneous throughout the airway and lung. These imaging tools will help clinicians assess asthma phenotypes such as remodeling due to chronic airflow obstruction, monitor disease progression, and evaluate response to asthma therapies. Emerging asthma therapies, such as bronchial thermoplasty, have started to utilize these imaging modalities to assess response and target treatment. In the future, clinicians will have a new imaging armamentarium to optimally manage their asthma patients.

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: Manuscript received August 10; revision accepted November 19.

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Chest

Clinical InvestigationsAcute Asthma: Admission Chest Radiography in Hospitalized Adult Patients

Section snippets

Materials and Methods

Results

Discussion

Chest

Clin Radiol

Severe asthma: course and treatment in hospital

NY State J Med

Clinical Investigations
Acute Asthma: Admission Chest Radiography in Hospitalized Adult Patients