Effective diagnosis and treatment of acute asthma in the emergency department requires prompt recognition of the signs and symptoms to prevent permanent damage and potentially fatal consequences. The risk of malpractice claims can be significant.

The scale of acute asthma in the UK

Worldwide, the prevalence of acute asthma has increased, yet asthma mortality has reduced significantly in the last two decades. However, there remains substantial evidence that asthma is still widely misdiagnosed.

It is estimated that asthma affects 10% of all Europeans and 8% of people living in the United States.

Asthma accounts for 600,000 emergency department visits in the UK.

The median length of stay for patients admitted to a critical care unit with asthma in England and Wales is 1.8 days.

Studies suggest that 10% of people admitted to hospital in the UK with acute asthma died within 28 days of discharge.

The hospital mortality rate from asthma in the UK is 0.6%.

The difficulties of diagnosing acute asthma

Failure to accurately diagnose an acute attack of asthma can be fatal. Underdiagnosis and overdiagnosis both present risks to patient safety and clinician exposure to litigation.

Underdiagnosis can result in prolonged and potentially dangerous symptoms. It can also result in airway remodelling, which often has a profound impact on a patient’s health and quality of life. Overdiagnosis of asthma leads to unnecessary treatment and delays in the management of the patient’s true condition. 

When a patient arrives at the emergency department with potential acute asthma, they will be assessed as to their presentation and previous medical history. This will include prior hospital admissions from the past 12 months and the patient’s long term and current reliance and use of β‐agonists.

It should be noted that acute asthma attacks can cause extreme distress in the patient (and parents, in the case of a child), who may have difficulty communicating.

Commonly misdiagnosed conditions in asthma patients

Asthma is one of the most commonly misdiagnosed illnesses. Certain conditions can mimic an acute attack of asthma, which makes diagnosis more challenging. What follows is by no means an exhaustive list, but such conditions include:

Foreign-body aspiration

Vocal cord dysfunction syndrome

Upper respiratory tract infection

Upper respiratory tract blockage

Pulmonary edema

Acute exacerbation of chronic obstructive pulmonary disease (COPD)

Hysterical conversion reaction

Munchausen syndrome

Cystic fibrosis

Anxiety disorder/panic attacks

Pneumonia

In children, acute asthma can also be misdiagnosed as croup, bronchiolitis and tracheomalacia.

The risks of mismanagement of acute asthma cases

There are many risks associated with the treatment of acute asthma, including the following that are of particular note:

As people with asthma often have allergies, they have a higher risk of developing anaphylaxis. A severe allergic reaction can have severe consequences for people with asthma. Drug-induced anaphylaxis and anaphylaxis caused by re-exposure to allergens for patients are the most common malpractice lawsuits relating to anaphylaxis.

A practitioner administering steroids for the treatment of acute asthma must be diligent in explaining potential side effects and gaining informed consent, including documentation. Without this, there is a risk of litigation. Close monitoring and associated record-keeping is crucial when steroids are prescribed.

Although studies have concluded that the risk is very low, publicity around potential teratogenic consequences of inhaled corticosteroids by pregnant women has heightened fears and concern of litigation among clinicians. Such patients may go undertreated as a result.

Emergency departments and acute asthma

Acute asthma is a common medical emergency. Despite international and national guidelines, acute asthma remains poorly managed and there are wide variations in care. This is despite the prognosis for many patients with acute asthma being good.

In terms of emergency medicine, having clear strategies on how to best manage acute presentations of asthma is key to good outcomes. As part of a wider procedure for the long term management of acute asthma, it is also important that both clinicians and patients receive education on potentially fatal exacerbations and the critical importance of timely intervention.

Practitioners must be aware of local policies, professional standards and their scope of practice to avoid becoming liable for litigation by putting their patients at risk, delivering ineffective care or breaching their duty of care.