Q:

7/16/2013  
When an asthma patient complaining of SOB arrives to the hospital ER, is placing them on a sat probe and only a sat probe an acceptable form of monitoring? We have an on going discussion of whether they should be placed on a cardiac monitor or not. What I am recommending is the patient should receive O2 until sats > 90, Cardiac monitor, IV access and peak flow assessment. I feel that with the patient possible self treatment before they get to us along with what we are now going to do quickly to them that ignoring the effect we might have on the heart rhythm is wrong. Yes, I can get a pulse on a sat probe. But my concern is what is going on to get me that pulse. I can not find any studies that address this issue.

A:

Thank you for your inquiry.

Normally I would feel quite comfortable, as long as the patient has a regular heartbeat on auscultation and the rate is under 120, treating a person with asthma in the emergency room without cardiac monitoring. However, I am going to refer your question to get the perspective of a pulmonologist in this regard. When I receive a response from Dr. William Mariencheck, who is a pulmonologist who deals with asthma as well, I will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We have received an inquiry from Dr. William Mariencheck. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. William Mariencheck:
The question concerns the monitoring of asthma patients complaining of dyspnea when presenting to an emergency room. Should all such patients be placed on cardiac monitoring in addition to pulse oximetry and peak flow measurement while establishing IV access and initiating treatment?

I checked with two area emergency rooms to discover their approaches. ER-1 actually placed all asthmatic patients on cardiac monitors upon arrival to the facility. ER-2 used triage information to decide the cardiac monitoring question. I actually favor the second approach.

The patient's appearance and several historical and physical parameters should help decide:

Heart rate greater than 110 or irregular rhythm reduction of oxygen saturation to less than 90% Presence of co-morbidities (e.g., obesity, hypertension, cardiac disease, COPD, advanced age) Use or anticipated use of continuous beta agonist aerosol or IV theophylline (rarely indicated) Patient appears to be in more distress than indicated by any above or other parameters chosen for triage team (a subjection judgment obviously)

Patients with the above finding are more safely managed with a cardiac monitor. I would not order monitoring otherwise in most cases. Young children probably require a modified list of criteria.

If you are writing a protocol for your emergency room and your personnel are not reliably well trained or they are inexperienced, or their training status is unknown, you would be better off opting to place all asthmatic patients with complaint of dyspnea on a cardiac monitor upon arrival.

Thanks for asking,
Bill Mariencheck, M.D.
MidSouth Pulmonary Specialists

AAAAI - American Academy of Allergy Asthma & Immunology