Worldwide increased prevalence and associated significant morbidity and mortality from bronchial asthma have led to the development of national and international guidelines on asthma management.1-8 Many studies have highlighted deficiencies in the actual implementation of such guidelines in clinical practice.9-13 At the Emergency Room (ER), such deficiencies in management include inadequate objective assessment of asthma severity, failure to provide adequate treatment, failure to objectively assess response to such treatment and inadequate arrangements for follow up. Review of the literature found no studies in the Kingdom of Saudi Arabia (KSA) addressing this issue or directly comparing the actual emergency care of acute asthma to published national or international guidelines. The Saudi National Acute Asthma Management Guidelines have been published in 1995 and in general, follow internationally accepted principles for asthma care. The aim of this study was to examine the implementations of the National Guidelines of Asthma Management at the Emergency Department at King Fahad National Guard Hospital (KFNGH) in Riyadh, KSA. King Fahad National Guard Hospital is one of the largest tertiary care hospitals in KSA, with a capacity exceeding 600 beds. The ER at KFNGH is one of the most modern state of the art departments in Riyadh with a comprehensive ER consultant-led service supplanted by a team of trainees, residents, fellows and staff physicians.

Methods. A retrospective analysis of charts of patients seen with acute exacerbations of asthma in the Emergency Department over a one year period (January through to December 2000). Offered interventions were compared to the nationally recommended management guidelines. The following information were specifically sought: 1. Demographic data (age, gender), 2. History of current asthmatic attack and its duration, 3. History of previous ER visits, hospitalization or intensive care admission or intubation, 4. Indices of severity (vital signs, pulse oximetry, peak expiratory flow rate), 5. Immediately prescribed medications, 6. Objectively documented parameters of response to offered treatment and 7. Prescribed take home medications and follow up arrangements. Due to the difficulties children may have in peak expiratory flow charting, this measurement was not substantiated when examining charts of those less than 12-years of age. To avoid seasonal, resident training or variable shift bias a maximum of randomly selected 15 charts per month were reviewed. Patients with any additional diagnosis to bronchial asthma were excluded.

Results. Total charts reviewed were 150. Eighty-five were male (57%). Mean age was 29-years, and age ranged between 3-79-years. Fifty-six patients (37%) were aged less than 12-years-old. Only 10 patients required admission (6.7%). History of nocturnal symptoms, details of the current asthmatic episode, its duration, and prior use of beta-2 agonist were documented in 40, 49, and 48% of patients (Table 1). Histories of previous hospitalization, intensive care admission, intubation, or regular outpatient clinic follow up were documented in less than 15% of patients (Table 1). Vital signs, including oxygen saturation by pulse oximetry, were documented in all patients. Peak expiratory flow was documented in 30 adult patients (30 of 94, 31%) (Table 1). Almost all the patients received bronchodilator therapy (148/150, 99%), the majority (98%) by nebulization. Most needed multiple doses (Table 2). Steroid therapy either orally or parenterally were offered to 72 patients (46%) (Table 2). Repeat objective clinical assessment of response to prescribed medications was documented in 48% of patients

Received 17th January 2004. Accepted for publication in final form 10th April 2004.