Original article 21 Chronic outpatient management of asthmatics attending the emergency department: a survey from a country with low income Lamia Ouanes-Besbes a , Jalel Knani c , Noureddine Nciri a , Fahmi Dachraoui a , Semir Nouira b and Fekri Abroug a Purpose Little is known about compliance with international guidelines of asthma management in developing countries where some medications are prohibitively expensive. Methods A survey was conducted in asthmatic patients attending the emergency department for acute asthma. Asthma severity was evaluated and conformity of chronic treatment with international guidelines was assessed. Additional features of asthmatic education were also evaluated. Results A total of 127 consecutive patients (mean age 34 ± 14 years) answered the questionnaire. Mild asthma was present in 19.7% patients, 56.7% had moderate asthma and 23.6% had severe asthma. Of the 124 known asthmatic patients, 33% had no treatment for chronic asthma. In the remaining, treatment adhered to international guidelines in 44% patients. The major cause of treatment inadequacy was the lack of inhaled corticosteroids (64%) or suboptimal dosage of corticosteroids (13%). Conformity to guidelines according to favorable or unfavorable economic conditions was 59% and 33%, respectively (P = 0.036). Treating physicians provided an ‘action plan’ for managing acute symptoms to 19% patients. Forty percent of asthmatic patients performed correctly the five components of metered dose inhaler use. Conclusion Our study reveals an important proportion of non-treated asthmatic patients. In most asthmatic patients, treatment did not conform with guidelines because of an underutilization of corticosteroids, mainly because of economic obstacles. European Journal of Emergency Medicine 13:21–25  c 2006 Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2006, 13:21–25 Keywords: asthma, developing countries, emergency medicine, guidelines, survey, therapeutics a Intensive Care Unit, b Emergency Department, Fatouma Bourguiba Hospital, Monastir and c Department of Pulmonary Medicine, Tahar Sfar Hospital, Mahdia, Tunisia. Correspondence and requests for reprints to Fekri Abroug, MD, Intensive Care Unit, CHU F. Bourguiba, 5000 Tunisia Tel: + 21673460672; fax: + 21673460678; e-mail: f.abroug@rns.tn Received 25 April 2005 Accepted 27 September 2005 Introduction Asthma is a chronic affection with a prevalence of almost 15 million people in the United States [1,2]. More than 12 billion dollars is spent on asthma care each year, 20% of which is dedicated to hospitalization [3–6]. USA expenditure on asthma care represents no less than 34% of the gross national product of a country like Tunisia in 2001, of which only 2.2% is dedicated to the health budget (www.tunisie.com/economie). In order to improve asthma management, several programs, consensus and expert recommendations were set out principally by scientific societies and authorities from the developed countries [7–11]. These guidelines recommend regular prophylactic medication to prevent chronic symptoms. They stress the importance of a step-by-step approach of asthma treatment, an approach that should include inhaled corticosteroids in moderate to severe asthma. All these recommendations also emphasize the impor- tance of both patient’s education and self-management of symptoms. The guidelines also recommend that all patients must be provided with an action plan that must be implemented each time an asthma attack occurs. These guidelines are intended for global application in both rich and developing countries. Yet, these guidelines were developed on the main basis of their efficacy from an evidence-based stand point and less credit was paid to the medication costs, especially for inhaled corticoster- oids that are not easily affordable in developing countries. The lack of alternatives for these countries might represent a cause of suboptimal quality of care although information is lacking about the extent to which these guidelines are implemented in less developed countries in which economic impediment might limit the access to essential medications like inhaled steroids, a study conducted through a questionnaire addressed to expatri- ate doctors practicing in developing countries suggested a less than optimal management of asthmatic patients in these countries because drugs are unavailable or are prohibitively expensive [12]. This is a matter of 0969-9546  c 2006 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.