Asthma Exacerbation

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Section IconIntroduction and Importance
Asthma Exacerbation
Asthma is a chronic inflammatory disorder associated with variable airflow obstruction and bronchial hyperresponsiveness.
Asthma exacerbations (or acute asthma) are episodes of worsened disease and occur across the spectrum of chronic asthma severity. A patient having chronic asthma severity at any level can have a fatal exacerbation.
In the United States (US) alone, asthma exacerbations account for at least 1.7 million Emergency Department (ED) visits and more than 200,000 hospitalizations.
Asthma costs society approximately $50 billion in direct costs, with approximately 50% related to exacerbation management.
Improving asthma care is a major US health policy objective.
Section IconOverall Approach
Supplemental oxygen titrated to maintain pulse oximeter oxygen saturation monitoring levels between 94 and 98%
If patient is able, obtain baseline percent predicted (or personal best) pulmonary function testing (PEF or FEVְְ₁) for objective assessment of severity of airways exacerbation.
  • Mild ≥70%, Moderate 40-69%, Severe < 40%, Respiratory Insufficiency < 25%. Increase the intensity/frequency of therapies with moderate, severe and respiratory insufficiency.
  • Serial subjective and objective reassessments to assess responses to therapy. Rapid reversal of airflow obstruction is indicative of better outcomes.
Assess Overall Risk factors for Death from Asthma Exacerbation.
History of near-fatal asthma
Hospitalization or ED visit for asthma in the past year
Current or recent use of oral corticosteroids
Using > 1 albuterol canister per month
History of poor adherence with medications and/or asthma management plan
Psychosocial problems/psychiatric disease
Determine Comorbidities that may Require Treatment in the Emergency Department
Exacerbation of heart failure
Diabetes (steroid administration increases blood sugar)
Determine Possible Triggers of Airflow Obstruction (when patient is stable)
Allergens (environmental, occupational)
infection (mostly viral etiology)
Exercise induced.
Medications (aspirin, non-steroidal anti-inflammatory drugs, beta-blockers
Menstrual related
Section IconClinical Features
The following recommendations apply to patients 6 years or older. For patients younger than 6 years, please see Considerations in Children.
Signs, Symptoms, and Diagnostic Testing
Typical clinical presentation includes an episode of progressive dyspnea and wheezing, often associated with cough and/or chest tightness.
Physical examination will typically include tachypnea, increased work of breathing (e.g., accessory muscle use, tripod position, words per sentence), and wheezing.
Diminished wheezing in severe cases can indicate poor air movement, which can suggest the development of respiratory failure.
Hypoxia and hypercapnia can develop in moderate to severe asthma exacerbations, but their absence should not provide reassurance.
Pulmonary function tests (PFTs) can be trended to measure trajectory and response to therapy.
Adjunct tests can be used to diagnose complications and associated conditions, such as a chest radiograph for pneumothorax and pneumonia (in conjunction with physical examination).
Chest radiograph and lab tests are only recommended to address clinical suspicion for other conditions and should not be considered routine.
Differential Diagnosis and Associated Conditions
Alternative/additional diagnoses should be considered in all cases, but especially in those marked by unusual characteristics or poor response to standard therapies.
Upper airway obstruction and stridor should be distinguished from lower airway obstruction and wheezing.
Anaphylaxis is the most prominent condition on the differential diagnosis for wheezing across all ages.
In adults, chronic obstructive pulmonary disease (COPD) is the most common alternative explanation for wheezing.
Cardiac asthma refers to wheezing caused by pulmonary edema (e.g., congestive heart failure).
Asthma exacerbations and its therapies are associated with complications, such as pneumothorax, acute coronary syndrome, and tachyarrhythmia. Chronic asthma can also predispose patients to pneumonia, metabolic syndrome, mental health conditions, and other chronic diagnoses.
Other medical problems can trigger or worsen asthma exacerbations, such as pneumonia and other respiratory infections, sinusitis, and seasonal allergies.
In children, the most notable alternative diagnoses beyond anaphylaxis include bronchiolitis and foreign body aspiration, among other causes of upper airway obstruction such as croup and bacterial tracheitis. For more information about children younger than 6 years, please see Considerations in Children.
Risk Factors and Severity Assessment
Asthma exacerbations are dynamic in nature and so clinicians must frequently reassess patients to determine their trajectory.
Helpful tools in asthma severity assessment include frequent reassessment of the patient’s symptoms and physical examination, continuous pulse oximetry, continuous capnography, serial blood gas analysis, oxygen requirement trends, minimum frequency of interventions (e.g., frequency of albuterol administration), and serial PFTs.
Important risk factors associated with fatal asthma exacerbations include history of near-fatal asthma exacerbation (e.g., intubation or ICU admission), ED visit or hospitalization within the past year, current or recent use of systemic corticosteroids, using more than 1 albuterol canister per month, history of poor adherence to outpatient management, and psychiatric comorbidity.
Ask about interventions prior to arrival, either self-administered or by EMS. It is important to consider whether each intervention could have been limited by improper technique or limited patient participation due to distress.
Section IconPharmacologic Treatments
The following recommendations apply to patients ≥6 years old. For younger patients < 6 please see Considerations in Children.
Algorithm: Summary of Standard Pharmacotherapy within the First Hour Image
Summary of Standard Pharmacotherapy: The First Hour in the ED
All patients should receive inhaled beta agonist therapy (e.g., albuterol).
Combined nebulized albuterol (2.5-5.0 mg) and ipratropium bromide (0.5 mg) can be administered three times within the first hour. Alternatives include 4-8 puffs albuterol (90 mcg/puff) and ipratropium bromide (18 mcg/puff) three times within the first hour via pMDI with spacer.
In severe cases, consider continuous nebulized albuterol at 10-20 mg/hr.
Corticosteroids such as dexamethasone 0.6 mg/kg/day, max 16 mg/day or prednisone 40-80 mg (1-2 mg/kg pediatric, max 60 mg) should be administered as early as possible, ideally within the first hour.
Intravenous corticosteroids may be preferred in severe cases although the literature supporting this is sparse.
Intravenous magnesium (typically 2 mg over 20 minutes) can be added to standard therapy for severe/refractory cases.
The guiding principle of emergency management of asthma exacerbations is the prompt reversal of airway obstruction.
Inhaled short-acting beta agonists (SABAs) and systemic corticosteroids mark the cornerstones of acute care for asthma exacerbations.
Inhaled anticholinergic agents are typically considered the third standard intervention to supplement SABA-mediated bronchodilation.
Adjunct therapies, such as intravenous magnesium, might be helpful additions to routine therapy, particularly in moderate to severe cases.
Proper technique is critically important for medications given via inhaler. If response to unwitnessed inhaled therapies is limited, consider whether the treatment was properly received.
Beta Agonists
Inhaled short-acting beta agonist (SABA) therapy (e.g., albuterol) is the main bronchodilator medication that should be used for all asthma exacerbations in the ED.
SABAs work through agonism of beta 2 adrenergic receptors, with the primary effect to relax smooth muscle in the airway to relieve bronchospasm/obstruction.
Albuterol can be administered via pressurized metered-dose inhaler (with a spacer) or with a nebulizer (gas flow rate typically set at 6-8 L/min).
Inhaler: 4-8 puffs (90 mcg/puff) every 20 minutes during the first 4 hours
Nebulizer: 2.5-5.0 mg every 20 minutes for the first hour (sometimes referred to as “stacked”), followed by 2.5-10 mg every 1-4 hours as needed.
Continuous albuterol can be administered via nebulizer in severe cases, typically started at 10-20 mg/hr. Experts typically recommend starting higher and weaning as tolerated, rather than starting lower and gradually increasing.
Systemic corticosteroids exert their effect by reducing inflammation, edema, and secretions, thereby relieving airway obstruction.
Systemic corticosteroids take time to reach peak effect to combat prolonged inflammatory processes, so prompt administration (i.e., within 1 hour) is critically important.
If the patient arrived by EMS, ask whether systemic corticosteroids have already been administered.
Intravenous corticosteroid options include methylprednisolone 40-125 mg (1-2 mg/kg pediatric, max 60 mg) or dexamethasone 16mg (0.6 mg/kg pediatric, max 16 mg) daily, and oral options include prednisone or prednisolone 40-80 mg (1-2 mg/kg pediatric, max 60 mg) daily.
Inhaled corticosteroids should not be used as a substitute for systemic corticosteroids and are not generally considered helpful in management of asthma exacerbation.
When administering corticosteroids, consider comorbid conditions that can be exacerbated, such as diabetes, psychiatric disorders, and hypertension.
Corticosteroid therapy should be continued daily for several days, regardless of ED disposition.
Inhaled anticholinergic agents (most commonly ipratropium bromide) are an effective addition to inhaled SABA therapy (but not a substitute).
Inhaler: 18 mcg/puff (with spacer), 4-8 puffs every 20 minutes for the first 3 hours
Nebulizer: 0.5 mg every 20 minutes for the first hour, followed by 0.5 mg every 6 hours
Many EDs offer a combined formulation of ipratropium bromide and albuterol, which can be administered together simultaneously via nebulizer every 20 minutes during the first hour (2.5 mg albuterol and 0.5 mg ipratropium bromide per dose).
Magnesium exerts its bronchodilator effect by inhibiting calcium influx into smooth muscle cells and through anti-inflammatory activity.
Intravenous magnesium sulfate (typically 2 g over 20 minutes) can be used to supplement routine therapy in severe cases.
Inhaled magnesium is generally not considered helpful for asthma exacerbations.
Nebulized epinephrine is not routinely used, as inhaled albuterol is the preferred bronchodilator agent to treat asthma exacerbations.
Systemic epinephrine (typically intramuscular or subcutaneous but occasionally intravenous) is not typically recommended for asthma exacerbations but can be used in severe cases especially when anaphylaxis is considered a likely alternative diagnosis to asthma.
Risks associated with intravenous epinephrine use, especially in vulnerable patients (e.g., cardiac risk factors), should be considered prior to administration.
Other agents
Methylxanthines (e.g., theophylline) and leukotriene modifiers are generally not considered helpful in acute care for asthma.
Ketamine stimulates bronchodilation but is not generally recommended for use solely for its bronchodilator effect. However, it is generally preferred over other sedative agents to facilitate noninvasive positive pressure ventilation or intubation when needed.
Heliox is a mixture of helium (typically 60-80%) and oxygen that is meant to reduce airway resistance, thereby improving air movement and work of breathing. In the absence of clear supportive evidence, Heliox is generally not prioritized and only attempted in severe cases where the capability exists.
Antibiotics are only indicated when bacterial infection (e.g., pneumonia) is suspected.
Section IconAcute Severe/Life Threatening Asthma
Clinical appearance
  • Patients with severe asthma may have several clinical features including diaphoresis, tripoding (leaning over on their hands) marked tachypnea, confusion, difficulty speaking more than a few words, intercostal retractions, abdominal breathing, and cyanosis. Note that with marked bronchospasm you may not hear wheezing but will identify a prolonged expiratory phase
Pulmonary function testing
  • Asthmatic patients with severe asthma generally have expiratory flow rates below 40% of predicted normal or may be unable to participate in pulmonary function testing. Because of chest wall discomfort the FEV1 flow pattern may mimic a restrictive pattern
  • Peak flow < 40% of predicted normal if adequate effort is used
Arterial and venous blood gases
  • With severe asthma the PCO2 increases above normal, the PO2 decreases below 60, and the pH decreases. The pH of a venous blood gas will show acidosis in the face of arterial acidosis, predicting hypercarbia.
Pulse oximetry
  • Pulse oximetry can be used to monitor oxygen therapy. A pulse oximetry < 90% may indicate a significant asthma exacerbation.
Subcutaneous epinephrine and terbutaline
Weight of the Evidence
  • There is no adequate evidence to suggest that subcutaneous beta-agonists have an advantage over inhaled beta-agonists. You may consider them in patients unable to cooperate with nebulized medication. You may consider them in patients with severe asthma, in the absence of compelling evidence
  • May consider in patients unable to cooperate with inhales beta-agonists or where anaphylaxis is a consideration
  • Epinephrine may be given as 0.3 ml (0.3 mg) subcutaneously q20 minutes x 3 doses
  • Terbutaline can be given as 0.25 ml (0.25 mg) subcutaneously q30 minutes x 2 doses Terbutalinen
  • Clinical evidence does not support the use of terbutaline preferentially in older patients
  • These drugs can be given in the face of sinus tachycardia as that is usually due to the respiratory distress rather than the effect of the drug
Magnesium sulfate
Weight of the evidence
  • Evidence from prior studies supports the use of intravenous magnesium sulfate in severe asthma.
  • There is little evidence to compel its use in mild to moderate asthma. There is little evidence to compel the use of inhaled magnesium
Intravenous magnesium sulfate
  • There is little evidence to suggest one dose over another
  • Typically, magnesium sulfate is given as 2 g over 20 minutes or 40 mg/kg up to 2 g in children
Inhaled magnesium sulfate.
  • Some studies have used magnesium sulfate 333 mg for nebulization.
Weight of the evidence
  • Overall, the evidence does not support the routine use of Heliox is asthma. Post hoc analyses of existing trials have a suggestion of improvement in pulmonary function in severe asthma
  • Various studies have used helium to oxygen mixtures of 80:20 to 60:40. There is inadequate evidence to distinguish between the mixtures.
Inhaled corticosteroids
Weight of the evidence
  • Meta-analyses of various trials suggest a small improvement in pulmonary function and a modest reduction in hospitalization rates in patients with severe asthma
  • Studies have used various dosing.
  • A representative dose would be budesonide 2000 micrograms or beclomethasone 5000 micrograms by nebulization. Fluticasone 2000 mcg can be given via an MDI with a spacer
  • There is little evidence comparing agents or dosing.
Leukotriene modifiers
Weight of the evidence
  • Little evidence for efficacy in children. Adult studies suggest improvement in pulmonary function in adults. The evidence is not compelling.
  • Montelukast studies have used oral dosing of 10 mg or intravenous dosing of 7-14 mg..
  • Some studies with Zafirlukast found an improvement in pulmonary function with oral doses of 160 mg.
Intravenous beta-agonists
Weight of the evidence
  • Overall, there is little evidence to support the use of intravenous beta-agonist. Some international guidelines suggest their use as a third line agent in children who cannot cooperate with other therapies
  • Limited studies have given as an example intravenous albuterol 0.5 mg om adults or 15 mcg/kg in children.
  • Limited studies have given terbutaline 500 mcg intravenously divided into 2 doses in adults. Dosing in children has ranged from 0.1 to10 mcg/kg/min.
Weight of the evidence
  • Although used extensively in the past, current evidence does not support the use of intravenous aminophylline, albeit some international guidelines recommend it as a third line agent on life threatening asthma. There is a narrow therapeutic window for its use
  • Typically, 5 mg/kg in children and in adults 5.7 mg/kg based on ideal body weight.
Noninvasive Ventilation
Weight of the evidence
  • The role of BIPAP and CPAP is more well established in the COPD population where it reduces the incidence of intubation. The role in asthma is less well established although it may be considered in patients with severe asthma who are able to cooperate with non-invasive ventilation. The recommendations generally are for BiPAP over CPAP in asthma exacerbation
Setup and monitoring
  • Set the FI02. If the patient has an adequate pulse oximetry on oxygen, then match that FI02. Otherwise start with a FIO2 of 1 and then titrate down.
  • For BiPAP patients
    • Start the EPAP at 4-8 cmH2O.
    • Start the IPAP at 4-10 cmH2O above the EPAP.
    • Start the respiratory rate at 12-16 although patients with significant air trapping may benefit from a lower respiratory rate
  • For CPAP patients
    • Start the CPAP at 3-5 cmH2O
  • High flow nasal oxygen is an alternative which has been more extensively studied in children
Intubation Indications
There are no rigid guidelines on when to intubate. It is based on clinical judgment assessing response to treatment. In the patient who has clinical or laboratory evidence of respiratory failure despite treatment consider intubation
Setup and monitoring
  • The patient should be pre-oxygenated to the extent possible
  • An assessment of the anticipated degree of difficulty of intubation should be made.
  • In patients with an anticipated difficult intubation consider the availability of adjunctive tools
  • Rapid sequence intubation may be of benefit in selected patients
  • Once intubated consider initial settings to include:
    • Tidal volume of 6-8 ml/kg ideal body weight
    • Respiratory rate of 10-12 breaths per minute
    • PEEP at 5 cm H2O adjusted as needed to keep plateau pressures < 30 cm H2O with intrinsic PEEP <10 cm H2O
    • Inspiratory flow rates of 60-75 L/min
Section IconConsiderations in Children
In patients ≥ 6 years of age the assessment and management of asthma exacerbations are essentially the same as those for adults.
However, in children < 6 years of age the symptoms and signs of acute asthma are not as well defined, moreover young children may not have a prior diagnosis of asthma.
  • Factors associated with the development of asthma include parental asthma, symptoms response to bronchodilators and physician diagnosed eczema.
Historical Features
Unique historical features include a history of prematurity, cough (at night), wheezing (with activity), increased work of breathing, eczema, fever, and upper respiratory symptoms (viral induced wheezing).
Physical examination focusses on excluding other diagnoses.
  • Check growth chart as poor weight growth is seen with cystic fibrosis and congenital heart disease
  • Determine if stridor (upper airway) or wheezing (lower airway)
  • Cardiac exam for heart murmurs (congenital heart disease) and upper vs lower extremity pulses (aortic coarctation)
  • Pulmonary for unilateral vs bilateral wheezing (unilateral wheezing associated with foreign body)
  • Abdomen for hepatomegaly (associated with congestive heart failure)
Pediatric Asthma Severity Score
The Pediatric Asthma Severity Score has been reported to be useful for the clinical assessment of asthma severity for children ≤ 5 years of age but has not been widely implemented as asthma specialists are reluctant to diagnose asthma in this patient group.
Differential diagnosis
Laryngomalacia/tracheomalacia - stridor, symptoms worsen with agitation and improve with prone position, and these abnormalities are usually present from birth.
Croup – stridor, “barky cough”, symptoms worse at night, may have URI symptoms, high risk populations- previous upper airway disease, previous airway procedures
Bacterial tracheitis – fever, stridor, toxic appearing child, does not respond to croup treatment (racemic epinephrine, steroids)
Foreign Body - acute onset with unilateral wheezing.
Cystic fibrosis - poor growth and gastrointestinal symptoms.
Congenital heart disease -cardiac murmur, pulse discrepancy upper and lower extremities, and liver enlargement.
Bronchiolitis - fever, upper respiratory symptoms, and wheezing (viral etiology).
Laboratory/radiographic testing and indications
RSV testing - indicated only if results would change management.
Chest radiograph - consider with hypoxia, asymmetric breath sounds, concern for foreign body.
Pulmonary function testing - children < 6 years of age are usually not able to perform.
Laryngoscopy/Bronchoscopy - indicated for atypical symptoms, failure to respond to therapy.
Supportive care - bulb suctioning if indicated.
Correct dehydration.
Refer to treatment section (special considerations).
Correct hypoxia - oxygen by face mask to maintain oxygen saturation 94-98%.
Beta 2 agonists – initiate, especially if parental history of asthma, child with eczema, history of prior response to Beta 2 agonists.
Ipratropium bromide - consider for moderate/severe exacerbations.
Magnesium sulfate - use has not been established in this age group.
High flow nasal cannula - controversial (may give a trial if unsure if patient has bronchiolitis or asthma exacerbation).
Noninvasive positive pressure ventilation - controversial (may try if severe exacerbation).
Intubation and mechanical ventilation for respiratory failure.
Section IconConsiderations During Pregnancy
Managed generally the same as nonpregnant patients.
No subcutaneous epinephrine (potential fetal artery constriction).
Supplemental oxygen to maintain a pulse oxygen level > 95%.
Additional management.
As part of initial assessment check fetal activity.
It is better for pregnant women with asthma to be treated with asthma medications than for them to have asthma symptoms and exacerbations.
Ongoing fetal assessment algorithm. Learn more here
Section IconPatient Disposition
Disposition decisions depend on improvements of patients’ symptoms and signs, consideration of their medical comorbidities, and patients understanding of and having the ability to carry out their treatments once discharged from the ED.
  • Minor symptoms at presentation without acute worsening. -- OR --
  • Substantially improved symptoms and normalizing vital signs and the ability to space out treatments after a period of observation in the ED.
  • Patients must be able to access prescribed medications, maintain the plan of care in the outpatient setting and understand any return precautions.
  • Home treatment includes a detailed plan on how often to use bronchodilator therapy, a course of oral steroids if indicated, discussion on avoiding asthma triggers (including smoking cessation) and patients understanding the symptoms and signs warranting return to the ED.
Admission or observation
Clinically not improving despite treatments.
Vital signs are not normalizing.
Diagnosis of pneumonia or history of cardiac disease (consider).
Requiring supplemental oxygen to maintain oxygen saturation.
Unable to wean nebulizer therapy to q 3-4 hr.
Concern for or inability to maintain outpatient treatment plan.
Intensive or intermediate care unit
Moderate to severe symptoms on arrival with minimal improvement or worsening despite aggressive management.
Hemodynamic instability.
Altered mental status or lethargy.
The need for non-invasive or mechanical ventilation or high supplemental oxygen high flow requirements.
Respiratory failure (hypercarbia).
Section IconAsthma Exacerbation Discharge Planning
Discharge Planning
Airway inflammation and peripheral obstruction may take several days to weeks to resolve. Up to 20% of ED patients with asthma exacerbation will have a relapse within two weeks of discharge and more than a quarter of patients have multiple subsequent ED visits. Patients will likely need continued medication therapy after discharge.
Post Discharge Medications
Short-acting beta-2-agonist (SABA)
  • Persistent residual airway inflammation will likely warrant beta-2-agonist utilization for a short time after ED discharge. Guidelines for chronic inhaled beta-2-agonist treatment recommend reserving daily use to rescue therapy alone.
Systemic corticosteroids
  • Cochrane review of 6 RCTs demonstrated decreased inhaled beta-2-agonist use, relapses, or hospitalizations in patients discharged with systemic corticosteroids versus placebo.
Inhaled corticosteroids (ICS)
  • To prevent future relapses and potential decline of lung function in future exacerbations.
  • ICS plus systemic corticosteroid non-significantly decreased risk of relapse compared to systemic corticosteroids alone.
  • Patients with asthma symptoms more than twice per month should take ICS whenever SABA is taken or be discharged with low-dose ICS plus long-acting beta-2-agonist combination inhaler.
  • In patients not using controller medications prior to ED visit and with characteristics of persistent asthma, consider initiating moderate-dose ICS.
Long-acting beta-2-agonist (LABA)
  • There is NO ROLE for the use of LABAs without the concomitant use of ICS.
  • Consider adding to ICS in patients with symptoms < twice per month.
  • Should discharge with ICS in patients having symptoms twice or more per month.
  • In patients not using controller medications prior to ED visit and with characteristics of persistent asthma, consider initiating ICS plus LABA combination.
  • Bacterial respiratory tract infections rarely contribute to asthma exacerbation.
  • Reserve antibiotics for patients with clear, objective evidence of infection.
Patient Education
Written discharge plan: Adults demonstrating self-management education with a review by a health care provider decreases post-discharge health care utilization.
  • Appropriate device usage:
    • Patients should demonstrate appropriate use of their inhalers.
    • A spacer should be used with MDI.
    • Portable, preloaded multi-dose dry powder inhalers need inhaled from mouthpiece rapidly and with force. A patient should be capable of this.
  • Medications/discharge medications
    • Difference between rescue and controller medications
  • Medication adjustments
  • Peak flow meter for daily measurements
  • Plan for worsening symptoms
  • Need for follow-up.
  • Smoking cessation in asthmatic smokers and/or smoking family members.
    • Cigarette smokers make up 1/3rd of adult ED/hospitalized asthma exacerbations
    • Smoking asthmatics have more respiratory symptoms, poorer lung function, and more parenchymal abnormalities than non-smokers.
Asthma Action Plans
Evidence suggests a written action plan coupled with prescriptions compared to unformatted prescriptions increases discharge medication adherence, improves asthma control, and increased physicians’ prescriptions of maintenance ICS and recommendations for medical follow-up.
There is a low prevalence of written action plans for ED patients with asthma exacerbation.
This suggests ED providers should develop a brief, personalized written asthma action plan with the patient at discharge.
Facilitating longitudinal care.
Follow-up care to primary care provider or asthma specialist within 1-4 weeks after ED discharge.
  • Evidence suggests better outcomes likely reduced risk of subsequent ED visits for asthma exacerbation with patients referred to asthma specialist.
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Developed by the ACEP Expert Panel on Acute Asthma
Reviewed by the ACEP Clinical Resource Review Committee

Support provided by Amgen and AstraZeneca


Charles Emerman, MD, FACEP (co-chair) Richard Nowak, MD, MBA (co-chair) Carlos A. Camargo, Jr., MD, FACEP Ann Dietrich, MD, FACEP Greg Peters, MD Vincent Peyko, PharmD, BCPS Julie Vieth, MD, FACEP


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