a 84 missing data
Figure 1. Frequency of emergency department consultations for asthma
Asthma diagnosis by level of care
At level III facilities, unspecified asthma accounted for 97.72 % (n = 1,244) of cases; at level I, 78.37 % (n = 87); at level II, 75.22 % (n = 258); and among uncategorized facilities, 91.58 % (n = 1,993) (Figure 2).
At level I facilities, asthma represented 15.30 % (n = 389) of all consultations. At level II, predominantly allergic asthma accounted for 4.66 % (n = 16) and nonallergic asthma for 5.54 % (n = 19).
Figure 2. Distribution of asthma diagnoses across health facility levels of care
Patients with five or more consultations
A total of 41 patients had five or more emergency department consultations for asthma. The patient with the highest number of consultations (n = 32) experienced most recurrences between May and August. Overall, these 41 patients accounted for the highest concentration of visits between April and August (n = 151) (Table 2).
Table 2. Intensity of emergency department use for asthma in 2021, ranked from highest to lowest according to the number of consultations among the 41 patients with five or more consultations within the year
|
Patient |
January |
February |
March |
April |
May |
June |
July |
August |
September |
October |
November |
December |
Total |
|
1 |
2 |
4 |
|
|
7 |
9 |
6 |
4 |
|
|
|
|
32 |
|
2 |
1 |
2 |
1 |
|
4 |
2 |
1 |
1 |
1 |
|
|
|
13 |
|
3 |
|
2 |
|
|
2 |
|
4 |
|
1 |
|
2 |
1 |
12 |
|
4 |
|
1 |
2 |
1 |
|
|
4 |
|
1 |
2 |
1 |
|
12 |
|
5 |
2 |
1 |
1 |
1 |
1 |
2 |
2 |
|
|
1 |
1 |
|
12 |
|
6 |
2 |
|
|
1 |
2 |
1 |
2 |
|
1 |
|
1 |
1 |
11 |
|
7 |
1 |
2 |
3 |
4 |
|
|
|
|
|
|
|
|
10 |
|
8 |
|
|
1 |
1 |
1 |
1 |
|
1 |
1 |
1 |
1 |
1 |
9 |
|
9 |
1 |
|
1 |
1 |
2 |
1 |
|
1 |
|
|
|
1 |
8 |
|
10 |
2 |
|
|
|
1 |
|
|
3 |
|
1 |
|
1 |
8 |
|
11 |
|
|
|
1 |
2 |
|
1 |
|
1 |
1 |
1 |
1 |
8 |
|
12 |
|
|
|
|
|
|
|
3 |
1 |
|
2 |
1 |
7 |
|
13 |
|
|
1 |
1 |
1 |
|
1 |
|
1 |
1 |
1 |
|
7 |
|
14 |
|
1 |
|
|
1 |
2 |
|
1 |
1 |
|
1 |
|
7 |
|
15 |
|
|
2 |
|
|
|
2 |
|
3 |
|
|
|
7 |
|
,16 |
|
1 |
|
|
|
|
1 |
1 |
|
|
2 |
2 |
7 |
|
17 |
|
|
|
|
1 |
|
1 |
2 |
1 |
1 |
1 |
|
7 |
|
18 |
1 |
|
|
|
|
|
|
|
|
2 |
1 |
2 |
6 |
|
19 |
|
1 |
1 |
|
|
1 |
|
|
2 |
1 |
|
|
6 |
|
20 |
|
|
|
|
|
|
|
2 |
|
2 |
1 |
1 |
6 |
|
21 |
|
|
|
2 |
|
|
|
1 |
1 |
|
|
2 |
6 |
|
22 |
|
|
|
|
1 |
|
|
2 |
|
1 |
1 |
1 |
6 |
|
23 |
|
|
|
2 |
1 |
|
1 |
|
|
|
|
2 |
6 |
|
24 |
|
|
|
|
|
|
1 |
|
|
1 |
2 |
2 |
6 |
|
25 |
1 |
1 |
|
|
|
|
|
|
2 |
|
1 |
1 |
6 |
|
26 |
|
|
|
|
|
|
1 |
2 |
3 |
|
|
|
6 |
|
27 |
|
|
|
|
1 |
1 |
1 |
1 |
|
1 |
|
1 |
6 |
|
28 |
|
|
|
4 |
|
1 |
1 |
|
|
|
|
|
6 |
|
29 |
|
|
|
2 |
|
|
2 |
1 |
1 |
|
|
|
6 |
|
30 |
|
2 |
|
3 |
|
|
|
|
|
|
|
|
5 |
|
31 |
|
|
|
1 |
|
|
|
1 |
|
1 |
1 |
1 |
5 |
|
32 |
2 |
|
1 |
1 |
|
|
|
1 |
|
|
|
|
5 |
|
33 |
|
|
|
|
|
|
|
|
|
|
|
5 |
5 |
|
34 |
|
1 |
|
1 |
1 |
|
|
1 |
1 |
|
|
|
5 |
|
35 |
1 |
2 |
|
|
|
|
1 |
|
|
|
1 |
|
5 |
|
36 |
|
|
|
|
|
1 |
1 |
|
|
2 |
1 |
|
5 |
|
37 |
|
|
|
|
|
|
|
1 |
1 |
3 |
|
|
5 |
|
38 |
|
|
1 |
|
1 |
|
1 |
1 |
|
|
|
1 |
5 |
|
39 |
|
|
|
|
|
|
1 |
1 |
|
|
2 |
1 |
5 |
|
40 |
|
|
|
|
1 |
|
1 |
|
1 |
1 |
1 |
|
5 |
|
41 |
|
|
|
|
|
|
1 |
1 |
|
1 |
1 |
1 |
5 |
|
Total |
16 |
21 |
15 |
27 |
31 |
22 |
38 |
33 |
25 |
24 |
27 |
30 |
277 |
1.consultation
2 consultations
3 consultations
Monthly distribution of consultations
An upward trend in consultations was observed over the course of the year. In January, 282 consultations were recorded, whereas December registered the highest number in 2021, with 560 consultations (Figure 3).
Figure 3. Frequency of emergency department consultations for asthma in MINSA facilities in 2021
January 6: First batch of 38 million Sinopharm vaccines purchased from China.
February 1-14: Mandatory 24-hour lockdown in Lima, Callao, Áncash, Pasco, Huánuco, Junín, Huancavelica, Ica and Apurímac. February 9: Vaccination of healthcare workers begins.
April 16-20: Vaccination of older adults ≥ 80 years of age. May 21: Vaccination of individuals aged 65-69.
July 12-31: Targeted lockdown announced in Lima and high-risk regions.
DISCUSSION
In 2021, the second year of the COVID-19 pandemic in Peru, over 4,000 consultations were provided to patients with a definitive diagnosis of asthma in MINSA facilities. Six out of ten consultations involved young adults, and most patients were women. This distribution is consistent with findings from a 2019 Brazilian study, which reported 729 emergency department consultations for asthma, with a mean patient age of 59.3 years (range: 20-89) and 73.6 % of cases occurring in women (17).
Throughout 2021, the number of consultations for asthma showed a progressive increase, peaking in December. This trend aligns with the evolution of bronchial obstruction/asthma episodes reported in the 2021 CDC-Peru epidemiological bulletin, which recorded 497 cases in week 1 and 1,198 in week 51 (18). However, it should be noted that this comparison considers data from social security facilities, Armed Forces and Police health services, and private clinics, encompassing both emergency and outpatient consultations.
The observed trend likely reflects the dynamics of the social restrictions during the pandemic. In February 2021, a mandatory 24-hour lockdown was enforced for 14 days in several regions, including Pasco, Huánuco, Ica, among others (19). A key milestone that may explain the subsequent rise in emergency consultations was the start of COVID-19 vaccination in February, initially targeting healthcare workers (20). By April, vaccination was extended to the general population, beginning with older adults ≥ 80 years of age (21). In July, lockdown was still focused on Lima and other regions (22). Thereafter, restrictions on movement were progressively relaxed, including the reopening of international transport and expanded use of open spaces, which facilitated access to health services and increased healthcare-seeking behavior (23).
Between May and July, consultations for asthma increased compared with previous months, likely due to the growing number of vaccinated individuals. Vaccination began in May for the 65-69 age group, in June for those aged 60-64 and in July for individuals aged ≥ 50 (21). This likely enhanced the perceived safety against COVID-19, prompting a gradual return to healthcare utilization and resulting in a marked rise in consultations from that period onward.
The phenomenon of reduced consultations during the pandemic was also reported in the United States, where pediatric emergency visits declined by 22 % in 2021 compared with the pre-pandemic period in 2019. This was attributed, among other factors, to the perceived risk by parents and caregivers, which led them to avoid seeking emergency care or medical attention. Nevertheless, the number of visits for neurodevelopmental disorders among children aged 0-4 years increased by 18 per week in 2021, a trend consistent with the findings of our study (24).
The analyzed data were drawn from multiple health facilities nationwide; however, the number of consultations was slightly higher than that reported by the Hospital de Emergencias José Casimiro Ulloa, where an annual average of 3,000 emergency consultations for asthma symptoms and wheezing is recorded (25). These figures are consistent with those of the present study, as they reflect pre-pandemic data and include symptomatology, not only definitive diagnoses as in the present study.
The five institutions with the highest number of consultations are the Instituto Nacional de Salud del Niño and the Instituto Nacional de Enfermedades Neoplásicas (National Institute of Neoplastic Diseases), both located in Lima at near sea level. The remaining cases are distributed across the country at varying altitudes. This is consistent with research conducted in Mexico, which reported a higher incidence of asthma in low-altitude areas and a lower incidence at higher elevations (26). Although the underlying cause of this phenomenon remains unclear, the existing literature consistently suggests that asthma symptoms tend to decrease at higher altitudes (26-28).
Unspecified asthma was the most frequently reported diagnosis across all three levels of care. A higher level of care is expected to yield more specific diagnoses; however, this is often not achieved due to the overcrowding of emergency departments and delays in obtaining auxiliary test results (29). Furthermore, asthma diagnosis in the emergency setting is primarily clinical. Accurate classification would require additional tools-such as spirometry, sputum or blood eosinophil counts, allergy testing, among others (30)-which are generally unavailable during acute episodes. Consequently, consultation is often concluded with a general diagnosis once the emergency has been resolved.
Regarding the frequency of consultations, the intensity of emergency department use for asthma was 1.25. During the pandemic, most patients required a single emergency consultation; however, one patient accounted for 32 visits. A study conducted between July 2008 and January 2009 in 58 primary care centers in Spain reported an average of 3.12 primary care visits and 0.69 emergency visits among patients presenting with worsening symptoms (31). In addition, the intensity of use was higher among patients aged ≥ 60 years and slightly higher among males.
This study has several limitations related to the dataset used for analysis. The dataset did not include consultations provided by other health systems in the country (EsSalud [Social Health Insurance], private clinics, Armed Forces health services). Additionally, the analysis was restricted to the variables included in the dataset, which limited the characterization of the consultations. Only cases with a definitive diagnosis of asthma treated in emergency services during a single year were included. Nevertheless, year 2021 encompassed key milestones that allowed us to describe how public health restrictions and measures influenced trends in emergency department consultations.
In conclusion, emergency department consultations for definitive diagnoses of asthma in 2021 were more frequent among patients aged 27-59 years and among women. Unspecified asthma was the predominant diagnosis across all levels of care, particularly at level III, the highest level of care. An upward trend in emergency visits was observed throughout the year.
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Author contributions: ARL and MF contributed to the conceptualization, methodology, validation, statistical analysis, data management and manuscript drafting. FR contributed to the conceptualization, statistical analysis, supervision and manuscript drafting. All authors reviewed and approved the final version submitted for publication and accept responsibility for its content.
Funding sources: The article was funded by the authors.
Conflicts of interest: The authors declare no conflicts of interest.
Corresponding author:
María Cielo Figueroa Herrera
maria.figueroa.h@alum.udep.edu.pe
Received: November 13, 2023
Reviewed: December 21, 2023
Accepted: February 5, 2024