Asthma in the ED

Any therapist who’s worked acute care has, no doubt, witnessed that middle-of-the-night patient presenting in the Emergency Department (ED) with symptoms of asthma. These include shortness of breath that may or may not interrupt speaking, hypoxia, rapid and labored breathing patterns, cyanosis, paleness, continual coughing, retractions, panic or anxiety, sweating, complaints of chest pressure or pain, fatigue and wheezing.

An absence of wheezing is not necessarily a good thing, though; the patient simply may not be moving enough air to wheeze. It actually is common to see wheezing occur after breathing treatments have been initiated because airflow begins to improve.

The patient may be experiencing any combination of these symptoms and in varying levels of distress. Regardless of symptom severity, an asthma flare-up is an emergency and needs to be treated quickly and aggressively. Without such attention, the patient could be facing a life-threatening situation.

The good news is that asthma is a reversible airway disease, but the question is, “How should it be treated, right here, right now, when the patient is in the ED?”

Classifications

To begin, let’s review asthma’s classifications.

Asthma is classified based upon severity and frequency of symptoms in one of the following degrees: intermittent, mild persistent, moderate persistent and severe persistent. These classifications are based upon symptoms before treatment. It is something that can change over time and a person with any classification of asthma is at risk for the severe attacks we often find in the emergency room.

Intermittent asthma is present when symptoms consist of wheezing, difficulty breathing, coughing and possible chest tightness, but do not occur more than two days per week and or interfere with normal activities. Nighttime, or nocturnal, asthma in this classification occurs no more than two times per month and lung function tests are normal when symptoms are not present.

Mild persistent asthma is present when symptoms occur more than two days per week, but do not occur daily or interfere with normal activities. Nighttime symptoms are present greater than two (but no more than four) nights per month and lung function tests results are 80% of normal when the patient is not having an attack.

Moderate persistent asthma is present when, without treatment, symptoms occur daily and the patient needs medication on a daily basis. Nighttime symptoms occur weekly, but not daily, and lung function test results are more than 60% of predicted but less than 80%.

Severe persistent asthma is present when symptoms occur throughout each day and limit daily activities to a great degree. Nighttime symptoms can be present daily and typically often.

In order for healthcare providers to determine the classification of asthma a thorough patient history is required, as well as the results of a recent pulmonary function test. The disease’s classification can help the patient as much as the provider. Each patient with a diagnosis of asthma needs to have an asthma action plan in hand at all times that tells them and their caretakers when and how to act in regards to their symptoms and the current state of their disease. Unfortunately, many patients will receive their diagnosis only when you see them in the emergency room in the middle of a flare-up.

Education is also a crucial element of asthma treatment. It allows patients the ability to understand where they are in regards to their disease management and what changes in their symptoms mean. Likewise, it encourages them to seek medical help prior to a potentially fatal flare-up, directing them on how and where to get it.

SEE ALSO: Asthma Inhalers Get Smart

Assessment and Treatment

In order to properly treat a patient you must first assess them. ED patients will most likely need immediate supplemental oxygen and bronchodilator treatment, which may be necessary to help the patient reach a point at which they can even speak because of difficulty breathing. You will assess the room air oxygen level and their heart rate, breath sounds and air movement, their use of accessory muscles (extra chest muscles to help you breathe when overworked) and note respiratory rate and pattern.

Medication should be given based upon symptoms and will be something along the lines of:

1. An initial dose of albuterol – 3 in the first hour – along with prednisone for inflammation control or a dose of albuterol/ipratropium bromide 3 times in the first hour along with prednisone.

2. A secondary dose of albuterol as a repeat treatment every hour for up to 3 hours.

3. If the initial dose did not improve symptoms, the physician needs to be notified and another dose of albuterol 3 times in the next hour will likely be given.

4. Oxygen adjusted to reach a saturation level of 95%.

Sometimes physicians will choose to use albuterol alone when medicating asthmatic patients. Others, they’ll use a combination medication such as the albuterol/ipratropium combination. This is based on physician preference as well as patient history.

The medication combinations open the airways in more than one way, like going into a house through the front and back doors at the same time. This can sometimes show better results but again, it depends upon physician preference and what the patient currently uses to treat their disease, as well as what other conditions the patient may have.

Contraindications of albuterol/ipratropium bromide are found in patients who suffer from some types of glaucoma, paradoxical bronchospasm, high blood pressure, diminished blood flow through the heart, abnormal heart rhythm, bladder blockage or bladder than cannot empty, enlarged prostate, seizures, overactive thyroid, diabetes, ketoacidosis or low potassium, as well as those who have allergies to beta adrenergic agents or anticholinergics.

Many asthmatic patients use a daily inhaled corticosteroid to maintain an open airway. During severe asthma flare-ups, the physician will often prescribe either additional doses of inhaled steroids or an oral or IV steroid to speed up the process of reducing inflammation and mucus production. This is safe for most people, including pregnant women.

Studies show that pregnant mothers with severe asthma are at a higher risk for preterm labor and low birth weights, but it is unclear whether the inhaled corticosteroids that treat asthma symptoms directly contribute to this or if it is the asthma itself that more greatly contributes to these situations.

The consensus is that inhaled steroids are safe for these women; the greatest risk to the child is failing to keep control of the asthma itself, not the use of the steroid. The use of inhaled steroids is often to help manage the mother’s asthma. These steroids seem to be safer for the child than the lack of control of the asthma and therefore are encouraged by most providers.

The use of IV or oral steroids should be determined on a case-by-case basis, since they can be more dangerous for the baby. This is another reason inhaled steroids are recommended for managing a patient’s asthma.

Reassessments and Education

While monitoring the patient, a full assessment needs to be performed between each dosing of medication by listening to the patient’s breaths, performing a visual assessment of breathing pattern and rate, evaluating their heart rate and adjusting supplemental oxygen to maintain a saturation level of 95% or greater.

It is also vital to get a peak expiratory flow (PEF) rate at each interval in order to evaluate the function of the airways and whether they are improving, and to establish a baseline for the patient. A PEF is obtained by having the patient blow three times into the PEF gauge with their most forceful blow, which measures the pressure that is exhaled. An average of the three blows is obtained and this will be used to measure improvement, or lack thereof, of the actual airways in the lungs.

A patient that is managing their asthma with an action plan will perform this activity each day at the same time to monitor their baseline. They will likely see a change in the PEF up to three days prior to actually feeling any change in their symptoms, helping them better manage their disease and flare-ups.

If the patient improves and has a good response to the treatment plan, you will see improvement in all symptoms. This is the time to educate patients on medication use – the proper way to take them, how to monitor themselves and how to provide an asthma action plan if they don’t already have one. Prescriptions for maintenance and emergency medications, if they are not already present, may also need to be explained. Monitor them until their room air oxygen saturation levels are greater than 92% and symptoms have subsided.

If they do not respond, then the physician should be notified. The patient needs to be hospitalized and an ABG, or arterial blood gas, will be ordered. This is a test where blood is drawn directly from the artery (instead of a vein where an IV would be put). It is deeper than veins and can be a very uncomfortable test. It will measure the various gases in the blood to give providers a direct look at what is happening inside the body such as pH, carbon dioxide levels and oxygenation levels.

The levels of these gasses let the provider know how the patient is breathing and how the body is handling it. The results, along with the symptoms, will determine whether the patient is admitted to Intensive Care or to a regular floor for monitoring. If the patient does not experience a significant enough improvement in symptoms, is becoming too fatigued or has blood gas results that indicate impending respiratory failure, intubation and the use of a ventilator may be necessary in order to save their life.

It is important to note that intubation will not make additional flare-ups more common, as flare-ups of asthma are due to several factors in the lungs such as swollen tissues, increased mucus production, a quivering of the airways and a variety of others. The severity of the asthma may lead to additional flare-ups that could require another intubation if the patient cannot control the symptoms.

Dawn Lesley Fielding is a respiratory therapist, educator and pulmonary rehab clinical specialist, Intermountain Healthcare, Salt Lake City, and founder of Chronic Lung Alliance, a nonprofit organization.

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