How to Handle Asthma Attacks in Emergency Settings

Recognizing an Asthma Attack Before It Escalates

• Early Warning Signs: Patients may present with subtle changes before a full-blown attack. These include coughing (especially at night), shortness of breath during mild activity, wheezing, and chest tightness. Monitor peak expiratory flow (PEF) for drops of 15-20% from baseline.
• Subjective Triggers: Encourage patients to recognize their personal triggers—ranging from dust, smoke, and cold air to emotional stress and viral infections. Awareness of these can prevent attacks.
• Increased SABA Use: A red flag often missed is increased use of rescue inhalers. If a patient is using their short-acting beta-agonist (SABA) more than twice a week, it’s time to reevaluate their treatment plan.

Immediate Steps During an Acute Asthma Attack

• Stay Calm: Patients panic; healthcare professionals shouldn’t. Calmly assess airway, breathing, and circulation (ABC).
• Assess Severity: Use parameters like:
  • Speech: Talking in words vs. full sentences
  • Respiratory rate: >30 breaths/min is severe
  • Accessory muscle use and paradoxical thoracoabdominal movement
  • Oxygen saturation: <92% on room air indicates a severe attack
• Administer SABA via Nebulizer or Inhaler with Spacer:
  • Deliver salbutamol (albuterol) 2.5–5 mg nebulized or 4–10 puffs via MDI with spacer every 20 minutes for the first hour.
• Oxygen Support:
  • Administer humidified oxygen to keep SpO₂ >94%.
• Add Ipratropium Bromide in Severe Attacks:
  • Especially useful in ED settings. Combine with SABA for synergistic bronchodilation.
• Systemic Corticosteroids:
  • Oral prednisone (40–50 mg) or IV methylprednisolone in severe cases. Corticosteroids should be administered early as their effects take hours to kick in.
• Magnesium Sulfate IV:
  • Administer 1–2 g over 20 minutes in life-threatening attacks or where SABA/anticholinergics have limited response.

Avoiding Common Mistakes in Acute Management

• Skipping Spacers: Many ERs still underuse spacers, despite evidence they are as effective as nebulizers and reduce systemic absorption.
• Over-Oxygenation: Giving 100% oxygen indiscriminately can suppress respiratory drive in patients with chronic hypercapnia (e.g., severe asthma-COPD overlap).
• Missing Silent Chest: A quiet chest with no wheezing in a dyspneic patient isn't a relief—it's a sign of near-total airway obstruction and impending respiratory arrest.

When to Escalate Care:

• ICU Admission Indications:
  • Rising PaCO₂ (>45 mmHg)
  • Altered mental status
  • Silent chest
  • Hypotension
  • Exhaustion or inability to speak
• Non-Invasive Ventilation vs. Intubation:
  • NIV may help bridge moderate exacerbations.
  • Intubation should not be delayed in decompensating patients. Use ketamine for sedation due to bronchodilatory effects.

Post-Attack Stabilization and Discharge Planning

• Continue Systemic Steroids:
  • Typically 5–7 days of oral corticosteroids post-discharge.
• Review Inhaler Technique:
  • Poor technique is a primary reason for relapse. Demonstrate and assess technique on-site.
• Step-Up Controller Therapy if Needed:
  • Consider inhaled corticosteroids (ICS) or ICS/LABA combination if SABA alone isn’t enough.
• Provide a Written Asthma Action Plan:
  • Color-coded zones (green/yellow/red), symptom awareness, and steps to take in each scenario.
• Encourage Peak Flow Monitoring at Home:
  • Patients can identify drop in function before symptoms worsen.

Preventing Future Asthma Attacks: Proactive, Not Reactive

• Address Environmental Triggers:
  • Dust-proofing, HEPA filters, removing pets if necessary, smoking cessation among household members.
• Manage Comorbidities:
  • GERD, allergic rhinitis, obesity, and depression can all worsen asthma control.
• Vaccination:
  • Ensure annual flu and pneumococcal vaccinations are up to date.
• Allergen Immunotherapy:
  • For patients with confirmed allergic asthma not responding to standard therapy.
• Biologic Therapies in Severe Asthma:
  • Omalizumab (anti-IgE), mepolizumab and benralizumab (anti-IL5), and dupilumab (anti-IL4/IL13) are revolutionizing treatment for eosinophilic and allergic asthma types.

Patient Education as a Life-Saving Strategy

• Red Flags Training:
  • Teach patients and families to spot worsening signs and act early.
• Proper Use of Rescue vs. Maintenance Inhalers:
  • Many patients misuse their medications. Reinforce this with visual aids and teach-backs.
• Mental Health Component:
  • Anxiety during or after asthma attacks can lead to hyperventilation and worsen symptoms. Address this during follow-up.
• Asthma in Pediatrics:
  • Ensure school personnel are educated about asthma management. Children should have a rescue inhaler available at all times.

Asthma and Exercise: Special Considerations

• Exercise-Induced Bronchoconstriction (EIB):
  • Use SABA 15–30 minutes before exercise or consider leukotriene receptor antagonists for long-term prevention.
• Build Physical Endurance:
  • With control achieved, encourage regular physical activity to enhance lung function and reduce attack frequency.

When the Usual Isn’t Working: Refractory and Fatal Asthma

• Difficult-to-Treat vs. Severe Asthma:
  • Rule out poor adherence, incorrect diagnosis (e.g., vocal cord dysfunction), and poor inhaler technique before labeling asthma as severe.
• Status Asthmaticus:
  • This is an emergency. It’s defined as a life-threatening asthma attack unresponsive to standard therapies and requires ICU-level care.
• Asthma Death Review:
  • Every asthma-related death should be investigated to learn systemic flaws—be it in access, communication, or under-treatment.

Asthma in Special Populations

• Pregnant Women:
  • Poorly controlled asthma poses greater risk to the fetus than medications. ICS is safe; educate OB-GYNs too.
• Elderly Patients:
  • Often underdiagnosed or mistaken for COPD. Be mindful of comorbidities and polypharmacy interactions.
• Occupational Asthma:
  • Encourage detailed history taking for work-related triggers—this is under-recognized and under-reported.

Tech and Apps: Enhancing Asthma Management

• Digital Inhaler Trackers:
  • These sync with apps to monitor adherence and provide alerts for missed doses or excessive rescue inhaler use.
• Telemedicine:
  • Especially valuable for follow-ups, technique checks, and remote monitoring during post-attack stabilization.

The Role of Multidisciplinary Teams

• Involve Respiratory Therapists: For nebulization, spirometry, and patient education.
• Pharmacists: Crucial for checking drug interactions, refills, and counseling.
• Psychologists or Counselors: Address anxiety, PTSD post-attack, and adherence issues in chronic disease settings.

Future Directions in Asthma Care

• Genotyping for Personalized Therapy:
  • Research is ongoing to match biologics with gene profiles.
• Biomarkers for Predicting Attacks:
  • FeNO, periostin, and blood eosinophils are gaining traction in predicting severity.
• Asthma and Air Quality Monitoring:
  • Real-time air pollution data integrated into asthma apps is being tested in urban populations.
• Patient Portals and AI Monitoring:
  • Future includes predictive algorithms for exacerbation risk and automatic alerts to patients and physicians.