Asthma: A Growing Problem
Sidney Braman, MD, Master FCCP: Hello. My name is Dr Sidney Braman, a professor of medicine at the Icahn School of Medicine and director of the Pulmonary Disease Management Program at Mount Sinai Hospital in New York City. I am joined today by Dr Navitha Ramesh, clinical assistant professor of medicine at Geisinger Commonwealth School of Medicine in Scranton, Pennsylvania.
We are speaking to you today as part of a collaboration between Medscape and CHEST. We will be talking about the issues that arise when adult and pediatric patients with moderate-to-severe asthma are treated in the emergency room and the urgent care setting.
This is a big problem, as you and I both know. There are a staggering 20 million adults and 6 million children with asthma; about 8% of the US population has asthma. This is a disease that in most instances can be controlled, but sadly enough, it results in approximately 3600 annual deaths, including about 250 deaths in children, according to a 2015 report from the Centers for Disease Control and Prevention. The number of visits to our emergency departments or urgent care centers for acute asthma is also staggering, accounting for 1.7 million visits per year.
There are several groups who are at high risk of requiring treatment in these settings. Women have higher rates of asthma, more severe asthma, and more emergency department visits than the general adult population. Children also have more asthma than adults. Lower socioeconomic groups are more likely to show up in the emergency department with their asthma. Where I practice, in New York City, the Puerto Rican population has been known to have a very high prevalence of asthma as well as severe asthma attacks. Those who use illicit drugs, who have other comorbidities like chronic obstructive pulmonary disease (COPD), and who have psychiatric illness are also at higher risk.
Even though we're talking today about moderate and severe asthmatics, one other important point to note is that a study has shown that even mild, intermittent asthmatics can have a severe life-threatening event and even mortality. This can occur despite their having been stable for a while and only requires the wrong exposure.
These are some of the statistics that I think are important to consider as we begin to explore the treatment of asthma in the emergency department. But to begin, what do you tell your patients regarding the warning signs that they may need to get to the emergency department?
When Is It an Emergency?
Navitha Ramesh, MD: I agree with everything that you said. Asthma is a growing problem in all age groups.
Asthma control begins in the outpatient setting by educating the patient, equipping them with enough information as to how they can control their disease, and giving each patient an asthma action plan for what they should be doing in a given situation.
The asthma action plan consists of three zones: green, yellow, and red. Once the patient hits the red zone, they should become aware that this may require their going to the emergency room. I instruct my patients to continue to use their other inhalers as before, and to use albuterol as a short-acting beta agonist every 2-4 hours. If they have used it [albuterol] at least three times and are not feeling better, that is the time to seek medical help. Some patients are already equipped to start oral steroids (prednisone) on their own. However, if they feel like all of these measures are not helping them, that they are subjectively not feeling better, then you should instruct them to go to the emergency room.
Braman: If you are an emergency room physician and a patient presents with a severe asthma attack, I think there are two things to consider. First, you should ask what part of this patient's history identifies them as being at high risk for mortality. Second, ask what it is you see in them during examination that also tells you that they may be at high risk for intubation and perhaps even mortality.
Ramesh: For emergency room physicians, it is good to know the background of the patient to increase your pre-test probability. Did this patient ever get intubated? Were they ever in the intensive care unit (ICU)? Have they had at least two asthma exacerbations needing hospitalization in the past year? Have they had at least three emergency room visits in the past year? Are they using so much short-acting beta agonist that they are finishing at least two canisters a month? All of these are indications that maybe this patient is sicker than we originally thought.
When you examine the patient, I do not think any lab work or x-ray or any other imaging studies would be helpful in an asthmatic exacerbation.
Instead, the important thing is to look closely for any signs of sickness. How does the patient look? Are they tripoding? Are they awake and alert? Are they conversing with you? Are they altered? Do they look fatigued? Are they using the accessory muscles? Is there any intercostal retraction? When you listen to the chest, are they moving any air at all or is it silent? The answers to these questions will give us quick indications as to whether they are very sick.
Braman: There was a while where I was noticing that peak flow meters were being used frequently in the emergency department. Now, for some reason, it seems as if physicians have gotten away from this practice, despite it being such an easy thing to do.
We know that if you are dealing with extremely low peak flow rates, for example below 40 L/min, the patient is in dire need of severe emergency attention and observation. Below 25 L/min, it is likely that the patient is going to need intervention with intubation and mechanical ventilation.
The other thing that is valuable to follow is if there is an improvement over time in the patient's peak flow rate. It is also good to know what the patient's personal best peak flow rate is, if that is something they can remember, in order to know what target you are aiming for. Peak flow meters are not used enough. It is an important lesson, because it is such an easy thing to perform and measure in patients, and it can be very helpful.
Ramesh: Using both together is important—frequently assessing their clinical features after you have given the appropriate treatment in addition to the peak flow. It is about putting everything together rather than just depending on the peak flow numbers.
Braman: After you have evaluated the patient and found them to be in need of some quick emergency treatments, what would you say is the standard treatment you should pursue?
Ramesh: There are three main things to consider. First, are they [hypoxemic]? Are they maintaining a saturation level over 90%? If not, I would first give them oxygen. Second, you would give them albuterol, a short-acting beta-2 agonist. Third, if it is a severe exacerbation, I usually like to give a continuous albuterol nebulization for at least 1 hour and also systemic steroids. At least one dose of IV [methylprednisolone] would be my first choice.
Braman: I think most emergency departments are now using a combination of albuterol, the short-acting beta-2 agonist, as well as a short-acting anticholinergic, ipratropium. After reviewing some of the studies, there is good evidence suggesting that this approach does improve outcomes and can even avoid hospitalization, though this is not the case with all studies. The widespread use of this treatment suggests that it may work but also that it is a very safe approach for the patient.
Speaking of safe approaches, one of the safest things we can do is give magnesium sulfate, [a smooth muscle relaxant that acts by blocking calcium ion influx to the smooth muscles]. What is the bottom line on magnesium sulfate, in your mind?
Ramesh: Magnesium sulfate is controversial because we do not have strong evidence for that. However, if I have a patient for whom I have done all the right things—given them oxygen, bronchodilator, systemic steroids—and yet they fail to improve or continue to be tight or bronchospastic, I usually give magnesium sulfate at 2 g over 20 minutes.
Braman: The aim is to do no harm, and magnesium sulfate does no harm. It might bronchodilate and release the smooth muscle spasms. As you said, it is something to consider moving to once you've done everything else and patient is still not improving.
Another thing that has increased in usage, again without very much evidence supporting it, is high-flow nasal oxygen. I know that the studies suggest that patients feel better using it and have fewer symptoms, but what about the outcomes?
Ramesh: We do not have strong evidence there, as you mentioned, but subjectively the patient feels better and the work of breathing improves with the flow. I usually give it in a patient who is awake and alert and who I do not think needs intubation.
Braman: Speaking of intubation, what about that pre-intubation, noninvasive positive-pressure ventilation? Here, too, if you look at national statistics, its use is widespread across the country. What about the evidence?
Ramesh: The evidence there is not great. We do have enough evidence to support noninvasive ventilation for exacerbations of COPD or congestive heart failure, or maybe for pneumonia in an immunocompromised patient. The evidence is not as strong for asthma exacerbations.[9,10,11] However, I have used it for short durations. Again, if the patient is awake and alert and you have done all of the above measures, you can give them noninvasive ventilation for about half an hour to an hour. But after that point, we have to make up our minds about whether we need to intubate this patient.
Braman: How do you make up your mind? What is the defining moment that says, "This patient is serious enough to get intubated"?
Ramesh: Any change in mental status would be a first sign for me. Once you perform an arterial blood gas test, as we do in the adult emergency rooms, if the pH is normalized or if the partial pressure of carbon dioxide is almost 40, that means the patient is fatigued. That would be a point where I would intubate. In asthma exacerbations, we do not actually wait for the patient to go into significant respiratory arrest before we do it. Instead, it is done in a semi-elective manner.
Braman: Heliox is another thing that has been used, though again the evidence is not so great. Do you use it?
Ramesh: Yes, we do use heliox, mostly in intubated patients. I am not in favor of doing so in patients who are not intubated. The concept behind this is that in asthma exacerbations, the airflow is turbulent in the airways, so using heliox may make the airflow get more laminar, perhaps allowing the medications to reach the small airways sooner. That is the thought behind it; but, like I said, I would not try it in nonintubated patients.
After the Exacerbation: What Next?
Braman: Once we have gotten the patient through the attack and they are stabilized, you are thinking about sending them home. At that point, we have to give them instructions to make sure that they do not have any return visits. This is obviously a teachable moment. How do we use it, and what can we offer the patient at the moment of discharge that might make a difference in the long term?
Ramesh: I completely agree with you that this is a teachable moment for patients. The first thing is to let them know that they had an asthma exacerbation that could have potentially been life-threatening. The second thing to do is give them asthma discharge instructions, provide oral corticosteroids to last them for at least 10 days, and make them an appointment with their primary care provider or pulmonologist.
The other thing we can do is help patients identify their triggers. Why do they think they had the asthma flare-up? Did they not take their medications? Were they exposed to something they are allergic to? Having them consider [their triggers] and then educating them to avoid these triggers is important.
Another thing I would like for emergency physicians to do more is to start patients on inhaled corticosteroids if they are not already on them. If they have asthma and they are not on inhaled corticosteroids and they are coming to the emergency room with an exacerbation, this is a good time to start them.
Braman: I totally agree. Even among patients who are on inhaled corticosteroids, often with something like a long-acting beta agonist, many may start to feel better and decide to stop their medicine. It is important that we use this as a teachable moment to make them understand that asthma inflammation persists, even though they are feeling better.
Speaking of feeling better, a group I also want to mention for special consideration is the elderly. There is now a study showing that elderly patients with asthma may not perceive the shortness of breath as well as younger individuals. I recently had a patient who was home all day with extreme symptoms, and when their family returned home from work that evening and asked what was wrong, the patient responded, "Oh, I don't feel anything, I don't feel so bad." In such patients who are poor perceivers, we may want to promote the use of in-home peak flow meters.
Braman: We have covered a lot today about identifying high-risk patients, considering their history and how they present, treating them with both well-established treatment modalities and ones where the evidence may not be as strong, and closely following their response. We also discussed how important it is to turn this into a teachable moment. We need to get patients who are not taking inhaled corticosteroids onto this treatment as a bridge, as well as other medications, such as a long-acting muscarinic antagonist or a long-acting bronchodilator. We need to ensure that they follow up with their physician, which often may not occur for weeks. Also, get these patients to identify and eliminate precipitating triggers of exacerbation. If that boyfriend's or girlfriend's cat is causing your asthma to get worse, maybe it is time to avoid their apartment.
Thank you, Navitha. It has really been fun discussing this with you. Thank you also to the audience. We enjoyed being with you today.
On behalf of the collaboration between Medscape and CHEST, we thank you for listening.
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Cite this: Asthma Emergencies: A Guide to Treating Potentially Life-Threatening Exacerbations - Medscape - Nov 02, 2018.