Welcome to the St. Emlyn’s induction podcast, where we dive deep into the management of asthma in the emergency department. Asthma is a prevalent condition that emergency medical professionals encounter frequently. This blog post will provide a detailed step-by-step guide to managing patients presenting with asthma, including case presentation, assessment, treatment, and discharge planning. Whether you’re a seasoned practitioner or new to emergency medicine, this guide aims to enhance your understanding and improve patient outcomes.
Listening Time – 20:11
Introduction
Imagine you’re in the resuscitation room when you’re alerted about an incoming patient. A 30-year-old female with a history of acute severe asthma is being brought in. She’s a smoker, consuming 20 cigarettes a day, and has had a history of hospital admissions, including an ICU stay a few years ago. As she is wheeled in, you notice she is short of breath with audible wheezing. This initial presentation provides critical information for immediate action.
First Steps: Rapid Assessment and Initial Management
Upon the patient’s arrival, it’s crucial to make a rapid assessment. Conducting an ABC (Airway, Breathing, Circulation) assessment is essential to confirm the diagnosis and gauge the severity of the asthma attack. Given the patient’s severe condition, it’s vital to start treatment immediately while continuing your assessment.
Immediate Actions
- High-Flow Oxygen: Administer high-flow oxygen to improve oxygen saturation levels.
- Nebulizers: Start with 5 mg of salbutamol and 500 mcg of ipratropium bromide. Don’t hesitate to administer another dose if needed.
- Listen to the Chest: A quick auscultation of the chest can help confirm the presence of wheezes and rule out other conditions like tension pneumothorax.
Understanding the Severity of Asthma
Assessing the severity of asthma is critical to guiding further treatment. The British Thoracic Society provides guidelines that classify asthma into mild, moderate, acute severe, and life-threatening categories.
Criteria for Severity
- Mild Asthma: Patients might experience mild dyspnea but can generally manage with minimal intervention.
- Moderate Asthma: Characterized by a peak flow more than 50% of predicted or best, moderate symptoms, and manageable at home with proper medication.
- Acute Severe Asthma: Marked by a peak flow below 50%, respiratory rate over 25, heart rate over 110, or an inability to complete sentences.
- Life-Threatening Asthma: Includes a peak flow less than 33%, low oxygen saturation below 92%, silent chest on auscultation, cyanosis, and signs of exhaustion.
Continuous Management: Treating Severe Asthma
In cases of severe or life-threatening asthma, continuous management and close monitoring are paramount.
Back-to-Back Nebulizers
Administering nebulizers continuously can help manage severe bronchoconstriction. Use salbutamol and ipratropium bromide back-to-back to provide relief.
Steroid Administration
Steroids play a crucial role in managing asthma by reducing inflammation. Administer oral steroids (1-2 mg/kg of prednisolone) or intravenous steroids if oral administration is not feasible.
Intravenous Bronchodilators
Consider intravenous bronchodilators like salbutamol if nebulized drugs are ineffective. Prepare IV salbutamol early to ensure it’s available when needed.
Magnesium Sulphate
Magnesium sulfate can be considered in severe cases. Although recent studies suggest it might not significantly impact, it is relatively safe and may benefit a small subgroup of patients.
Advanced Interventions: When Initial Treatments Fail
If the patient’s condition does not improve with initial treatments, advanced interventions may be necessary.
Critical Care Consultation
Engage with critical care colleagues early if the patient requires intensive care or ventilation. Ventilating an asthmatic patient is complex and requires experienced personnel.
Additional Therapies
- Ketamine Infusion: Ketamine can act as a bronchodilator and is used in managing severe asthma.
- CPAP: Continuous Positive Airway Pressure (CPAP) can be used in cases of severe air trapping and respiratory distress.
Importance of Senior Support
It’s vital for less experienced doctors to seek senior help when managing severe asthma cases. These patients require the most experienced care available.
Discharge Planning: Ensuring Safe Transition
For patients showing improvement, careful discharge planning is essential to prevent relapse and ensure ongoing management.
Criteria for Discharge
- Stability: Ensure the patient is stable for at least 6-8 hours after initial treatment.
- Follow-Up: Arrange follow-up with a general practitioner or asthma nurse within a few days.
- Medication Review: Ensure the patient has access to their inhalers and understands their use.
- Safety Netting: Advise the patient to return if symptoms worsen, even if they are already on their way home.
Safety Measures
Natalie May from St. Emlyn’s emphasizes the importance of advising patients to return if they have any concerns, even after leaving the hospital. Ensuring patients have their therapy and understand their treatment plan is crucial for safe discharge.
Conclusion: Recap and Key Takeaways
In summary, managing asthma in the emergency department requires a systematic approach:
- Rapid Assessment: Quickly assess the severity using ABC and confirm the diagnosis.
- Immediate Treatment: Administer high-flow oxygen and nebulizers without delay.
- Continuous Management: Use back-to-back nebulizers, steroids, and consider IV bronchodilators and magnesium sulphate.
- Advanced Interventions: Engage critical care and consider additional therapies like ketamine and CPAP.
- Discharge Planning: Ensure the patient is stable, arrange follow-up, review medications, and provide safety netting advice.
Asthma management in emergency settings is challenging but manageable with the right approach and timely interventions. Always prioritize the patient’s safety and seek senior support when needed.
Podcast Transcription
Welcome to the St. Emlyn’s induction podcast. I’m Iain Beardsell and I’m Simon Carley. We’d like to talk to you today about a very common presentation to the emergency department: the shortness of breath patient who presents with asthma. This will be a case you’ll see quite often. We’ll start with a case presentation and go step by step through the management of that patient, focusing on key things in their history, examination, and further planning for their inpatient or outpatient care or their discharge.
Simon, you’re in the resuscitation room, and we’ve got a patient who’s just been alerted. They’re coming into the hospital. It’s a 30-year-old female with a history of acute severe asthma, and she’s suddenly short of breath this morning. Very little else in the history; all you know is that she’s a 20-a-day smoker and in the past, she’s had to stay in the hospital, even having an ITU admission once a couple of years ago. She’s wheeled into the resuscitation room, puffing away in front of you, short of breath, with audible wheeze. What’s your first step?
Well, I think there’s quite a lot of information you’ve given us there already, which we need to take heed of. The ambulance crews have alerted us to this patient, so they’ve got a concern about what’s going on, and we need to take those concerns very seriously. If they’re worried, we should be worried too. She’s 30, with a known history of asthma, which helps if the patient comes with a bit of a diagnosis beforehand, but we need to keep in mind that it might be something else. She’s a smoker, which might help precipitate an attack and is probably not very good for her, but it’s very unlikely that she’s got anything like COPD at the age of 30. The fact that she’s short of breath as you see her come into the resuscitation room and that you can hear the wheeze as she’s being wheeled in makes me think that this is an asthma attack, potentially towards the more severe end of the spectrum. We need to take this girl seriously.
So, we’ve highlighted that this girl is poorly; she’s ill. What’s first? Are you going to stand next to her and take a nice comprehensive history, asking her about her previous exacerbations and whether she’s got any pets, that sort of business?
I think that information will be useful, but we can get to it later. If somebody’s got severe asthma, you need to make a rapid assessment. It’s really an ABC assessment as we do in many other conditions, but you need to get a good idea of whether this is asthma to confirm your diagnosis and then get an idea of how severe it is because that’s going to guide your next stages of management.
And do you do that while treating the patient?
I’m a big fan of cracking on and giving patients things that I think are going to make them better. In this case, when we’ve got a good diagnosis and the paramedics have started therapy, as we’re transferring this patient from the ambulance trolley onto the ED trolley, if we’ve not already set up to do it, we should be continuing the management that the paramedics have done. That would initially include getting them onto high-flow oxygen and continuing their nebulizers if they’ve already been given or starting nebulizers if it hasn’t been done yet. You might want to have a quick listen to the chest to confirm your diagnosis and make sure you’re not missing something bizarre like a tension pneumothorax. If you see the patient, they look like an asthmatic, they sound like an asthmatic, you have a listen to the chest, they’ve got masses of wheeze on both sides, which is the sort of picture you’re painting for me. I think get on with some oxygen and nebulizers while you continue your assessment.
So we’re going to treat as we find out information. So nebulizers—what nebulizers particularly and doses are we going to try and give this young lady?
In the initial stages, I go for five milligrams of salbutamol and 500 micrograms of ipratropium, and I don’t really worry if they’ve just had one five minutes before. I’m making a clinical assessment that that patient is still having problems, and therefore I just crack on and give another one while we’re continuing our assessment.
And for the pharmacology geeks out there—and we’ve all got a bit of geekiness—just remind us how each of those works.
Salbutamol, which is a beta-2 agonist, is going to influence the airways, relax the smooth muscle in the airways, and hopefully increase ventilation and subsequently gas transfer. Ipratropium is slightly different; it acts on the muscarinic acetylcholine receptors, blocking them, and again should produce some bronchodilation. The key thing with both of those, of course, is that they’re acting on the muscle, so you get a degree of bronchodilation, but that’s not the full story in asthma. You have bronchospasm, but you also have mucus production and secretions in the airways, and these drugs may not have quite the effect on those elements as you would hope.
And that will bring us on to other treatments we’re going to need, but that’s the key point for asthma that I think is important to remember. This is about getting the air, the oxygen from the outside world, and transporting it to the alveoli where it can be transferred across into the bloodstream. This is a problem of gas transport. There will be that mucusy stuff in the lungs, and that may a little bit affect the gas transfer further down, but what we’re trying to do is increase the amount of gas that can go from the outside world to the alveoli where it’s needed.
So we’re going to give some nebulizers: salbutamol, ipratropium, excellent. From the high-flow oxygen, trying to get those sats up as high as we can. Any other treatments you want to give straight away?
I think at this stage, I probably wouldn’t treat any further now, but I would make my assessment to get an idea of the severity, get some numbers to look at, and get a feel for where we’re going to go with this patient.
So the nebulizers are up and going. What criteria should we use to judge whether this is a severe or life-threatening episode of asthma?
Well, there are a number of things you can use, and things like the British Thoracic Society have some good guidelines you can look at. They’ve got a number of criteria, but you should have something in your department which gives you some degree of objectivity about asthma severity assessment. There are features that would be consistent with mild attacks, so just some mild dyspnea. By “chest is getting a bit tight,” and then there’s a grading level going through moderate symptoms, acute severe symptoms, and then life-threatening symptoms. Looking at their peak flow, I’m sure you’re familiar with taking peak flows: blow into the tube, see how far she can go. People who’ve got a peak flow more than 50%, so 75% of their predicted or best, would be in the moderate category. You’re still going to have to treat them, watch them for a bit, but they’re not really going to give you massive anxieties there and then. Moving up, you’ve got acute severe asthma, so they’ve got a much lower level of peak flow, below 50%, high respiratory rates over 25, high heart rates over 110, or inability to complete a sentence in one breath because it depends on the length of the sentence. Beyond that, you’ve got the life-threatening ones, which are the ones that I’m really interested in, the ones that give me anxiety because asthma still kills. It’s been around for ages, we’ve got good therapies, but we’re still getting asthma deaths and we need to concentrate on this group. The sick ones have really low peak flows. When I say really low, the guidelines often say things like less than 33%, but in my experience, these people usually can’t do a peak flow and it’s not a great idea. If they’ve got low sats, below 92%, if you take a blood gas and their PO2 is less than 8, if they’ve got normal or high CO2s, if the chest is silent, if they’re cyanosed, if they’re not breathing well, if they’ve got associated features like hypotension or a dysrhythmia, if they’re exhausted, tired, look as if they’re getting exhausted in front of you. That’s a group of patients you have to take extremely seriously and treat aggressively.
All of those criteria are really important, but if we pull them together, the end of a bedogram, when you look at the patient, they look really sick. That’s the point at which you can almost come away from worrying about all these numbers. You don’t need to memorize them, you don’t need to go to a computer, you don’t need to go to an app to find out if this is acute or life-threatening. They look sick. Ask a non-medical friend, “Does this person look ill?” and they will say yes. This is the point at which we need some help. As Simon says, we still have young people dying of asthma and we’ve got to do everything we can to stop this. So you’re going to get your therapy on, you’ve got your nebulizers going, and if they’re in that life-threatening group, you call for help. Now in my hospital, that would be the consultant in emergency medicine, in many places that would be the case. But if you’re overnight and don’t have that support, get yourself a senior to come and help you in the resuscitation room because early intervention may well help save this person’s life.
So we’ve got this sick person in front of us, Simon. We’ve given some nebulizers, there’s a little bit of an improvement. You’ve taken a bit more of a history, you found out that in the past they have recurrent episodes, maybe six episodes a year, they often have to come to hospital, and they’ve been to intensive care at least once in the past. What are you going to be doing now? Continue with the nebulizers, other therapies you want to consider?
Certainly. The nebulizers, I think, in a patient who’s severely unwell, just back-to-back them, continuously nebulize them all the time. You don’t have to go back to giving one salbutamol nebulizer every four hours; that’s a very bad idea. Continuously nebulize. There are a number of other therapies out there, which I’m sure people will be familiar with. The first being steroids. Everybody knows that you give steroids for asthma, but there’s a real question about when you give them and how quickly they work because they’re going to try and turn the whole mechanism off. They’re going to reduce the inflammatory process, but they’re not necessarily something which is going to make your patient better in the next half an hour, which is really your focus in resuscitation. So, yes, sure, get the steroids in. Give oral steroids—oral steroids are fantastic unless there’s any reason why they can’t take oral. Give oral steroids 1-2 mg per kg for something like prednisolone, but it’s not a high priority. Your high priority is managing the ventilation, the airflow in and out. What else can you do for that? We’ve got our inhaled bronchodilators, and in my experience, we often find people struggling with the decision about when to start intravenous bronchodilators. So, salbutamol, and I suppose we’re going to have to mention aminophylline—people still use that. When do you start considering giving IV salbutamol?
Well, I think what you have to think about is that a nebulised drug has to get to the point of action, so it has to be able to get to the area where it needs to be working. If you’re at that life-threatening stage, all of those parameters you mentioned are really indicators that the gas, whether that’s the oxygen you’re giving or the air from the outside world or your nebulizer, are not getting to where they need to be. So, if your sats are falling, if there’s a silent chest, if there’s no gas transport at all, then the drug simply can’t work. It’s not going to be effective, and that’s definitely the point where I’m thinking about IV therapy. Over the years, my threshold for starting intravenous therapy has gone down, and I now use it probably at an earlier stage in patients. Certainly, in the patients who come in with acute life-threatening features, I’ll consider and actually make up salbutamol as the patient’s arriving. I’ll ask my colleagues to make it up so that I know it’s there and can be used and started at any point.
So we’ve got intravenous bronchodilators. We use IV salbutamol. I know some people still use aminophylline; I’m not so keen on it, but the evidence for one versus the other isn’t fantastic. You will find different practices locally. The other one is magnesium. Magnesium is a really interesting one because it has come into asthma management over the last 10 years and is now extremely popular for acute severe and life-threatening asthma. But we’ve had a bit of a change over the last year with recent publications of trials which we’ve covered on St. Emlyn’s. So, magnesium in acute severe asthma—there was a nice trial, the 3MG trial, which demonstrated that, well, actually, maybe it didn’t make that much of a difference. With magnesium, I always come back, as I do, and mention the whole time, between the harm and benefit. Magnesium to me is a relatively benign drug when it comes to harm. I think there may be some benefit in a small subgroup of people, but it’s unlikely to cause the patient to get worse. So, I think about giving magnesium, but I don’t let it prioritize against the other things that I’m more keen on. If the choice was between giving back-to-back nebulizers or the need for intravenous bronchodilators versus having the nurse draw up the magnesium, I’m going to go for those bronchodilators first. If everything else is done and we’re still not getting anywhere, then I might ask the nurse to draw up the magnesium, and we might give a bolus dose of magnesium. But it’s always that harm-benefit ratio that I’m trying to consider.
In the studies done last year, they excluded the acute life-threatening group anyway, so the data in that group we don’t know. Your point about how the human factors work here is essential. My concern is when I’ve been in the resuscitation room and somebody said, “Okay, probably time to give bronchodilators.” Let’s try the magnesium for half an hour, and if that doesn’t work, we’ll try the intravenous bronchodilators, the salbutamol. That to me seems a bit topsy-turvy on the basis of the current evidence. I don’t particularly object to people giving it, but it’s no longer my number one priority as a next stage in therapy after bronchodilators aren’t getting me where I need to go.
So we’ve got a patient that came in with acute severe asthma, perhaps towards the life-threatening end. We’ve given high-flow oxygen with nebulizers back-to-back, salbutamol and ipratropium. We thought about getting some steroids into the patient, and we’re going to do that whichever way we can whilst not interrupting that bronchodilator therapy. If things don’t seem to be improving, we’re going to think about intravenous bronchodilator therapy. I think our choice would be salbutamol. And again, if we get the chance whilst all those therapies are acting, magnesium may be of benefit. Now, if things aren’t improving, Simon, obviously, if you’re the doctor who’s just starting in emergency medicine, by now, you have somebody next to you who is helping you. You must call for help. What is going to be the next stage? What are they going to be suggesting if things still aren’t getting better?
I think at this stage you would want to have a conversation with your critical care colleagues because this patient is either going to HDU or ICU. They may or may not need ventilation. Ventilating the asthmatic patient is tiger country in medicine. It’s dangerous, difficult, and you need experienced anesthesia and critical care support to do that. It can be a life-ending event, so it’s really, really tricky. There are a number of other things at this stage which can be used, and the evidence is now getting smaller and smaller to support these ideas, but other things which people may talk to you about are things like ketamine infusion. Ketamine is a bronchodilator; it can be used to manage the very severe asthmatic. CPAP is being used paradoxically if you think about it with air trapping and asthma, but non-invasive ventilatory strategies are increasingly being used to manage these patients. But again, you would have to do that with significant critical care input if you don’t already have that within your emergency department.
The reason we mention these is not because we want you to be doing them, but to have an awareness of what your colleagues might be suggesting when your senior colleagues come in to help you in the resuscitation room. At no point are we suggesting that as a less experienced doctor in emergency medicine, you should be drawing up the ketamine and just seeing if it gets the patient better. You need senior help with these.
Now that’s the acute severe asthmatic or the life-threatening asthmatic patient who’s not getting any better. What about the patients, Simon, let’s go back a bit. You’ve given some nebulizers, and things are turning around. They’re improving a bit. They’re now able to talk in sentences. They tell you that they had the window open, they’ve been mowing the lawn all day, they know that’s not particularly good for them, and they’ve had a reaction and are keen to head home. How do we decide which of those patients who had a bad episode but are now getting better can be safely discharged, and who needs to stay in the hospital?
It’s a really good question because this is another area where you can accidentally head off down the wrong track. If you’ve had a patient come in who’s been so severe that you’ve identified them as either acute severe or life-threatening when they first arrive, even if they have a fantastic turnaround with your initial nebulizers, I would be extremely cautious about sending them home or allowing them to go home. I would like them to stay in the hospital long enough that I’m reasonably assured that the steroids I’ve given them are having an effect because our steroids are a mechanism to turn off the whole process. So for me, any patients in those groups I would keep for six to eight hours. Any patient who I’ve seen come through the door and thought, “This person needs an immediate nebulizer,” that’s a cognitive trigger to say, “Actually, you’re going to have a period of observation on our short stay ward.” I’d be cautious about giving significant interventions to patients and then letting them go home early if my initial impression was that they were quite sick.
These are high-stakes interventions. These are often young people. The time we need to invest to be sure and safe is worthwhile. So I’m always pushing that we keep an eye on these patients for longer. The need for a nebulizer doesn’t necessarily trigger hospital admission because you can never be quite sure who took that decision to give the nebulizer. But if you’re at the stage of needing nebulized therapy and you’ve ended up in the emergency department in the back of a blue-light ambulance, almost regardless of how quickly you turn around, this is not a patient in whom you’re chasing the target to get them out of your department in four hours. You are finding a spot where you can look after them and safely plan their discharge.
The British Thoracic Society also has some recommendations about other things we need to put in place for discharge planning. Be careful with these patients. They need to be well safety-netted. Natalie May, who works with us at St. Emlyn’s, always says to the patient, “Come back if you have any concerns. Even if you get to the car park and have concerns, come back.” That’s really good advice. You have the whole human factors type thing, but you also need to make sure the patients have their therapy, that they have access to their typical inhalers, that they know how to use their inhalers, that you’ve checked their technique, and that they have someone safe to go home with. Those are the sort of things you need to safety-net your patient around. Are there any other things that you do with your patients, Iain?
I guess the only other thing that I would think about recommending is a follow-up with a general practitioner or the asthma nurse in the next couple of days following their exacerbation. Just to reinforce those messages about appropriate inhaler use, whether they need to be on any further therapies, because there are some oral therapies, like Montelukast, the leukotriene antagonist, that sort of thing, which may be recommended if the patient is getting further exacerbations. Generally, especially in the UK, we’re looking for asthma to be managed in the community by our general practice colleagues and the specialist asthma nurses. So I’d always, if starting long-term therapy, want to do it in collaboration with those colleagues, not just on the back of that acute exacerbation on my own in the emergency department. We can be careful with these patients and look after them well.
So there we have it. We’ve talked a little bit about asthma. We’ve talked about how we believe we should manage these patients aggressively when they first come and then rounded off with a couple of little things we’re hoping to encourage you to weedle out of our emergency medicine practice so that they don’t need to happen anymore and give you some reasons for that. Let’s recap what we’ve talked about.
We’ve talked about recognizing the life-threatening or acute severe asthma episode. End of the bed, you’ll often know that, but we can use some objective measures with which the British Thoracic Society has eloquently put into their guideline. We’re going to give high-flow oxygen and plenty of nebulizers back-to-back. None of this “give it every four hours” business. Keep giving salbutamol, keep giving ipratropium. We’re going to think about getting some steroids into the patient. We’re going to use oral or IV, whichever is most appropriate for that patient at that time. Very early on, we’re going to think in the life-threatening and acute severe ones about whether they need intravenous bronchodilator therapy, probably salbutamol. We’ve mentioned a bit about magnesium. It probably won’t do any harm; it may do some benefit, but don’t let it get in the way of the other things you’re doing. And as we always say in our induction podcast, get somebody experienced alongside you. These are poorly patients, and they need the most experienced care available.
So that rounds off this induction podcast talking about asthma. Please go back and look at iTunes. There are plenty of other induction podcasts available on a wide range of topics, and we’ll keep bringing out more over the next few months. It’s been good to talk to you. Good luck with your emergency medicine, and as ever, take care.
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