Asthma is chronic disease that results from inflammation of the airways. Patients with asthma may experience air trapping within the lungs making exhalation difficult. Although there is no cure for asthma, avoidance of triggers and treatment of acute attacks and prevention of new attacks are the mainstays of treatment.
Symptoms of an acute asthma attack include shortness of breath, wheezing, coughing, chest tightness, and increased production of sputum. It is common to have difficulty expelling air from the lungs.
The causes of asthma are complex and not completely understood. There appear to be genetic factors as well as environmental factors. Both outdoor pollution and poor indoor air quality have been linked to asthma. Exposure to dust, pet dander, mold, cockroaches, various chemicals, and cigarette smoke are known risk factors. Some patients with mild asthma may only experience attacks during colds and other upper respiratory infections.
Relief of airway spasm is usually the first step in treating an asthma attack. A class of drugs called beta-agonists are very effective in relaxing smooth muscle within the airways. Albuterol is the most widely-known beta-agonist and it is delivered by metered dose inhalers (MDIs) or by nebulization through a mask. When treatment at home with these medications are ineffective, it is important to seek medical treatment right away. Severe asthma attacks can be fatal. The doses of Albuterol we can use in the emergency department require careful monitoring of the patient as rapid heart rates and abnormal heart rhythms can be side effects of high doses.
Steroids are used to treat inflammation. Inflammation of the airways is a key feature of asthma. Steroids are often given to patients, particularly with moderate to severe attacks. They don’t work immediately however and work best for long term prevention of asthma attacks. Steroids can be delivered by nebulization (face mask), as pills, or injection.
Anticholinergic agents dry up secretions and prevent additional mucous production. Ipratropium bromide (also known as Atrovent) is the most common medication used in this class. Atrovent is typically combined with the first few breathing treatments.
This class of drugs interfere with an enzyme that is involved in bronchospasm (tightening of the airways), mucous production, inflammation, and vascular permeability (leaky blood vessels). Singulair and Accolate are examples of this type of medication. They are generally not helpful for acute attacks but they are helpful in reducing symptoms are severity of future attacks. They may be more useful for patients with certain underlying causes of asthma.
There are many other treatments for asthma which include long-acting beta-agonists as well as combination drugs such as Advair. These drugs potentially pose more risk and their use is considered carefully.
The mineral magnesium is also useful in treating patients with severe asthma attacks as it can contribute to smooth muscle relaxation. We also can provide life-saving machines that can support breathing during severe attacks.
The severity of asthma as an illness can be graded based on the frequency of attacks and the impairment in lung function. Asthma can be generally divided into intermittent and persistent. Persistent asthma is subdivided into mild, moderate, and severe.
Patients with intermittent asthma have no more than two episodes of asthma flare-ups within a week and no more than two nighttime episodes of asthma within a month. Between episodes, patients are entirely asymptomatic (free of symptoms).
Patients with mild persistent asthma have more than two episodes of asthma flare-ups within a week but fewer than daily episodes. Regular activity may be affected but lung function is typically better than 80% of expected.
Patients with moderate persistent asthma typically have daily episodes of asthma plus frequent sleep disruption but night time flare-ups occur no more than once a week. Lung function is typically between 60-80% of expected without treatment.
Patients with severe persistent asthma have symptoms daily and frequently. Normal activities are limited and lung function is typically below 60%.
Asthma emergencies needs immediate treatment. There are few sensations as terrifying and potentially dangerous as being unable to breathe. We maintain zero wait times for patients and our Emergency Medicine Residency-Trained Physicians are well-trained in the management of asthma.