I can recall the image instantly: It was the early 1970s when the typical prescription for patients with shortness of breath (SOB) was immediate dosing of Intermittent Positive Pressure Breathing (IPPB) with the all-powerful solution of 0.5cc Isoproterenol along with a 4cc dose of saline, in conjunction with a heaping helping of prednisone.
It worked very well, as long as the patient's pulse did not exceed a margin of safety. One had to be careful not to set off a cardiac emergency while reversing the bronchospasm. But how sweet it was to see a person respond so well to chemicals within moments - to see them come back from the horror of breathlessness and be well again. It was one of the joys of being a clinician - the feeling of being a true instrument of humanity - in the early days of COPD's 'pink puffers' and 'blue bloaters'.
Today, we still use bronchodilators, corticosteroids and more. The bronchodilators have surely changed for the better, advancing from the primitive, hyper-side-affecting adrenergics like Bronchosol and Isuprel. But there remain many key variables in what an emergency room asthma scenario can be, and the most important one is the condition of the patient before entering, including their own understanding of the asthma disorder and its management.
Causation of the emergency (referring to a state of severe dyspnea due to bronchconstriction) can vary from a relatively mild allergic reaction to anaphylaxis with symptoms beyond wheezing to include rash, vomiting and unconsciousness. These are the more difficult cases, especially when a patient is not verbally responsive, and the family is unaware of what the condition is or what to do about it.
It is then that the clinician must use investigative means to rule out a variety of mimicking issues that could waste precious time. All of this can be avoided if the asthmatic is proactively discovered and, along with their relatives and friends, educated about the causes and treatment of the condition before it escalates.
Some basics include symptom evaluation, knowing one's personal best peak flow meter reading, having a list of asthma triggers and previous asthma symptoms, and knowing the names and doses of medications currently used by the patient. These things are essential to avoid complications while treating even what may appear to be a textbook case of asthma.
Otherwise, there can be roadblocks during treatment that are truly unexpected and sometimes serious. These include overmedicating the patient or failing to discover the true source of the emergency. Both can inhibit a positive outcome.
A typical asthma emergency requires investigation followed by actions quite similar to those taken even far back in the 1970s, with systemic cortisone and bronchodilators being the foundation for reversal. With these actions, a case of asthma-driven SOB can disappear in moments - but the real expertise is in the policy of educating the patient about their disorder so that emergencies are reduced or even eliminated.
This should be the responsibility of every clinician who deals with such common diseases as asthma. The real difference between now and the 1970s is the idea of an "action plan" for patients who have a recurring disorder like asthma. This plan has the patient aware of his or her own peak flow, of proper medication use (perhaps, as an example, the use of a 'spacer' with inhaled meds) and the avoidance of triggers.
Our goal is tuning a keen sense to detect advancing symptoms before they get out of hand. Otherwise we are made to use up time investigating more than we should have to.
Once these have failed, or if an action plan is absent, the ER is certainly the place to be, and the clinician then has the opportunity to use stronger meds, skills and techniques - things that the patient doesn't have at their disposal at home or even the doctor's office.
Every good medical professional knows the basics of treating asthma. Therefore, when the dust clears, it is 'communication' that is truly key - not only to prevention but to virtually all life-saving emergency treatment measures for asthma in the modern emergency room.
Daniel Fardella, RRT, PhD, has been a writer and filmmaker in addition to practicing as a respiratory therapist.