Dr. Simone French
, Contributor
THE NEED for urgent care during an acute attack of asthma is
highlighted by the fact that the
majority of deaths from acute asthma
in Jamaica occurs before the person
reaches medical attention.
Asthma is a condition characterised by reversible narrowing of the airways on a background of inflammation. This disorder affects 150 million persons worldwide. Acute attacks require prompt treatment if hospitalisation and death are to be avoided.
The symptoms of asthma include shortness of breath, wheezing, tightness in the chest and cough. At first sign of these symptoms, the asthmatic patient should immediately begin treatment by using an inhaler. If symptoms are not significantly improved after 20-30 minutes, the patient should repeat the
medication and seek medical attention.
Often when the attack occurs, the patient does not have any medication with them. In this situation it is best to seek treatment immediately at a healthcare facility. An impending asthma attack can be detected prior to the onset of overt symptoms by a decrease in the peak expiratory flow rate (PEFR) measurements in motivated patients who have peak flow meters and use them appropriately. This allows early initiation of therapy at home and averts severe attacks and hospitalisation.
Emergency treatment of asthma includes use of bronchodilators, corticosteroids, oxygen and reassessment to determine whether the patient is improving or deteriorating. Bronchodilators are medications that open the airway and make breathing easier. They are called reliever medications as they allow the patient to breathe more easily. During an emergency, they are often given via a nebuliser. This machine delivers the medication as a fine mist that is inhaled by the patient. They are also found in various types of inhalers.
STEROID USE
Most persons require steroids during an acute attack. These agents do not relieve acute airway narrowing but break the underlying cycle of inflammation that causes wheezing. In so doing, they prevent the narrowing that results from inflammation and thus are generally called controller medications. Taken alone they will not abort an acute asthmatic attack but are important in preventing recurrence of symptoms.
Steroids may be given orally, intravenously or via the nebuliser during the attack. They may be continued for one to two weeks at the discretion of the physician. Persons with very frequent attacks may require a longer period of steroid therapy. There are other non-steroidal controller medications such as leukotriene antagonists that may be prescribed.
Because the disease is characterised by intermittent exacerbations it is often viewed as episodic. This approach results in poor control during wheeze- free periods. Many asthmatics have persistent cough, chest tightness and sleep disturbance indicating sub-optimal control and persistent airway narrowing. Left alone these persons over time develop permanent lung damage. It is important therefore, that asthmatic patients be followed up in their wheeze-free periods to determine whether there is sub-clinical airway narrowing and inflammation. This requires partnership with a family physician who can assess the pattern of disease and the triggers.
Common triggers include pet fur, cockroach and mite particles, smoke, upper respiratory tract infections and sinusitis. The physician will alter treatment regimes with the goal of achieving minimal or no symptoms. Certainly, with the newer long-acting reliever and controller medications, many patients can be educated to eliminate the need for emergency room visits.
COMMON MISTAKES MADE BY
ASTHMA PATIENTS
Waiting too long to seek medical attention. This is dangerous as the
likelihood of hospitalisation or death increases.
No medication available at the time of attack. Patient may run out of medication or leave them at home. Asthmatics should have their medication with them at all times even if the last attack was some time ago.
Poor inhaler technique. This reduces effectiveness of the medication, as it does not reach the lungs in sufficient concentration to have optimal therapeutic effect. This can be addressed through use of a spacer device or newer delivery systems for medications.
Using controller medication, that is, steroids, only during an acute attack. While these medications are important to suppress inflammation they will not open the airways and improve breathing during an acute attack of asthma.
Failing to visit a family doctor
after the attack. Follow up visits are important. This allows for reassessment including peak flow measurements to determine response to treatment and
pattern of attacks. The doctor can then assist the patient in charting a treatment plan that is geared to minimising or eliminating acute attacks.
Dr. Simone French, Consultant Emergency Physician, Emercare Medical Centre.
