An Asthma Attack is a Medical Emergency

Introduction

Public information on First Aid for Asthma should be widely available. An asthma attack is a medical emergency. It should be taken very seriously. Asthma attacks are also known as flare ups or exacerbations. When someone has an asthma attack, many people don’t know when or at what stage to call for emergency help. In the UK National review of asthma deaths (NRAD), nearly half of those who died had not called for or got help when they were dying.  

In the NRAD 45% of those who died did not get medical assistance

We will never know why those people did not get medical assistance when they were dying from an asthma attack. Clearly many had not been provided with an asthma self management plan. However, even some with a plan and still they did not call for help. I think it may have been because they were not clear when they should have called for help.

Personal asthma self management plans need improvement

Clear instructions on calling for emergency help not often included

Many plans do not clearly state when emergency assistance for someone having an asthma attack is needed. Personal asthma action plans (PAAPs) provide information on asthma. Including its medication, how to recognise danger signs and what to do in asthma flare ups. However, most plans include information on when to call for help. Listen to my podcast on emergency help for people with asthma and members of the public here also available on spotify and Apple Podcast platforms.

One size does not fit all – Asthma education should include details on

  • What asthma is and how it causes problems for you
  • What triggers (or sparks off your asthma attacks)
  • What is your treatment, how does work in simple terms, and when you should take it.
  • You need to know how to use your inhaler.
  • How do you know when your asthma is going out of control or flaring up.
  • What do you need to do when it does flare up and of course what medication to take.
  • You also need to know when to worry and when you need to call for medical assistance.
  • Most importantly you need to know when to call for emergency help.  

Therefore provision of asthma education to prevent flare ups needs expertise!

People with asthma need lots of information on their disease. For that reason training, expertise and sufficient time is needed for anyone delegated to teach patients. Expertise is needed to provide asthma self management plans for patients and parents of children with asthma. The tasks listed above do not all have to be provided by one individual. For example, inhaler technique could be taught by a pharmacist who has had training.

Different personal asthma plans should be tailored to individual needs

In the UK most general practice computer systems have only one template for personal asthma plans. As I have noted in this blog, ‘one size does not fit all’. One single ‘off the shelf’ template of a personal asthma management plan cannot contain all the information needed to manage every patient’s asthma. To put it another way, I think there should be a suite of different asthma plans each with a different purpose. Some examples of different plans are:

  • A general asthma self management plan for children or for adults and adolescents
  • A plan for Maintenance and Reliever Therapy (MART), see here for a description and an example.
  • A plan for ‘As Needed Anti-inflammatory Reliever (AIR) Therapy’, see example
  • A ‘Three step Asthma Plan’, see example

So there are many different types of asthma management plans!

A special plan – First AID for asthma flare ups

General training on first aid is widely available. In addition training in resuscitation is available in fact its compulsory for all health care professionals and key people in organisations. However, Asthma First AID training is not widely available for asthma – an asthma attack is a medical emergency. Its important to realise that asthma is the commonest chronic childhood disease and affects about 7% of adults. Asthma attacks could and do happen in public places. It follows that First Aid Training for managing asthma should be compulsory for organisations, schools and public recreation facilities.

Examples of Asthma FIRST AID posters and plans:

Some examples of First Aid for Asthma are shown below. Easily accessible information is needed to enable a member of the public to assist them. Specific features needed in an Asthma First AID plan- the australian one is an excellent example

  • National Asthma Council Australia, link here. There is one for adults and adolescents, and one for children under 12. The under 12 one includes use of a spacer with and without a mask.

An example of an Asthma First Aid Plan for children which includes use of a spacer with and without a mask

Reproduced with permission from the (c) National Asthma Council Australia. https://www.nationalasthma.org.au/asthma-first-aid accessed 5th September 2023

An example of First Aid information for members of the public to assist a child under 12 who is having an asthma attack. (c) National  Asthma Council Australia, reproduced with permission

An example of an Asthma First Aid Plan for Adolescents and Adults

Reproduced with permission from the (c) National Asthma Council Australia https://www.nationalasthma.org.au/asthma-first-aid accessed 5th September 2023

An example of First Aid information for members of the public to assist an Adult or Adolescent over 12 who is having an asthma attack. (c) National  Asthma Council Australia, reproduced with permission

Carers and parents should be provided with clear emergency instructions

Clear specific indications for calling for emergency help for someone having a severe asthma attack should be available for anyone responsible for day to day care of people with asthma. This also applies to the workplace, schools, public recreation facilities.

Conclusion

When to call for emergency help for a life threatening asthma attack

An asthma attack is a medical emergency because this is a signal that something serious has gone wrong. So anyone who has had an asthma attack needs a detailed assessment, in other words a post-attack asthma review by someone trained to do so. The purpose of the review is to identify any modifiable risk factors and deal with them to prevent future attacks.

Clear instructions are needed

Identify the red flags for emergency asthma assistance. In my view this should be very clearly stated in all asthma self management plans and Asthma First Aid Posters and infograms. My ‘Top 3 List’ of red flags below could be used in addition to any advice from the patient’s own doctor. The problem is that someone having a severe asthma attack may not have any of the signs or symptoms associated with severe attacks – so call for medical help if at all concerned about an asthma flare up!

  1. The short acting reliever (usually blue ie salbutamol, albuterol, terbutyline) should last for at least 4 hours – So the first thing the plan should state is: I need emergency help if my blue short acting reliever is not helping my symptoms or if I need it again within 4 hours.
  2. Next, waking due to cough, wheeze, breathing difficulty and shortness of breath is a danger sign. So next, I need emergency help if I’m waking up at night with cough or wheeze or shortness of breath
  3. Many people have their own Peak Flow Meter and if you have one: I need emergency help if my peak flow rate falls below 60% of my best : Enter best x 0.6 =        (l/min)

 

Then the additional item on this emergency plan should be about what you tell the emergency services: What you tell them will determine how rapidly emergency assistance is dispatched:

Information to include: That the person has asthma; say if they have breathing difficulty;  and to say if they are waking because of asthma; say if the reliever is not working; and if they can do Peak Flow, what their reading is now and what their best reading is.

How to recognise an asthma exacerbation (attack)

Asthma attacks can be dangerous

Early warning signs or symptoms of an asthma exacerbation (asthma attack) include cough, extra use of reliever inhaler, difficulty breathing, wheezing, or difficulty sleeping because of these symptoms. Asthma Control test (ACT)score below 20 also indicates a possible exacerbation or attack. Asthma attacks can be very severe and dangerous. They can flare up without warning. Early warning signs of an asthma attack must be recognised both by patients and doctors to prevent deterioration This applies to patients and health care professionals.

Asthma is a chronic ongoing disease

Asthma is an ongoing chronic disease and what happens is that there are times when people with this disease are very well, and others when it flares up. These flare-ups can be very sudden or they can develop slowly over weeks.

Acute sudden asthma attacks are easy to diagnose

When someone with asthma suddenly becomes short of breath, which may include wheezing (that is a whistling nose coming from the chest) most people with asthma and most doctors will recognise this and make the diagnosis. In these circumstances treatment will usually be started quickly.

Asthma awareness is needed to recognise gradual onset attacks

Clinical awareness of asthma by doctors and attention to detail is necessary to diagnose an asthma attack that is developing slowly. It can take a few weeks sometimes for an attack to develop.

Asthma expertise essential in primary care and ED/A&E

Asthma is a very common disease. Therefore anyone working in Early warning signs of an asthma flare up include new difficulty breathing, wheezing and coughing. Doctors often get caught out because asthma attacks can develop slowly. So its essential that any doctor (or nurse) who sees patients in primary care or in emergency departments should know how to diagnose an asthma attack that is developing. See information on asthma here.

Diagnose asthma flare-up until proved otherwise

Any patient presenting with increased use of their reliever inhaler, cough, wheeze, or shortness of breath is developing an asthma attack until proved otherwise. Detailed history and lung function measurement is essential – take asthma seriously. Waking at night and failure to respond to bronchodilator reliever and fluctuating peak flow help facilitate early diagnosis.

By the time wheezing is heard FEV1 has dropped up to 30%

A common mistake made by health care professionals is that they rely on their stethoscope to assess severity of asthma. The problem is that by the time wheezing is heard with a stethoscope there may be up to 30% obstruction of airflow. 1, 2,3,4,5,6 So the terms ‘mild wheeze’ or ‘slight wheeze’ are misleading and provide a false sense of reassurance for clinicians. Much more important to measure lung function (spirometry or Peak Expiratory Flow (PEF) and respiratory rate. Most importantly, during a severe attack there may be no abnormal findings – so the medical history and lack of response to reliever medication are essential to take note of.

  1. Spence DP, Graham DR, Jamieson G, Cheetham BM, Calverley PM, Earis JE. The relationship between wheezing and lung mechanics during methacholine-induced bronchoconstriction in asthmatic subjects. American Journal of Respiratory and Critical Care Medicine. 1996;154(2):290-4. Link
  2. Springer C, Godfrey S, Picard E, Uwyyed K, Rotschild M, Hananya S, et al. Efficacy and safety of methacholine bronchial challenge performed by auscultation in young asthmatic children. Am J Respir Crit Care Med. 2000;162(3 Pt 1):857-60.
  3. Sanchez I, Avital A, Wong I, Tal A, Pasterkamp H. Acoustic vs. spirometric assessment of bronchial responsiveness to methacholine in children. Pediatr Pulmonol. 1993;15(1):28-35.
  4. KOH YY, CHAE SA, MIN KU. Cough variant asthma is associated with a higher wheezing threshold than classic asthma. Clinical & Experimental Allergy. 1993;23(8):696-701. Link
  5. Noviski N, Cohen L, Springer C, Bar-Yishay E, Avital A, Godfrey S. Bronchial provocation determined by breath sounds compared with lung function. Arch Dis Child. 1991;66(8):952-5.
  6. McFadden ER, Jr., Kiser R, DeGroot WJ. Acute bronchial asthma. Relations between clinical and physiologic manifestations. N Engl J Med. 1973;288(5):221-5.

Evolving asthma attacks need aggressive treatment

Increase corticosteroid treatment – inhaled or orally – should be initiated soon as possible to avoid an attack developing.

Self-Management plans should include how to recognise attacks

People with asthma must be taught that onset of cough, wheeze, shortness of breath or difficulty breathing are early warning signs of a developing exacerbation or attack. This would help patients prepare for consultations for uncontrolled asthma. It is extremely helpful for a clinician if a patient brings recordings of lung function (Peak Flow, spirometry) and also details of symptoms in the last few weeks (Ideally the results of an ACT (Asthma Control Test) and a record of the number of times the reliever has been used and how effective it has been. This information will help both patient and doctor (or asthma trained nurse) in deciding on treatment for the attack.

Pressurised asthma inhalers and the environment

Pressurised asthma inhalers contribute very little to global warming

There is a lot of pressure for doctors to prescribe dry powder inhalers rather than pressurised dose inhalers – this is potentially harmful and may increase contribution to global warming. The reason for this advice is to protect the environment; however asthma inhalers contribute very little (less than 0.1%) to global warming. Furthermore, someone who cannot use a prescribed inhaler there is a risk of having an asthma attack. The downside is that treatment of asthma attacks then contribute substantially to global warming. So simply switching people from pressurised inhalers to dry powder types without ensuring they can be used correctly is potentially harmful for the environment.

There are two main kinds of inhalers

Pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs). The pMDIs contain propellants called Fluorinated Gasses (F-Gasses). F-gasses contribute to global warming, however the pMDIs contribute less than zero point one percent (<0.1%) of global warming potential.  Our GINA Lancet paper discusses future risks posed for people with asthma because of new regulatory proposals to limit availability of F-gasses for medical use.

There is an environmental crisis

The UK Government announcement that new oil drilling licences are being considered and last year an announcement was made on the news that a new coal mine is to be opened in the UK. However, peoples lives are potentially being threatened by recommendations to change people’s asthma inhalers ‘to save the planet’.

 Discussion to reduce use of pMDIs

There is currently a lot of discussion about the environment and the effect of the F-Gasses on the potential for global warming. These F-Gasses are used mainly for industries such as those in air conditioning and heat pumps, and a very small proportion of these gasses are used as propellants in pressurised metered dose inhalers (pMDIs) used for treating lung diseases like asthma and chronic obstructive pulmonary disease (COPD).

 Inhaled medication is essential for people with lung disease

Ensure people can use their inhaler correctly

These inhaler devices are necessary and in fact essential for controlling the symptoms of these lung diseases and for preventing attacks that can lead to hospitalisation and sometimes death. So it is essential that people are shown how to use their inhaler correctly and this cannot be done if these are switched without a face to face consultation.

 Not everyone can use all of the inhaler devices

Many people, including doctors and nurses, cannot use inhaler devices correctly. Therefore the patient’s needs should be the first consideration when changing from a pressurised inhaler to another type. As the pressurised inhalers contribute very little to global warming clinicians should think carefully before switching someone to a device they cannot or will not use.

 Many people argue that doctors should be prescribing dry powder inhalers(DPIs)

Doctors are encouraged to prescribe dry powder inhalers (DPI), instead of pMDIs.

 Lifestyle versus life-saving argument

This switch from pMDIs to DPIs is justified by statements comparing the global warming effect of a pMDI with a journey by car or aeroplane. For example see the advice from NICE, see here.

 The unintended consequences of switching people inappropriately to inhalers they cannot or don’t want to use

One of the main risks of people not using their inhaler correctly is that they may have an asthma attack/exacerbation/flare-up – which could be life threatening.

Treating asthma attacks contribute to global warming
Global warming impact of treating an asthma attack

 Treatment of asthma attacks have consequences for global warming

 The arguments for switching inhalers from pMDI to DPI do not include unintended consequences such as asthma attacks and the global warming potential resulting from their treatment.

Estimates derived from one paper :

 Example calculation of the effect of an asthma attack on the environment: (with help from Patrick Henry Gallen)*

  • Average number of days spend in hospital per asthma discharge in the UK: 3.4 (OECD 2018)
  • Number of asthma-related hospitalisations in the UK: 94.6 per 100,000 population = ~63,694 hospitalisations (OECD 2018)
  • Average CO2e for newly registered vehicles: 121.3 g/km (Department for Transportation 2015)
  • Hypothetical journey: 16.09 km/10 miles (5 miles to and from hospital)
  • Hypothetical number of journeys and visitors: 2 visitors visiting twice

Example of Global warming potential due to treating an asthma attack

  • 507.8 kg CO2e per hospitalisation
  • 32,343,813 kg CO2e / 32343.8 tonnes CO2e per year due to asthma hospitalisations in the UK

 Note that this model does not into account emissions related to a possible outpatient trip prior to hospitalisation or emissions related to inhaler usage and other devices or maintenance/manufacturing thereof (e.g. O2/nebulisers).

Further evidence of hospital care of an asthma attack and its contribution to the environmental footprint: see https://link.springer.com/article/10.1007/s11367-021-01998-8 which concludes “The ICU generates more solid waste and Greenhouse Gasses (GHGs) per bed day than the acute care unit. With resource use and emission data, sustainability strategies can be effectively targeted and tested. Medical device and supply manufacturers should also aim to minimize direct solid waste generation.”

Choose the right inhaler for the patient

Our our GINA Lancet paper makes it clear that the patients needs must be prioritised when choosing an inhaler.

Global initiative for asthma inhaler choice figure
Inhaler selection – first ensure what is best for a patient

Conclusion

When considering prescribing inhalers for asthma the most important thing is to select one that the patient likes and can use properly. One of the consequences of getting this wrong is that the person may have an asthma attack which may be very serious. In addition the treatment of an asthma attack contributes adversely to global warming.

  • I was priveledged to work with Patrick on the severe asthma index of the Copenhagen Institute for Futures Studies