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!

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.
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
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.

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
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.
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.
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
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.
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.

End asthma attacks- Post attack Review

There have been at least 4 asthma deaths in children and young people in London recently. Asthma attendances at the ED and Urgent Care Centres are increasing and there is considerable variation in hospital admissions throughout the United Kingdom. Furthermore the UK has the highest number of childhood asthma deaths in Europe and third highest overall in the high income countries world wide. These stats are shocking despite the fact that the UK has Nationally produced guidelines (SIGN/BTS and NICE) and free access to medication for children.

While there are local pockets of evidence based care for asthma there has been no clear national directive to implement the NRAD recommendations.

It seems that little has changed nationally in asthma management in the ten years following the National Review of Asthma Deaths. What on earth is going on?? In essence, we don’t seem to have learnt any lessons from past research by implementing change in practice in managing asthma. This was so clearly illustrated in the tragic cases of Michael Uriely, who died from asthma at the age of 9 years and Sophie Holman who died at age 10 and also Kalila Griffiths who died age 24. The coroner’s regulation 28 statement (on a potentially preventable death) is published on the Chief Coroners website at https://www.judiciary.gov.uk/publications/michael-uriely/ .

In my view, the UK asthma guidelines while very detailed, are not user friendly and very out of date. While it great for academics to read about specific research findings, jobbing, busy GPs and nurses need very clear simple advice. In particular related to post attack reviews.

An asthma attack is a signal that something serious has gone wrong – an urgent review to identify modifiable risk factors and optimise care is needed.

The post attack review has two aims.

i) To determine whether the attack is over

ii) to identify modifiable risk factors and optimise care to fix these. A list of modifiable risk factors is available in Box 2-2 in the GINA Strategy document at https://ginasthma.org/reports/ and are also discussed in my Asthma Spotlight Podcast: see youtube https://t.co/mYvVZ4qGf7, Asthmaspotlight, https://apple.co/3Eo2OjR

Please also see my lecture on this topic at: https://www.pcrs-uk.org/resource/demand-webinar-keeping-people-asthma-safe

Pulse Oximeters overestimation in dark skinned people

What is an oximeter

Pulse oximeters are unreliable in dark skinned people. I learnt some worrying news at the 2022 Winter British Thoracic Society meeting . This relates to pulse oximeters that are in common use to assess people with heart or lung diseases. These are the small devices that fit on a fingertip measure the amount of oxygen circulating in the bloodstream. These devices measure the oxygen level by shining a light through the fingernail.

Oxygen is essential for life – how are levels measured in your body

Two methods are generally used to measure oxygen levels in the blood. One is by using a pulse oximeter described above, and the level is summarised as SpO_2. The other method is by measuring arterial blood gas by drawing a small ammount of blood from an artery (usually in the arm) and this measurement is depicted as SaO₂. The arterial blood gas (SaO₂) being the more accurate measurement. So the ‘gold standard’ measurement of blood oxygen levels is by arterial blood gas measurement – however this is an invasive test involving an experienced person taking blood from an artery and then taking it, packed in ice, quickly to a laboratory or a machine in a hospital ward if available to do the measurement. The reason why pulse oximetry has become so popular is that its very convenient and patients as well as health care professionals and assistants can easily do the measurements.

The function of the lungs is to get oxygen from the air into the blood via the lungs, and also to expel (get rid of) carbon dioxide which is harmful if it builds up in the body. Pulse oximetry only measures oxygen levels while arterial blood gas measures both oxygen and also carbon dioxide levels and the latter is therefore more reliable in determining if someone is going into or in respiratory (or lung) failure.

Usually when a person is well, the oxygen readings are between 95 and 100%. When someone is unwell, for example with a lung disease like pneumonia or during an asthma attack, doctors usually get concerned if the readings drop down towards and below 94% and they get very worried if these are below 91%.

Now, Ive always been aware that the pulse oximetry readings (SpO₂) can be slightly innacurate and also that the readings may be very inaccurate if someone has nail polish. However, what I knew a little about, but not how serious, was the size of the inaccuracy is in people with dark skins.

Oxygen levels are misleading in people with dark skins

The problem in everyone, irrespective of the colour of their skin, is that the pulse oximetry level is always higher than the true arterial levels. is that the readings may be falsely high in people with dark skin. There has been some research that shows that the difference between the true oxygen level in the blood (SaO₂) and the pulse oximetry reading (SpO₂) in dark skinned people can be as high as 11.7% compared with those with white skin which can be 3.6%. One study showed that the mean over-estimate of oxygen saturation is 1.4% ( 95% Ci +0.5 to +2.3) in people with non-white skin compared with white skin. What this means in real life is that there is a big risk that doctors may underestimate the severity of oxygen depletion in dark skinned people if they only rely on pulse oximetry.

Possible dangerous implications of reliance on oximeters alone

This has implications for people having asthma attacks and therefore, medical personnel as well as people with asthma need to be taught not to ONLY rely on pulse oximetry levels when deciding on the severity of an asthma attack (or severity of pneumonia or other conditions that result in reduced blood oxygen levels). Other measurements need to be taken into account, for example in the case of asthma, symptoms (cough, wheeze, shortness of breath, or difficulty breathing) respiratory rate, peak expiratory flow (PEF) or FEV1 with a spirometer, as well as pulse rate and blood pressure, And Therefore, if there are signs of worsening asthma despite ‘normal’ SpO₂ people with asthma should seek medical assistance.

Conclusion

When assessing a patient with dark skin, be aware that pulse oximetry will overestimate the true blood oxygen level (the arterial oxygen level). Therefore – dont only rely on the pulse oximetry reading when assesing a person having an asthma attack (or a chest infection). Use the clinical history, other vital signs (NB Respiratory rate, pulse, blood pressure), other indictions of respiratory failure (drowsiness, altered breathing, cyanosis) and response to treatment. Also refer early to a specialist and test the arterial oxygen level early in people with dark skin and pulse oximetry readings of 94% and lower.

Enough oral steroids for asthma attacks

Introduction

Oral steroids (corticosteroids) are needed when treating acute asthma attacks

Oral steroids are usually needed for treating acute asthma attacks. Most importantly they should be continued until the attack (exacerbation) has resolved.

Treatment of acute asthma exacerbations

Asthma attacks (also known as exacerbations) should be managed by treating the acute symptoms with drugs; and also by establishing why the person had an attack; and whether any preventable risk factors can be addressed to regain control. In my opinion, and the findings of the NRAD, not enough effort is put into the last two aspects of treatment of asthma attacks. In this item, I discuss the drugs and will address the other issues in a later blog.

Note for people with asthma and families:

This blog is not intended as medical advice for individual people with asthma. Always consult your own doctor for advice, but please do feel free to use this blog as a basis for discussion.

Drug treatment of asthma attacks includes

High doses of reliever medication (short acting bronchodilators, salbutamol – usually delivered via an oxygen driven nebuliser or a blue inhaler using a spacer device.)
Oxygen (Ideally used to drive a nebuliser at flow rates over 6L/min)
Corticosteroids (prednisolone, cortisone) – life saving drugs during attacks which help to clear up the inflammation that occurs before and during attacks.

Corticosteroid tablets or injections take about 6 hours to work

So its really important to start the oral corticosteroids as soon as possible. however there are often delays in starting these drugs in hospital so an obvious solution is to provide patients with a course of oral corticosteroids so they can start these themselves.

No one knows how long an asthma attack lasts

Many doctors prescribe oral corticosteroids for 3, 5 or 7 days without any follow up evaluation. This is illogical since no one can predict how long an attack will last.

Tamara Mills had 47 asthma attacks in her last 4 1/2 years of life

24/47 were attendances at A&E (ED) and 21/47 were hospital admissions

With permission of Tamara’s mother I share her sad story. Tamara died just before her 14th birthday. Of her 47 flare-ups (Attacks/exacerbations) 20 were re-attendances due to incomplete treatment of attacks. With the exception of one of these attacks she was prescribed 3 or 5 days of oral corticosteroids without any follow up by an asthma doctor. The only time she got 14 days post attack treatment was after she had a near fatal attack while in hospital.

A respiratory paediatrician was fortuitously on duty on one occasion

The morning after Tamara was resuscitated after having a life threatening asthma attack while in hospital she saw a paediatrician with a special interest in asthma for the first time

This was the only time she got 14 days of oral corticosteroids for acute asthma

Tamara was prescribed 14 days of prednisolone (oral corticosteroid) only once. This was the only time her asthma was taken seriously. That was by chance because she saw a paediatrician with a special interest in asthma that morning. See the coroners report here. However, she was never referred to an asthma specialist after this admission to hospital.

Why it is inappropriate to prescribe oral steroids for a fixed time

The problem being that a proportion of people have another attack soon after being treated for one. One of the explanations for this is that the first attack wasn’t treated until completely resolved . For more on this see here.

Conclusion

So what do people with asthma and health professionals need to do in order to try to reduce the number of preventable asthma attacks?

In my opinion, three things:

People treated for asthma attacks should see their doctor (or asthma nurse) before they run out of corticosteroid (cortisone) tablets so they can be advised whether their attack has resolved, whether to continue or stop these tablets and also so that the health professional can identify what went wrong/what led to the attack and optimise the treatment.
To be provided with a peak flow meter and symptom diary chart when sending someone home after treatment of an asthma attack. This could help patients, their carers and health care professionals determine whether the attack has resolved based on the readings as well as symptoms. These readings can help decide when the attack is over and when to discontinue corticosteroids.
The health care professional should do a detailed asthma review (see here how to do a post attack review)after the attack to determine what went wrong and to optimise treatment based on the assessment.

How long does an asthma flare up take to resolve?

No one knows how long an asthma attack lasts

No one knows how long an asthma flare up lasts. Asthma flare ups are also known as asthma attacks or an asthma exacerbation. Asthma exacerbations and hospital admissions can be prevented by anti-inflammatory treatment. Well controlled asthma should not flare up.

Doctors often treat attacks for a fixed time period

No one knows how long an asthma attack takes to resolve. However health professionals often treat attacks as if they do! Most asthma guidelines recommend oral corticosteroid treatment for attacks. The UK SIGN Guideline states very clearly that these corticosteroids should be continued until the attack resolves. From my knowledge, most people are treated for attacks with fixed corticosteroid courses of 3, 5 or 7 days. How do these doctors & nurses know the attack will be over in 3, 5 or 7 days?’

Oral corticosteroids should be continued as long as an attack lasts

According to the United Kingdom (BTS/SIGN) Asthma guideline section on treatment of acute asthma attacks/ Flare ups / exacerbations:

In Adults: Continue prednisolone (40–50 mg daily) until recovery (minimum 5 days).
In Children: Treatment for up to three days is usually sufficient. But the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days.

So the key message is that oral corticosteroids should be continued until the attack is over. The excellent acute asthma section (chapter 9) in the 2019 version of the BTS/SIGN Guideline is essential reading. To download it click here.

How to tell if an asthma attack is over

It may take days or weeks for an asthma flare-up to resolve. An asthma flare up or attack is over when a person is free of symptoms. An asthma attack is not over yet If rescue reliever medication is needed. When the Peak Expiratory Flow or Spirometry has returned to the patients usual best level the attack is over. Therefore treatment for attacks should continue until the attack has resolved.

Asthma is a chronic ongoing disease – not an acute disease

Asthma is a chronic ongoing disease, nonetheless it is often treated as if it is an acute illness. The attack is usually treated very well although, surprisingly, a large majority of these people are not followed up for a review to identify and deal with any modifyable features.

An asthma flare up or attack means something has gone wrong

Someone whose asthma is appropriately treated with preventer medication, should be free of attacks, and therefore an attack signals a failure of treatment. In addition, asthma attacks are a well known risk factor for future attacks and therefore people are most vulnerable after an attack.

It follows that clinicians should aim to ensure that after asthma attacks are resolved that any modifiable factors are identified and dealt with to try and prevent another attack. Listen to my asthma podcast (second from bottom) here. This is one of the two main purpose of a post attack review.

Post asthma attack reviews

The purpose of the post attack review is:

i) to assess the progress of the current attack to determine the need for treatment. Including:

assessing current symptoms for example using the Asthma Control Test (ACT),
requirement for reliever treatment,
night time symptoms including waking due to asthma
lung function (Peak Flow or spirometry).

Peak flow chart showing when an attack was over — Peak flow chart showing resolution of an asthma attack. This woman presented for the first time with an asthma attack. I did not know what her normal peak flow was so we used a peak flow chart to inform us when it would be safe to stop her oral corticosteroids

ii) to identify modifiable risk factors causing the attack and optimise care. Modifiable risk factors include:

failure by doctors to prescribe controller medication (mainly inhaled corticosteroids);
failure by patients to refill prescriptions for controller medication,
excess reliever prescriptions and over-reliance by patients on these.
For more information on modifiable risk factors see GINA Table 2-2 and Table 11 (page 82) in the BTS/SIGN Guideline).

More details on post attack reviews here.

Conclusion

Keep patients safe and reduce GP’s workload by using post attack reviews to maintain asthma control.

An asthma attack signals something needs to change. Identifying modifiable risk factors and dealing with them will reduce future attacks. This will help to prevent asthma flare ups, hospital admissions and avoidable deaths. When should post asthma attack reviews be done? Ideally before the oral corticosteroids run out or within a week. Many primary care colleagues argue that this is not feasible due to heavy worlkload. A practical solution is to simply block off one appointment every afternoon for a post asthma attack review. If not taken up by midday it could be used for another patient that day.