Category: Latest Posts

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.

Asthma information for all

Information to control asthma , prevent asthma attacks and deaths:  Updated  June 8th 2023

Dr Mark L Levy FRCGP: @bigcatdoc ; @ginasthma

People with asthma can ensure they keep safe by learning as much about asthma as possible. In this way you can learn what questions to ask your doctor and what you could expect for your or your child’s asthma care. Health care professionals of course need access to the most up to date information to keep their patient’s asthma well controlled in order to prevent attacks.

This page contains information and links to resources and publications on asthma. There is a podcast that explains the rationale and use of this information and you can listen to the podcast as well as my other podcasts on asthma at: https://bigcatdoc.com/podcast-asthma-spotlight-2/ and on spotify and Apple Podcasts

Examples of innovative implementation to improve asthma care:

National and International Societies for people with asthma:

International Patient associations:

Self management plans to help control asthma to prevent attacks and hospital admission.

Monitoring and checking your asthma control:

Specialist Medical Societies: These societies all work to improve the health of people with asthma (and other diseases)- many of their events and educational videos and materials are accessible online . Some of these also have patient working groups and patient representatives.

International professional respiratory / asthma organisations:

Patient resources from GINA and specialist societies available in Individual countries: These ones listed are those that I’m aware of that have patient representatives or resources for people with asthma

Guidance and Guidelines to control asthma to prevent attacks and hospitalisation

Some examples of Country specific Asthma Guidelines on diagnosis, control, treatment and asthma self-management:

Further Reading and some lectures / webinars:

  • National Review of Asthma Deaths (NRAD) – this was a review of asthma deaths during the year from February 2012 in the United Kingdom. A panel of 176 doctors, nurses and pharmacists with expertise in asthma were tasked with assessing the medical records to determine if i) These people had evidence of asthma; ii) If these people died from asthma and iii)  if there were any lessons that could be learned from these sad cases: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
  • This is a link to a half hour webinar I did on the post attack review – if you have had an asthma attack, it means that something serious went wrong and therefore by listening to this talk that was intended for health care professionals, you can find out what to expect, and to ask for when you attend your doctor for a check-up or review after you had an attack
  • Chapter on acute asthma: SIGN/BTS 158 (2019) https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ (Ch 9) – this was last updated in 2019, and the chapter on acute asthma is helpful for assessment by health professionals and also for people with asthma (and parents of children with asthma)
  • Article summarising GINA 2022 recommendations – intended for General Practitioners and General physicians and Paediatricians – and may be useful for people with asthma to understand how some treatment decisions are based on evidence and used by doctors: https://www.nature.com/articles/s41533-023-00330-1
  • JACI Paper on MART- this is an article explaining Maintenance and Reliever Treatment for asthma which also includes a link to a MART self management plan : https://www.jaci-inpractice.org/article/S2213-2198(21)01128-4/fulltext

Training Resources on Asthma for doctors and nurses:

UK Resources:

Press

Correct use of inhaler images can help to educate people with asthma and health care professionals. The blue reliever inhalers are NOT intended for regular use – they are for emergency use and for temporary relief of symptoms. For royalty free images available from IPCRG click here

Occupational Asthma – some resources:

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.