Acute asthma: severity and acute care

Acute asthma is an acute or subacute worsening of symptoms and airflow beyond the patient's usual state, set off most often by a viral upper respiratory infection, an allergen or pollution, or inhaled corticosteroid treatment that has lapsed, and it can kill a patient whose asthma seemed mild, so the nurse grades the severity of the presentation from the clinical picture rather than from the history -- whether the patient can talk in sentences, in phrases or not at all, can lie down, is agitated, the respiratory rate, the use of the accessory muscles, the air entry and the wheeze, the saturation and the peak flow against the patient's own best -- reads drowsiness, confusion, cyanosis, a silent chest and exhaustion as the life-threatening attack and never as settling, keeps in mind that anaphylaxis, a pneumothorax, inducible laryngeal obstruction, pneumonia, heart failure and a pulmonary embolus present as acute breathlessness with or without wheeze and that anaphylaxis alongside asthma gets its intramuscular epinephrine before any bronchodilator, and acts in order: sitting the patient upright, giving oxygen only when the saturation is below the threshold that calls for it and titrating it to the prescribed target range with its upper limit rather than to the highest flow the device allows, knowing that the oximeter can overestimate the saturation in a patient with dark skin, giving the short-acting beta-agonist in repeated doses by pressurized metered-dose inhaler and spacer, one puff at a time with the inhaler shaken before each, which serves in all but the most severe attack where the nebulizer is used, adding inhaled ipratropium for the moderate and the severe presentation, giving the systemic corticosteroid early in every attack that is more than mild because it takes hours to act, monitoring continuously with the lung function repeated after the first hour, and escalating the patient who is worsening or not responding; carries the drug treatment safely -- no sedative, anxiolytic or hypnotic for the agitation, which is hypoxemia and not anxiety, because these drugs depress breathing and are associated with avoidable asthma deaths, beta-agonist doses repeated on the response rather than piled on, since overtreatment produces tachycardia, tremor, hypokalemia and a lactic acidosis whose compensatory hyperventilation is easily read as the asthma getting worse, a short course of oral corticosteroid that is stopped without a taper, and no routine antibiotic, chest film or blood gas -- watches for the deterioration that is the real danger, the patient who tires: the chest that goes quiet because too little air is moving to wheeze, the respiratory rate that falls, a carbon dioxide that is normal or rising when the effort of breathing should have driven it low, a pulse that races and then slows, a blood pressure that falls, a sudden one-sided chest pain that is a pneumothorax, and a level of consciousness that drops, all of which call for the critical care team who will ventilate rather than for another bronchodilator; and judges the response and the readiness to go home on the repeated assessment and on a lung function held up for hours after the last reliever dose rather than on the wheeze having gone, sending the patient home on an inhaled corticosteroid-containing maintenance treatment, preferably the combination inhaler used as both maintenance and reliever, with the reliever taken as needed and not routinely, the inhaler technique checked with a spacer, an interim written action plan, the corticosteroid course completed, and follow-up within days, because a single exacerbation that needed urgent care or an oral corticosteroid is itself a red flag that the asthma treatment must be reviewed, and because the patient who has had a near-fatal attack, an urgent visit in the past year, a recent course of oral corticosteroid or none of the inhaled one, who over-uses the reliever, has no action plan, a food allergy or a psychiatric or psychosocial problem, is the patient who dies of the next one.