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Acute Severe Asthma - lives lost unexpectedly 


Asthma is a common problem. 5.4 million people in the UK have a diagnosis of asthma which is approximately 15% of the population. In children the prevalence is higher, at about 21%, meaning that in a class of 30 school children 6 are likely to have asthma.1

It seems that the general perception of asthma is that it is a bit of an inconvenience and many of the general population are shocked to learn that people still die from it. That may be why, in part, the findings from The National Review of Asthma Deaths presented in the report Why Asthma Still Kills were shocking reading for the health community and the public alike.2

The report found that 45% of people died without seeking help in their final fatal attack.2 Were they unaware of the seriousness of the situation? Or did they not know where or how to seek emergency help? There were warnings that might have raised danger flags for some of the patients that died, indicators that should raise concerns – 47% had previously been admitted with asthma, 21% within the previous year. 21% had attended an A&E department with an asthma problem within the previous year, 12% twice or more. 10% had been admitted in the 28 days preceding their death.2

So what are the processes for following up these patients, what safety nets exist?

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There may be more subtle clues, things that need a more detailed look. Of those that died maybe unsurprisingly 39% had severe asthma – the higher risk patients.

But what about the 49% with moderate asthma? Or more worryingly the 9% with mild asthma?2 Was this mild asthma, under-treated asthma, or the person who just never attends routine review? 43% of those that died hadn’t been reviewed by their primary care practice within the 12 months preceding death – something to consider when patients with mild to moderate asthma don’t respond to a letter?2

It is well documented that personalised asthma action plans help people to manage their asthma better yet only 23% had documented evidence of receiving a plan.2,3

Further clues from prescribing information were revealed which were not at all surprising yet slipped through the system. Overuse of bronchodilators is a recognised indicator of poor control and risk factor for near fatal asthma 4 yet 39% of people who died received 12 bronchodilator inhalers in the previous 12 months and 4% received 50.2 This prescribing information may not be an accurate reflection of actual usage but should have been followed up. 

Equally worthy of enquiry are patients on ‘unusual’ prescribing regimes. In the report 3% of people were prescribed long acting bronchodilators without any inhaled steroid and 14% were prescribed both medications but in separate inhaler devices.2 Prescribing information is available in primary care and is auditable. Clinical systems can be set to run the data collection part of the audit on a regular basis and members of the team have different skill sets that contribute to the full process – pharmacy technicians, pharmacists, data management staff, clinicians – to review the data. Does this happen regularly?

Acute severe asthma may not be something that feels like a medical problem that fits within your area of practice either because somebody else within your workplace deals with it – ‘The Asthma Nurse’ - or because you work in an area where emergencies are not a feature.

The problem is it may be sprung upon you. If ‘The Asthma Nurse’ is on holiday and you are the only one there, or simply because away from your usual workplace an asthma emergency occurs and you are called upon to help because you are a health care professional so of course you know what to do! As previously mentioned, asthma is a common problem and life-threatening asthma doesn’t always strike where one might expect.

What is the emergency asthma situation?


It might be called an exacerbation, flare up or asthma attack and can be mild, moderate or severe. It is classified according to clinical signs and presenting peak flow measurement. Symptoms include increased cough, wheeze, breathlessness, night waking, and increased rescue use. Delay in presentation is common but has been identified as a preventable risk factor for asthma deaths.5

It’s interesting to be aware of information patients are given to manage acute situations. Asthma UK is a trusted source of information and one that nhs.uk links to for their information.6  Asthma UK explains what an asthma attack is (choosing to use the words ‘asthma attack’) explaining that asthma can be fatal, and that 3 people die from asthma attacks in the UK every day. It stresses the point that if the person is having an asthma attack it is vital they act now.

The four-point plan is:
1. Sit up straight - try to keep calm
2. Take one puff of your reliever inhaler (usually blue) every 30-60 seconds up to 10 puffs
3. If you feel worse at any point OR you don't feel better after 10 puffs call 999 for an ambulance
4. Repeat step 2 after 15 minutes while you are waiting for an ambulance

This information should be included and clearly explained in all personalised asthma action plans.7 As stated in The Lancet, during an exacerbation, patients are breathless, coughing, and often panicking, all features that impede effective use of inhaled therapy at the time when it is most needed.

Should there be a Plan B for some of these people? There was an interesting suggestion in The Lancet that patients who have had an exacerbation, or who are at risk of having one, should be given an emergency pack containing a salbutamol pMDI and antistatic chamber supplied as part of a personalised asthma action plan.8

In the social situation your role may be no more than to keep the person calm, help them to take an appropriate amount of inhaled bronchodilator (even though this is higher than their usual dose) and summon help without delay by calling an emergency ambulance. 

In the healthcare situation, even in the absence of ‘The Asthma Nurse’ things need to move further and faster. Firstly, it is vital to be certain this is an asthma emergency you are dealing with not an inhaled foreign body, pneumothorax, PE or something else. People with established asthma will present with other emergencies and those who have not previously been diagnosed with asthma can present for the first time in the emergency situation. 

An accurate history is vital:
- How long have symptoms been present?
- When did symptoms worsen?
- Was there a trigger? 
- Any new medication? 
- Has any treatment for asthma been taken? 
- Did it help?

Examine the person. Start by looking. Observe the person’s colour, respiratory effort when moving about, coughing, can they complete a full sentence? Measure temperature, pulse rate and rhythm, peak expiratory flow rate compared to the persons previous best (or predicted value if best not known) , pulse oximetry, listen to breath sounds and assess consciousness.

Risk stratification of people with asthma is useful especially if it has been completed individually in advance of the acute situation and is kept up to date. There are recognised risk factors for fatal asthma which include medical, social and personal aspects such as previous near fatal episodes and admission, high salbutamol use and non-compliance with treatment or monitoring, drug or alcohol misuse, social isolation, and severe legal, marital or domestic stress.4 A check list inside a cupboard door could act as an aide memoir.

Assessing asthma severity and management


An assessment of severity of acute severe asthma is made based on these threshholds and treatment is determined from this. All treatments, and an assessment of response to treatment must be documented in the patient notes.

An assessment of life-threatening asthma is made when ANY of the following are present: (9)
- Peak flow < 33% of best or predicted
- Oxygen saturation ≤ 92% or less
- Cyanosis
- Exhaustion or poor respiratory effort
- Silent chest
- Bradycardia or cardiac arrhythmia
- Altered conscious level or confusion
- Hypotension

Management of life-threatening asthma in adults: (9)
- 999 ambulance
- Oxygen driven nebulised salbutamol or terbutaline
- Oral Prednisolone (IM methylprednisolone if unable to take oral)

Management of life-threatening asthma in children: (9)
- Children with severe or life-threatening acute asthma should start treatment as soon as possible and be referred to hospital immediately following initial assessment.
- Supplementary high flow oxygen (via a tight-fitting face mask or nasal cannula) should be given to all children with life-threatening acute asthma or oxygen saturation < 94% to achieve normal saturations of 94–98%.
- First-line treatment for acute asthma is an inhaled SABA (salbutamol or terbutaline) given as soon as possible.

An assessment of acute severe asthma is made when: (9)
- Too breathless to complete a sentence in one breath
- Peak flow rate 33-50% of best or predicted
- Resp rate ≥ 25/minute adults, ≤ 40/minute in children aged 1–5 years, ≤ 30/minute in children aged over 5 years
- Heart rate ≥ 110/minute adults, ≤ 140/minute in children aged 1–5 years, ≤ 125/minute in children aged over 5 years

An assessment of moderate asthma is made when: (9)
- Increase in asthma symptoms
- Peak flow 50-75% of best or predicted
- No features of acute severe asthma

Management of acute severe and moderate asthma: (9)
- Maintain oxygen saturation level at 94 – 98%. Give oxygen (including oxygen driven nebs) if hypoxic.

- Unless life threatening asthma, give multiple doses of salbutamol or terbutaline by metered dose inhaler and spacer. If poor response, try nebulised ipratropium and salbutamol whilst waiting for the ambulance.

- Systemic steroids take 4-6 hours to take effect whether given orally or injected so the sooner given the better the outcome. (4, 10)


Once people with acute severe or moderate asthma have received initial treatment a decision needs to be made regarding admission. The BTS Guideline on the Management of Asthma also give clear guidance on considerations for admission in these situations:4

  • Any feature of life-threatening asthma
  • Severe asthma not responding to initial treatment
  • PH near fatal asthma
  • Asthma attack despite adequate dose steroid tablets prior to presentation
  • Diagnostic doubt
  • Poor social circumstances (living alone/socially isolated)
  • Poor response to treatment (still have significant symptoms)
  • Physical disability or learning difficulties
  • Psychological problems
  • Pregnancy
  • Other reason such as evening presentation, family concern, clinician concern such as concern about adherence
This information is available from The BTS Guideline on the Management of Asthma.4 It is a lot to commit to memory and in an emergency you’ll never be able to find the web page so either find it now and bookmark it, or do it the old fashioned way and print out the tables and stick them inside a cupboard door (laminated for CQC!)

Case Study 

I remember Jane calling into morning triage having been awake with asthma for 2 nights. She was someone who occasionally ran into seasonal problems with her asthma control but usually got things back under control. She had a good understanding of her disease, how her inhalers worked and knew what she could step up and down as part of her personalised asthma action plan. She also knew 2 nights of symptoms was a warning that things had gone too far. She came into late morning surgery and I was quite shocked at how unwell she was. She was pale and looked poorly and coughed throughout the consultation. 

Her temperature was normal but her pulse rate was raised at 108bpm, respiratory rate raised at 25/minute, PEFR was just 230 which was 55% of her previous best. Pulse oximetry was normal at 98%. 

Jane was given 40mgs oral prednisolone and 10 puffs Salbutamol via spacer and improved – PEFR 380 – but she was just exhausted. 

Jane had previously been admitted to hospital with an asthma attack 2 years ago but had been off work for the last 2 months with depression. Her husband had recently also been made redundant. 

Despite Jane’s initial response to treatment because of the severity of her symptoms, her exhaustion and social circumstances Jane was admitted to hospital as she was at risk of fatal asthma. She remained in hospital for 4 days. 


The adage prevention is better than cure is apt in the case of acute severe asthma.

If people with asthma can be helped to establish what good control looks like so that they can recognise and act upon deterioration, then the acute situation will more easily be avoided. Appropriate onwards referral for those with difficult to control asthma or severe asthma will also help in achieving a more stable state for these people.


References
Date of access of all websites: January 2020

  1. Asthma UK (2019) Facts and statistics https://www.asthma.org.uk/about/media/facts-and-statistics/
  2. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Report. London, RCP, 2014. www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf
  3. Pinnock (2015) Supported self management for asthma. https://breathe.ersjournals.com/content/breathe/11/2/98.full.pdf
  4. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2019. Available at: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
  5. Edmonds M, Camargo CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database of Systematic Reviews 2003, Issue 3. Art No: CD002308.
  6. Asthma UK (2019) Asthma attacks https://www.asthma.org.uk/advice/asthma-attacks/
  7. Asthma UK Your Asthma Action Plan https://www.asthma.org.uk/advice/manage-your-asthma/action-plan/
  8. Keeley D. Partridge M. Emergency packs for asthma and COPD. Published online April 5, 2019 https://dx.doi.org/10.1016/S2213-2600(19)30046-3 
  9. British National Formulary https://bnf.nice.org.uk/treatment-summary/asthma-acute.html
  10. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department treatment of acute asthma with systemic corticosteroids (Cochrane Review). In: The Cochrane Library, 2001.

Carol Stonham, MBE has received an honorarium from GSK for developing this article/content.

PM-GB-ASU-WCNT-200001 February 2020

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