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Status Asthmaticus

Asthmatic Crises

Status asthmaticus is defined as an acutely arising aggravation of an asthmatic attack, that fails to resolve with the use of bronchodilation therapy.


Presentation

Status asthmaticus is a condition that may threaten the life of the patient and should therefore be recognized and treated immediately. The most characteristic, although by no means pathognomonic, symptom that the patients present with, is dyspnea. Usually, individuals presenting with status asthmaticus suffer from asthma that is difficult to control, and therefore have a prior medical history of hospitalizations, intubation and corticosteroid intake.

The following signs are expected to accompany a severe asthmatic attack and indicate a threat to the respiratory system:

  • Wheezing sounds or decreased sounds during auscultation
  • Pulse that exceeds 120 bpm
  • More than 30 breaths per minute
  • Pulsus paradoxus
  • Use of accessory muscles
  • Refusal to decline below the angle of 30 degrees

Another sign that is a strong indicator of a pending respiratory compromise is the silent crest. In some cases, pulmonary function is so obstructed, that the flow of air is inadequate to produce the characteristic wheezing sounds. In general, patients with status asthmaticus appear fatigued and unable to speak properly, due to their inability to breathe. A presentation that is further complicated by confusion or lethargy is invariably a sign of imminent respiratory failure.

Tachycardia
  • We report the case of a middle-aged indigenous male who suffered an ST-elevation myocardial infarction and then pulseless ventricular tachycardia arrest while still in the acute phase of treatment for status asthmaticus.[ncbi.nlm.nih.gov]
  • S&S of acute resp failure Fatigue Restlessness Dyspnea Tachycardia Increased BP[quizlet.com]
  • Tachypnea ( 30/min), tachycardia ( 120/min), and an inspiratory fall in systolic blood pressure (pulsus paradoxus) of more 15 mmHg are also more common in severe attacks.[enotes.tripod.com]
  • There was a much higher rate of other adverse events (30.5%) with the majority of these being sinus tachycardia (23 patients) or hypertension (30 patients).[emlyceum.com]
Anisocoria
  • On hospital day 2, she was noted to have anisocoria. Imaging showed diffuse cerebral edema with central herniation. Difficult ventilation and hypercapnia directly contributed to her severe cerebral edema.[ncbi.nlm.nih.gov]
Otalgia
  • A case of status asthmaticus and spontaneous hemothorax is described in a 29-year-old female of African descent who presented to the emergency room after 2 days of severe cough productive of yellow sputum, otalgia, sore throat, subjective fevers, chills[ncbi.nlm.nih.gov]
Incontinence
  • Shortly after arrival she suffered a respiratory arrest, seizures, and urinary incontinence. She was immediately intubated.[academic.oup.com]

Workup

Patients who present with an acute asthmatic attack must be continually monitored in terms of pulmonary function, in order to keep efficient track of the degree of airway obstruction. An FEV1 or PEF value that has reached the levels of less than 30-50% of the normal values or individualized normal values is a sign of pending respiratory arrest.

Patients who display profoundly severe symptomatology should be cautiously examined regarding FEV1/PEF, due to the potential bronchospasm that deep inspiration might induce [16]. An arterial blood gas examination should also be performed and pulse oximetry can be the first step towards the evaluation of oxygen values in a non-invasive way.

Another useful examination is the chest radiograph, which may serve no purpose towards the monitoring and diagnosis of status asthmaticus, but certainly helps to eliminate other etiologies [17]. A complete blood count is necessary solely when individuals are febrile and report sputum discharge. Theophylline levels should be investigated in cases of patients who are treated with the drug.

The actual decision to proceed to intubation is reached on the basis of clinical criteria, depending on respiratory capacity, levels of consciousness and oxygen values. Usually, patients with status asthmaticus present with both hypoxemia and hypocapnia; levels of CO2 that rise are oddly an indicator of a potentially threatened respiratory system and hypercapnia usually requires mechanical ventilation.

Treatment

Treatment of an asthmatic attack should be prompt and effective, because the latter may jeopardize the patient's respiratory function and, therefore, life.

The first steps towards treating asthma includes the administration of nebulized β2 adrenergic antagonists, which are the cornerstone of bronchodilation therapy [18] [19]. Correcting bronchospasm is vital for the amelioration of the patient's symptoms. Anticholinergics can also be administered alongside β2 adrenergic antagonists, since they contribute to the treatment and prevent complications [20] [21].

The administration of corticosteroids, orally or parenterally, is necessary when an individual presents with severe symptomatology, and due to the delay of their effect (six to twelve hours) they should be administered as promptly as possible. These drugs help to combat the inflammation that accompanies an asthma attack and to relieve the patient's symptomatology. Furthermore, patients will greatly benefit from oxygen therapy, as an acute attack of asthmatic etiology can greatly reduce the amount of oxygen a patient receives.

Failure to reverse an attack with the aforementioned measures is an indicator of a possible respiratory compromise. These patients should be monitored meticulously in terms of both pulmonary and cardiac function, since they also run an immediate risk of cardiac arrest, if respiratory function is not restored. Epinephrine or terbutaline can be administered subcutaneously in such cases and, as a last resort, intubation will eventually be required to ensure adequate breathing [22]. Anxiolytic medications can be administered to those patients who continue to experience distress and agitation due to reduced amounts of oxygen, but only immediately before intubation.

Prognosis

Indeed, the most useful prognostic marker concerning status asthmaticus and an asthmatic attack in general, is the initial response to the treatment with bronchodilators [12] [13]. An asthmatic attack is estimated to rarely result in death: approximately one out of 2,000 individuals will eventually die because of such a cause. It has been observed, that in order for status asthmaticus to lead to death, the attack needs to develop over a period of about 12 hours, which delineates the need for the patient to present for treatment as promptly as possible.

A patient who presents with moderate symptomatology is treated at an emergency level for 4-6 hours; after this period of time has passed, if the attack remains refractory to bronchodilation attempts, the patient is in immediate need of intensive care unit (ICU) admission [14] [15]. Nevertheless, other studies have shown that failure of the attack to resolve within the first 2 hours of treatment greatly reduces the possibilities of its responding in the next hours; in the light of this information, a physician may decide upon ICU treatment earlier than the 4-hour period.

Etiology

With regard to the exacerbation of asthmatic attacks, they can arise in two ways [3] [4]:

  • Slowly exacerbating attack, which develops insidiously over a period of days, before it reaches the state of status asthmaticus.
  • Sudden onset asthma exacerbation, in which case the asthmatic status is reached within a period of hours, as opposed to days.

The etiology of status asthmaticus regards either factors related to the patient, or environmental factors. On the one hand, poor patient compliance, inadequate treatment and psychological factors can play a vital role and lead to the patient presenting with the severe symptomatology of an asthmatic attack. On the other hand, exposure to allergens the patient is strongly sensitive to, food allergies and sensitivity to nonsteroidal anti-inflammatory drugs are some of the most common culprits behind an asthmatic status, that is unrelated to patient compliance. Individuals with a strongly atopic profile exhibit an increased risk of experiencing such an attack when exposed to allergens.

Epidemiology

Status asthmaticus is a presentation of asthma that seems reserved for individuals living in underprivileged conditions, due to the lack of proper management and professional care [5]. During the past years, deaths caused by status asthmaticus have indeed shown a steady increase, with approximately 100,000 deaths occurring annually on a global level [6]. Death can occur due to asthma in cases that the attack leads to severe respiratory compromise; usually, death occurs to individuals suffering from severe disease that is unmanageable, but can arise in any case of well-controlled asthma, which is acutely exacerbated [7] [8].

Sex distribution
Age distribution

Pathophysiology

Asthma is a condition that affects the airways and respiratory capacity, that is strongly triggered by allergen reactions and mediated by the release of cytokines and other cellular substances. In general, the initial stages of asthma can be treated with the administration of bronchodilators, such as short- and long-acting β2 antagonists. Failure to control the mild asthmatic attack, inadequate patient compliance or an exposure to an allergen that is too strong for an individual with a profoundly atopic profile may lead to severer consequences and death.

The exacerbated type of asthmatic attack that is accompanied by the greatest risk of death is status asthmaticus, namely an attack so severe that it does not respond to the standard bronchodilation therapy and threatens the respiratory function. Usually, an individual is exposed to an allergen they are intensely sensitive to; this leads to the release of histamine, leukotriene C4, prostaglandins and various other mediators of the inflammatory process. The airway undergoes profound bronchospasm and becomes edematous, while the permeability of the capillaries is augmented and mucus is over-produced. As a result, the airway is put at a considerable risk of mucus occlusion, which is the most common cause of death induced by status asthmaticus.

Secondary to mucus occlusion, pulmonary hyperinflation in combination with the distended alveoli and the mismatch in ventilation/perfusion (V/Q) can lead to severe hypoxia and potentially cardiac arrhythmias, which can also threaten the life of the patient [9] [10] [11].

Prevention

In order to manage status asthmaticus and prevent its recurrence, patients need to be educated concerning the medications they need to take at home, the treatment scheme and how to recognize a pending attack. Each individual suffering from asthma should avoid exposure to strong allergens.

Drugs used at home to prevent the exacerbation of an asthma attack, such as inhaled β2 antagonists and corticosteroids should be taken responsibly and adequate follow-up should not be neglected.

Summary

Status asthmaticus is an acute attack of asthma that does not resolve with the administration of the standard treatment, which comprises β2 adrenergic antagonists [1]. It may be caused by poor patient adherence to the treatment scheme, inadequate medications prescribed or the over-exposure to an allergen.

The attack may develop over the course of some days, or, in the most extreme cases, over a few hours; diagnosing the condition and treating it properly are pivotal in order to prevent respiratory and subsequently cardiac compromise [2].

A patient who presents with an asthma attack is initially treated with inhaled β2 adrenergic antagonists, corticosteroids, anticholinergic medications and oxygen. If the attack is refractory to continuous attempts, it is considered status asthmaticus and the patient needs to be monitored closely due to the considerable hazard which exists for the respiratory system. Based on clinical criteria, the decision to move the patient to an intensive care unit and intubate may be required to prevent complications.

Patient Information

Asthma is a relatively common condition that affects the lungs. It is primarily of allergic causes and leads to inflammation and temporary constriction of the airway.

A patient with diagnosed asthma can suffer an attack when they are exposed to an allergen they are very sensitive to, when they experience stress or when their condition is poorly managed. The individual finds it hard to breathe and usually fails to speak properly, because of the inadequate breathing. Other symptoms that may be displayed are more frequent pulses than usual (over 120 per minute) and wheezing sounds that may be heard by the doctor during auscultation or even with a bare ear.

Inhaled beta-antagonists are the first step to treat an asthmatic attack, together with corticosteroids, anticholinergics and oxygen. After these medications have been administered in repeated courses, if the patient does not respond, the condition is defined as status asthmaticus and it may seriously threaten the individual's life, as breathing is severely obstructed.

Patients with status asthmaticus are carefully monitored both as far as the respiratory system and the cardiac system are concerned, since they run the risk of succumbing to a heart attack, following respiratory failure. They are usually moved to an intensive care unit (ICU) and, as a last resort, intubation may be necessary to prevent extreme respiratory distress and failure.

References

Article

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  2. McFadden ER Jr, Warren EL. Observations on asthma mortality. Ann Intern Med. 1997;127:142–7.
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  9. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 8: advanced challenges in resuscitation: section 3: special challenges in ECC. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000;102(8 suppl):I229–52.
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Last updated: 2018-06-22 06:14