What is an asthma attack?
Asthma by definition is a heterogeneous disease, usually characterised by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity. Together with variable expiratory airflow limitation. With an asthma attack these conditions worsen significantly and the focus is on monitoring, managing and, if possible, reversing them.
Asthma deaths during an asthma attack.
In later decades acute asthma deaths in Ireland have fallen from a peak of around 160 per year to current of about 50 or about one person per week dying from an acute asthma attack even with the rise of number of asthmatics in the country. The reason for this sharp decline may reflect the increasing use of evidence-based care and inhaled corticosteroids. Why people with severe asthma attacks die is unclear. More recently, the National Review of Asthma Deaths in the UK and Northern Ireland was completed and report published in 2014. This and other studies have shown that around 90% of asthma deaths have preventable factors. An Irish study into asthma deaths in the 1980s highlighted delays in obtaining appropriate medical help, poor objective measurement of asthma severity, infections, inappropriate sedation and under-treatment of the asthma condition were contributing factors.
This recent confidential inquiry into over 200 asthma deaths in the UK and N. Ireland (Royal College of Physician 2014) concluded that most of these deaths occurred before admission to hospital. Most patients were elderly with chronic severe symptoms, in a minority the fatal attack occurred suddenly in patients with mild disease. However, there were preventable factors such as:
Most of the attacks of asthma which were severe enough to require hospital admission develop relatively slowly over a period of six hours or more (over 80 per cent developed over more than 48 hours). There is therefore time for effective action to reduce the number of attacks requiring hospitalisation.
Patients had more likelihood of a hospital admission or ED visit for their asthma in the previous year, and more likelihood of a previous near-fatal attack.
Inappropriate sedation without specialist monitoring or ICU access was seen (assessment and monitoring (PF, O2 sats, signs) use of sedation, and over use of β2-agonists.
Heavy or increasing use of β2 agonist therapy alone without other therapy such as corticosteroids was associated with asthma deaths. In many cases patients received inadequate treatment with inhaled corticosteroids or steroid tablets and/or inadequate objective monitoring of their asthma.
Adverse psychological and behavioural factors: those who died were significantly more likely to have learning difficulties, psychosis or prescribed antipsychotic drugs, financial or employment problems, repeatedly failed to attend appointments or discharged themselves from hospital, to have drug or alcohol abuse issues, obesity or a previous near-fatal attack. Healthcare professionals thus must be aware that patients with uncontrolled asthma and one or more adverse psychosocial factors may be at risk of death during an asthma attack
Follow up of an attack or flare up was inadequate with widespread underuse of written management plans.
Acute Asthma Guidelines
The twin aims of the National Clinical Programme for Asthma (NCPA) are to maximise the health and quality of life of people with asthma and prevent avoidable mortality.
As part of that remit the NCPA has also collaborated closely with the National Clinical Effectiveness Committee (NCEC) at the Department of Health to develop and recently launch the National Clinical Guideline for the Management of an Acute Asthma Attack in Adults.
There is also an acute guideline in children. These guidelines are necessary because in Ireland, asthma affects about 460,000 patients but over 50 per cent have an uncontrolled asthma condition. Uncontrolled asthma leads to an average annual 50,000 attendances to GPOOH services and almost 20,000 attend ED with asthma attacks, and over 5,000 hospital admissions, including some to ICU.
About one patient per week dies with asthma, while generally elderly, younger children and adults also die needlessly from this very treatable and manageable condition.
What are the criteria for referral
and admission to hospital?
The initial assessment of a patient with an acute asthma patient attack is whether this is a life threatening or severe attack. Such patients are at increased risk and will likely require admission. Therefore, refer to hospital any patients with features of acute severe or life-threatening asthma.
In addition, adult patients with any feature of a life-threatening or near-fatal asthma attack or a severe asthma attack that does not resolve after initial treatment should be admitted to hospital. Admission may also be appropriate when peak flow has improved to greater than 75 per cent best or predicted one hour after initial treatment but concerns remain about persistent symptoms, previous history or psychosocial issues.
Discharge following an asthma attack
Following discharge from hospital or emergency departments, more than 15 per cent may re-attend the ED within two weeks. Education will reduce this significantly.
Prior to discharge, asthma education provided by trained staff with a focus on inhaler technique and PEF record keeping, providing a guided written PEF and symptom-based management plan have been shown to reduce morbidity after the asthma attack and relapse rates by up to 65 per cent in ED and GP out of hour’s attendances and hospitalisations for asthma.
Follow up should be arranged prior to discharge with the patient’s general practitioner or GP practice asthma nurse within two working days and after a hospital admission for acute asthma attack follow up with a hospital specialist asthma nurse or respiratory physician around one month after admission and also followed up in specialist OPD for at least one year or if this was a near fatal asthma attack then, indefinitely.