(December 23, 2008 - Insidermedicine) On a recent trip to Washington, we caught up with Dr.Stephen Teach, (MD, MPH) who is the Associate Chief of the Emergency Medicine and Trauma Center, and Associate Director of the Children's Research Institute Center for Clinical and Community Research, at the Children's National Medical Center. Dr. Teach is also a professor of pediatrics and emergency medicine at the George Washington University School of Medicine and Health Sciences.
What is asthma?
Asthma is a chronic disease of the lungs in which the tubes which transport air from the environment around us down into the air sacs in our lungs become inflamed and constricted so that instead of being wide open and easy for air to pass through, they get swollen and constricted, and the area that the air has to flow through is constricted, causing wheezing coughing, shortness of breath, or chest pain. Those symptoms wax and wane, and children in particular can go through long periods where they have virtually no symptoms at all, and then that period of relative quiet of the disease can be interrupted suddenly by what’s called an acute exacerbation, or, more commonly, an asthma attack, in which the child will relatively quickly become short of breath, will start working heavily to breath with the chest going up and down, the muscles between the ribs sucking in and out, the stomach going in and out, the child will often times look very anxious, agitated, or complain of pain in the chest, and will be coughing a great deal. Those are signs that the asthma is really suddenly out of control, and caregivers need to be tuned in to those symptoms. The best thing at those points is to have a plan organized ahead of time whereby medicines can be delivered to reverse the acute exacerbation.
When should a trip to the Emergency Department be considered?
When it reaches a point when a family may want to actually seek care in an emergency department, the child’s work at breathing may be extreme, the child may be turning blue around the lips, the child may be unable to talk in complete sentences, and may be coughing a great deal. That is really a time when a family should drop everything that they’re doing and pay all of their attention to the child, and even considering calling 9-1-1 and arranging emergency transport to the hospital.
What types of therapy are available following an asthma attack?
All families that have a child with asthma in the home should be prepared for an acute sudden severe asthma attack. The cornerstone of acute therapy is the use of short acting beta-agonists, the most common of those is albuterol. It comes in two forms, it can be delivered by a nebulizer, or increasing popular is delivery by an inhaler.
What should be expected after presenting to the emergency department?
More and more emergency departments are developing very well organized systems of care to deal with children who are suffering acute asthma exacerbations. Remember that there are more than 700’000 visits to emergency departments nation-wide due to asthma every year, so it’s a very common disorder, and emergency departments increasingly have very systematic ways to approach it. These are called Asthma Care Clinical Pathways, so that if a child presents to the emergency department, what a family should expect is that their child will be identified as asthmatic, identified as having an acute asthma exacerbation, and then started immediately on therapy to open the lungs up. Typically that therapy consists of two things; one is going to be a short-acting beta-agonist, better known as albuterol, and the second, most of the time, will be oral dose of a steroid medicine. Steroids work in the short term to decrease the inflammation and swelling in the tubes and open them back up so that the child can breath more easily.
If I had a child who was having an asthma attack, the first thing I would do is assess the severity of their symptoms; I would try to look at how fast they’re breathing, how hard they’re working to breathe, whether they’ve turned blue around the lips, whether they’ve become sleepy and their mental status is beginning to change. Then I would grade my response based on how severe the attack was. If it is a relatively minor attack then I might just start breathing treatments, usually with breathing treatments of albuterol, usually just with an inhaler – 2-3 puffs using a proper spacing chamber device, and then see the response to that, and then continue those treatments every 3-4 hours. For more severe attacks a family should have a plan for giving more albuterol back to back, while they are on the phone seeking asthma care from their primary care provider, or possibly even calling an ambulance to take them to an emergency department.