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Asthma can kill.

July 5, 2011

Matthew Vasey MD1, Amal Mattu MD2



1Lincoln Medical and Mental Health Center - Weill Cornell Medical College, Department of Emergency Medicine
2University of Maryland Medical Center - University of Maryland School of Medicine, Department of Emergency Medicine

Deaths from exacerbations of asthma are exceptionally tragic events. Even in my few years as an emergency medicine resident I have gained experience with pediatric, adolescent and adult patients brought into the emergency department having taken their last breath prior to arrival or literally taking their last breath on arrival. Respiratory failure in the controlled setting can be enough of a challenge in itself, throw in an otherwise healthy, now frantically desperate twenty year-old, confused from lack of oxygen, aggressively thrashing their arms and legs seconds from fatal collapse and this exceptionally tragic scenario begins to take shape. The fact that this tragic fatal outcome is entirely preventable makes it even more so.

Research into these events after the fact has demonstrated failures by both patients and doctors to recognize the severity of the situation and respond appropriately. (1,8) Of note for the sake of conversation, one study later looked more closely and found men are less likely than women to report severe asthma symptoms and activity limitations due to asthma. (3) Asthma is a disease that affects over twenty million people, six million of whom are children. (7) That is nearly one of ten people in the United States with a potentially rapidly fatal and entirely controllable disease. Asthma affects the ability to breath in two ways simultaneously. First is through bronchoconstriction, or tightening of the airway, imagine breathing through a narrow drinking straw. Second is through inflammation, or swelling within the airway walls. It is easy to see how it would be difficult to breath effectively and have appropriate gas exchange of oxygen of carbon dioxide through a narrow and wet airway. In an exacerbation of asthma, or "asthma attack", because of the mechanisms described above, air is able to be brought into the lungs but has difficulty being pushed out compramising this healthy gas exchange. All of this leads to a suffocating and life threatening experience for the patient.

While working as an emergency physician in Brooklyn, one of my senior colleagues Dr. Marc Leber and co-authors looked back at forty-six patients who were admitted to the Intensive Care Unit or ICU due to near fatal asthma. They concluded near fatal asthma did seem to come from a lower socioeconomic group and the greatest difference between the forty-six patients with near fatal asthma and a group of similar patients without near fatal events was the use of home nebulizer. (5) A device used at home for administering aerosolized treatments such as albuterol, atrovent and normal saline for the management of asthma.

Doctors with asthma research experience agree that patient education is important in the management of the patient with asthma although there is not a consensus approach to patient education in the emergency department. (4) My suggestion is for the patient with asthma or the parent of a child with asthma to develop an Asthma Education Plan or AEP with their doctor so patients can better assess the severity of their asthma attack and better prevent fatal or near fatal asthma outcomes.

Here are separate examples of Asthma Education Plans that may be printed, discussed and considered for development at your next doctor visit:

NYC.gov AEP - Click to view
NIH.gov AEP - Click to view

With over two million emergency department visits in the United States for the management of asthma, ending up in the hospital because of asthma is not uncommon. (2) If you become one of those two million patients, hopefully able to be discharged home safely from the emergency department not requiring hospital admission, make sure your doctor educates you about your medications, inhaler technique and steps for recognizing your symptoms and treating your future asthma attacks. You should be provided a discharge plan, scheduled a follow-up appointment and prescribed enough medications to last until that appointment. (6) A team approach involving patient and doctor with individual accountability is the optimal means for prevention of the exceptionally tragic event that is fatal asthma.

References:
1. Benatar SR. Fatal asthma. N Engl J Med 1986; 314(7):423-9.
2. Camargo C, Richardson L. Epidemiology of asthma. In: Brenner BE, ed. Emergency Asthma. New York, NY: Marcel Dekker; 1999:59-80.
3. Cydulka R, Emerman C, Rowe B, Clark S, Woodruff P, Singh A, Camargo C. Differences between men and women in reporting of symptoms during an asthma exacerbation. Ann Emerg Med 2001; Volume 38(2) 123-128.
4. Emond S, Reed C, Graff L, Clark S, Camargo C. Asthma education in the emergency department. Ann Emerg Med 2000; Volume 36(3) 204-11.
5. Guishard K, Powel KA, Moshures V, Leber M, Farhat S. Factors associated with near-fatal asthma both social and medical. Ann Emerg Med - Supplement 1998; Volume 32(3) Abstract 186.
6. Lasarus S. Emergency treatment of asthma. N Engl J Med 2010; Volume 363(8):755-64.
7. National Heart Lung and Blood Institute Diseases and Condition Index. Asthma. http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhoIsAtRisk.html
8. Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults: a review. Chest 2004; 125:1081.
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