Professional Documents
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Asthma: Pathophysiology
Pathophysiology
1. Extrinsic or intrinsic factors
trigger an airway reaction
2. Patient develops bronchospasm
and bronchoconstriction.
3. Patient develops bronchial
edema/inflammation.
4. Increased mucous production
forms a plug in the smaller
airways.
5. Difficulty exhaling – air trapping
6. Poor gas exchange. Hypoxia,
hypercarbia.
7. Increased respiratory water loss
– dehydration.
8. ABG’s or capnometry shows
PaCO2 is low (if patient is still
wheezing. High PaCO2 / ETCO2
respiratory / ventilatory failure.
Asthma: Assessment Findings
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Use the beta drugs with caution on patients that are over 55 y.o., excessively
tachycardic (>130), history of hypertension or cardiac problems.
CEU Article # 7
“Asthma Attack!”
By Bob Page, AAS, NREMT-P, CCEMT-P, I/C
Director of Emergency Care Education
St. John’s Regional Health Center
Springfield, Missouri
Case Presentation
On a cool, crisp autumn night, you are called to a residence for a person
who is having trouble breathing. On arrival you locate the patient, a 28
year old man who appears to be in acute respiratory distress. You discover
that his name is Bill Miller and that he has a history of asthma. He states
this latest attack started about 25 minutes ago and he has used his
“inhaler” twice without relief. He tells you he believes that his puffer is
empty.
Room air pulse oxymetry (SpO2) shows 92% and a pulse rate of 98. You
apply humidified O2 via non rebreather mask at 15 lpm. Within 3 minutes,
the pulse ox reads 94% yet Bill is still not breathing any easier. An IV is
established of Normal Saline running at 125cc/hr. Cardiac monitor is
applied and shows a sinus rhythm rate of 98 with normal axis and narrow
complexes. You prepare to administer albuterol via small volume
nebulizer. The patient is familiar with the device and immediately picks it
up and begins using it. After about 5 minutes, he nods his head to
acknowledge that the medication is helping him breathe easier.
There are two basic types of asthma. The first one is called extrinsic
asthma and involves acute episodes triggered by an allergic reaction to an
inhaled irritant. Frequently there is a family history of allergies like
hayfever. The onset usually occurs during childhood or in young adults.
About 50% of the time it occurs before age 10. Childhood asthma usually
improves with age. The second type of asthma is intrinsic asthma. In this
disease, other types of stimuli initiate the acute attack. These stimuli
include respiratory infection, exposure to cold air, exercise and exertion,
drugs such as aspirin, stress, and inhalation of irritants like cigarette
smoke. Intrinsic asthma usually has an adult onset after age 30 in 33%.
Many patients have a combination of the two types.
Pathophysiology
Assessment Findings
The assessment can begin enroute by simply knowing what time it is.
Because our circadian rhythm (internal clock), naturally occurring anti-
inflammatory hormones are at high levels in the morning and low at night.
For this reason, asthma conditions often get worse at night. On initial
assessment you will usually find the patient sitting upright, leaning forward
with hands on knees. This is referred to as the “tripod position”. They are
frequently and obviously using accessory muscles to breathe. Retractions
may also be noted. Less obvious is accessory muscles of the abdomen
that are used for exhalation. Sometimes you may need to place your hand
on their abdomen as they breathe to feel for accessory muscle use. The
patient may also have a productive cough of thick, tenacious mucous. This
is encouraged!
The best way to avoid an attack is to avoid the asthma causing irritants or
drugs like aspirin. Good ventilation in the home and workplace are
recommended. When an attack occurs, controlled breathing techniques
and a reduction in anxiety often lesson the severity and the extent of the
attack because a feeling of panic often aggravates the condition. Regular
swimming sessions are of great benefit, particularly to children, to
strengthen chest muscles and improve cardiovascular fitness.
Try to calm and reassure the patient. Coach their breathing efforts. Allow
the patient to assume the most comfortable position for breathing. If the
patient has their own inhaler and knows how to use it, allow them to do so.
In some jurisdictions, EMT-B’s are allowed to assist in the delivery of an
albuterol inhaler after first contacting Medical Control. Contact your
Medical Director to find out what your service allows.
ALS Care
Although albuterol and other beta 2 drugs are designed to have minimal
cardiac effect, it has been reported to increase heart rate or some ectopy.
Therefore, a cardiac monitor should be utilized when a patient is using
these drugs. A few cases of reflex bronchoconstriction have been reported
after albuterol administration so be aware of this fact.
In the event the patient is not moving air well enough or is unconscious
and can not hold a nebulizer, you could try terbutaline (Brethine ) 0.25
mg via subcutaneous injection. Terbutaline is another beta 2 specific drug
that has worked very well in acute asthma. Again, as with any beta drug,
monitor heart rate and rhythm carefully as terbutaline can cause
tachycardias.
In cases that are refractory to the above drugs, the old standby,
epinephrine may be used in subcutaneous injection. The dose is 0.3 to 0.5
mg of 1:1000. Pediatric dose is 0.01mg/kg (of 1:1000) Watch carefully for
tachycardias. Use epinephrine with extreme caution, if at all in patients
with known cardiovascular disease or those over age 55. Today’s beta 2
drugs are as effective as epinephrine and should be used before as to
minimize possible cardiovascular effects.
Status Asthmaticus
Summary
Selected References
Name:
Address
City/state/Zip
A. Histamine B. Albuterol
C. Atropine D. Prothrombin
C. Edema D. Bronchdilation
A. True B. False
9. A patient suffering an asthma attack loses his/her radial pulses upon inhalation. This
condition is called..
10. Which of the following medications prescribed to a patient would indicate a possible
history of bronchoconstriction or asthma?
A. Nitroglycerin B. Insulin
C. Digitalis D. Ventolin
EMT’s STOP HERE: Paramedics must complete questions 11-15 for category IB credit.
A. Albuterol B. Methylprednisolone
C. Terbutaline D. Metaproterenol
A. Vasodilation B. Bronchoconstriction
C. Bronchodilation D. Diuresis
15. Which of the following drugs is generally NOT effective in the acute asthma attack?
C. Alupent D. Atrovent
Return Quiz and Self-addressed stamped envelope to St. John’s EMS Education Programs
1235 E. Cherokee
Spriingfield, MO 65804
• Asthma
Conclusions: Natural virus infection and real life allergen exposure in allergic asthmatic
children increase the risk of hospital admission. Strategies for preventing
exacerbations will need to address these factors.exacerbations: virus infection and
allergen exposure increase the risk of asthma hospital admissions in children