This is the protocol for Asthma:Asthma
Let’s break it down!
With as common as asthma is, most people have either experienced asthma at some point in their lives or known somebody diagnosed with it. In the US, asthma affects more than 25 million people and it’s the most common chronic disease of childhood (affects 9.5% of children).
Although soldiers are typically barred from enlisting if they have had any asthmatic episode past the age of 13, we all know what our recruiters told us to say…. which is nothing. With that being said, soldiers who experience asthma will likely be aware of their history of asthma and will hopefully be forthcoming about it when an episode occurs. For more info about the pathophysiology of Asthma, check out the osmosis video below:
In addition to dyspnea (shortness of breath) and decreased oxygen saturation, one of the hallmark signs of asthma is wheezing. You may be able to hear as you approach the patient or you might only be able to hear it upon auscultation. One common misconception about asthma is that patients have a problem getting air into their lungs. The real problem, however, is that patients can’t get air OUT of there lungs. Because of this, the wheezing will typically be heard upon expiration, not inspiration. In severe cases, you’ll hear nothing at all. This is called “Silent Asthma“, which is an indication that no air is passing at all.
Another complication of bronchoconstriction is what’s known as “air stacking“, which is when the air trapped inside the bronchioles begins to build up and actually put significant pressure on the heart. Subsequently, you may find your asthma patients with a remarkably low diastolic blood pressure.
Patients who can only speak in 1 or 2-word sentences are typical. Patients in respiratory distress may also posture in the classic tripod position to help facilitate the usage of accessory muscles to breathe. To get an idea of what this looks like, check out the video:
The mainstay treatment for asthma is plenty of albuterol. Albuterol is a beta 1 agonist medication, which means it acts as a bronchodilator. This will help expand the bronchioles and allow more air to flow in and out of the lungs. In most cases, albuterol is enough to control your average asthma attack. You can administer it via a meter-dosed inhaler, or you can use a nebulizer. Below are videos explaining how to do both:
If shit starts hitting the fan and the albuterol isn’t helping, then it’s time to bring out the big guns: Epinephrine and Dexamethasone
Epinephrine is also a very potent bronchodilator that’ll help with oxygen exchange. In many cases, albuterol doesn’t work because the abnormal mucous production is asthma inhibits the actual delivery of the drug to the deeper portion of the lungs. Using epinephrine is useful because you can bypass this struggle and just give the medication via IM. The protocol states 0.5mg of epinephrine, but if all you have is a 0.3mg Epi-pen, then you can use that.
Dexamethasone (Decadron) is a corticosteroid, which helps reduce the inflammation in the lungs. Although you won’t typically see rapid results from dexamethasone, it’s safe for the patient and it’ll help aid in recovery. If you don’t have dexamethasone, you can use another steroid like Methylprednisolone (Solu-Medrol).
3. Establish IV access
IV access will be important for follow up treatment, whether that be for additional future medications or for fluid boluses to counteract the pressure on the heart from air stacking. Either way, it’s a must-have for any critical patient.
4. Oxygen w/ pulse oximetry monitoring
This should probably actually be one of the first things you do. Hypoxia will be one of the first problems to arise from asthma; it would behoove you to get ahead of it. If the patient isn’t getting oxygen already from the albuterol treatment, then using a non-rebreather O2 mask would be the best. If the patient cannot tolerate a face mask, then nasal canula will work.
5. If fever, chest pain, and productive cough, consider Bronchitis/Pneumonia protocol
Asthma is not an infectious process so we shouldn’t really be expecting any fever. Chest pain is possible, but it won’t be localized to a particular area of the chest as pneumonia would. Asthma doesn’t typically cause any profound coughing. The treatment for bronchitis/pneumonia is similar, but may also involve antibiotic treatment.
Mild episodes of asthma may only last for a few minutes, but more severe ones can last for hours or days. Asthma is treatable, but it’s also not something we want to play around with. There’s always a risk of back-to-back episodes of asthma so it’s important to continue medications even after the patient responds well. If your initial treatment isn’t going as planned, then an Urgent evacuation is a must. Some asthmatic patients crash quickly and will ultimately require intubation and a lengthy stay in the ICU.
Good luck out there!
- EMRAP Corependium: Asthma
- UpToDate: Acute exacerbations of asthma in adults: Emergency department and inpatient management
- Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, 2005-2009. Natl Health Stat Report. 2011;(32):1–14.
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.