Asthma attack

Pediatrics for Parents, August, 2004 by John E. Monaco

According to his mother, Andrew has had asthma all his life. Now, at age 13, she feels she understands his disease well. He has been admitted to the hospital more times than she can count, and he knows the local emergency room staff all too well. She has seen him have attacks when he has colds, when the weather changes, when he is stressed at school, after shampooing the rug, and sometimes for no reason at all. He has always been good about telling his mother exactly how he feels, and although he has been quite sick at times, she has always felt that they have gotten him the medical care he needed in plenty of time.

This time, things were different. They had recently moved, and changed schools and, perhaps most importantly, changed doctors and hospitals. Still, Andrew's mom always made sure the nebulizer worked, so aerosolized breathing treatments could be given at the earliest sign of an attack. He had been prescribed Singulair and Advair, two asthma medications designed to stabilize the inflammatory response, in an effort to prevent attacks. He was protected, or so she thought.

This particular morning, Andrew woke up and told his mother he couldn't breathe. This had happened many times before. They had established a routine that if Andrew woke up in this state, he would try a couple of breathing treatments with albuterol, and if his breathing didn't improve, she would take him to the pediatrician or to the emergency room, depending on the time of day and how sick she thought he was. But this time the breathing treatments only worked for a short period. And as soon as the treatment ended, Andrew would say he felt "tight" again.

After trying this three or four times, she decided to take him to the doctor. She delayed a little more than usual because this time would be their first visit to this new pediatrician. Luckily, he wasn't too busy and took them right in.

When Andrew arrived he was in significant distress. He was barely able to get into the exam room without having his mother hold him up. Once in the room, he did not have enough respiratory volume to speak. He breathed with pursed lips, and sat in the "tripod" position on the examining table (hunched over, leaning on his hands).

What struck the pediatrician most, however, was the look of panic on Andrew's face. Recognizing all these signs as those of impending respiratory failure, he placed Andrew in an oxygen mask, hooked to a portable oxygen tank he kept in the office for emergencies like these. Then, wasting as little time as possible, he placed Andrew in his own, private car and drove him to the emergency room at our hospital, only a couple of blocks away.

He was taken in immediately, IVs were started, and breathing treatments and high concentration oxygen were begun. Within minutes, he relaxed, but just as his mother experienced, the minute the albuterol treatments were stopped, he began to have difficulty breathing again.

This was when our team was called. We brought Andrew up to the pediatric intensive care unit (PICU), where we started continuous albuterol treatments for one hour. He was given IV steroids and antibiotics. Again, while the treatments were going, he appeared more relaxed. When they were interrupted the panicked look returned to his face, signifying severe respiratory distress.

His physical exam was remarkable for one very important finding--no breath sounds could be heard through the stethoscope against his chest. This means we couldn't hear any air movement. This sometimes happens in severe asthma attacks, where the presence of wheezes actually signifies improvement since it at least marks some degree of air exchange.

Andrew required several types of treatment that are infrequently used, but available for these situations. First, he was given continuous albuterol throughout the entire night. Continuous exposure to the bronchodilator allows the deeper airways to receive benefit gradually as the larger, more peripheral airways finally began to dilate. This can be a very gradual process.

Secondly, we made heliox available to Andrew. Heliox is a mixture of oxygen and helium. Room air is a mixture of primarily oxygen and nitrogen. Helium, being lighter than nitrogen, allows for easier airflow into the smaller airways, easing work of breathing while treatment continues.

Thirdly, he received magnesium sulfate intravenously. This works by theoretically relaxing smooth muscle allowing for better air exchange. In Andrew, luckily, all these measure seemed to work to some degree, buying time for the other measures, steroids, bronchodilators, to begin to do their job.

Eventually, about eight hours into his treatments, Andrew began to improve. The first sign that he had improved was that his work of breathing lessened. This is perhaps the most important respiratory sign in pediatrics--even more important than how lungs actually sound. Eventually, however, we could actually hear a small amount of air movement when listening with the stethoscope. But the final sign, the one that I knew heralded Andrew's improvement, was his smile, which replaced the panicked look he had shown throughout most of the day.