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Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
Methacholine challenge: PC 20 : 1.0 mg/mL
Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
Sinus CT: Mild mucosal thickening
Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
Immunoglobulin E (IgE): 25 IU/mL
Allergy-skin test: Positive for dust, trees
Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

Esophagram/barium swallow: Negative
Esophageal manometry: Negative
Esophageal impedance: Within normal limits
ECG: Within normal limits
Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2 One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2 The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5 Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2 A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10 In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10 Shortly after the AIR trial, the Research in Severe Asthma (RISA) trial was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11 In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11 Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2 trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6 Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6 In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6 Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both the AIR and the AIR-2 trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12 Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12 This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7 This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

Introduction

Asthma affects over 18 million adults and more than 6 million children in the US. Thus acute exacerbations are common ED presentations, accounting for 1.6 million visits per year in the US. Patients with acute asthma exacerbations present with symptoms ranging from cough and chest tightness to dyspnea and audible wheezes to respiratory failure. A common medical adage states that “not all that wheezes is asthma.” Several other conditions can mimic asthma, including chronic obstructive pulmonary disease (COPD), acute decompensated heart failure (ADHF), acute coronary syndrome, pulmonary embolism, pneumonia, pneumothorax, and airway foreign body. However, acute asthma can usually be diagnosed with a thorough history and physical exam.

Initial Actions and Primary Survey

When approaching a patient with an asthma exacerbation, a clinician needs to quickly evaluate the patient’s airway, breathing, and circulatory status; determine the severity of this episode; and decide whether the patient needs immediate airway support including intubation. Factors such as vital signs (especially respiratory rate and pulse oximetry), signs of respiratory distress (such as ability to speak and use of accessory muscles), pulmonary exam (including wheezes and amount of air movement), and mental status are important components of this initial assessment/primary survey. Remember that lack of wheezing can be an ominous sign in a patient with respiratory distress and poor air movement.

If the patient’s respiratory status allows, a history should be obtained, focusing on current symptoms, prior episodes, known precipitants, home asthma control regimen, medication compliance, and other comorbidities. Risk factors for death from asthma include prior intubation and/or ICU admission, recent ED visit or hospitalization for asthma, recent/last course of steroids, frequent asthma-related ED visits or admissions, frequent use of “rescue” short-acting beta agonists (SABAs) such as albuterol, and cardiopulmonary comorbidities. It is important to note that a lack of risk factors does not eliminate the risk of severe morbidity and mortality.

As mentioned above, the exam should focus on assessing the severity of disease and identifying signs of respiratory distress/failure. The clinician can use other portions of the exam to identify/exclude other causes of dyspnea (e.g., neck exam for jugular venous distention, cardiac exam for murmurs or gallops, extremity exam for peripheral pulses or edema).

Depending on the severity of the current exacerbation, a patient may initially require continuous cardiac monitoring and/or pulse oximetry, supplemental oxygen, initiation of therapy with inhaled SABAs and anticholinergics, administration of steroids, use of non-invasive positive pressure ventilation (NIPPV), and/or rapid sequence induction (RSI) and intubation.

Presentation

Asthma is a chronic inflammatory condition resulting in hyperresponsiveness to environmental and infectious exposures. Airway smooth muscle obstruction, bronchospasm, and mucosal edema then ensue. An acute exacerbation is usually characterized by progressive cough, shortness of breath, chest tightness, and wheezing.

Common triggers include infection (upper respiratory infection in adults, respiratory syncytial virus/parainfluenza in children), exposure to cold or dry environments, stress, physical exertion, or inhaled irritants (e.g., dust, cigarette smoke, air pollution).

Diagnostic Testing

The ED diagnosis of acute asthma is usually made by thorough history taking and physical examination. Diagnostic testing is often unnecessary unless the diagnosis is uncertain or a complication is suspected. Furthermore, testing should not delay the initiation of treatment.

Laboratory testing: A complete blood count may be obtained if infection is suspected; however, its usefulness is limited as the white blood cell count may be elevated in acute asthma without any underlying infection. For patients who take theophylline, a level may be drawn although it would not help determine further management. A basic metabolic panel may be helpful in patients with kidney disease, those on diuretics, or those who will require multiple doses of SABAs (as beta agonists can lower potassium levels by shifting it intracellularly).

Blood gas: Although blood gases are unnecessary in most patients with an asthma exacerbation, they can provide useful information in those who remain hypoxic despite supplemental oxygen, are unresponsive to initial therapy, or are in severe respiratory distress. Blood gases are used to assess for hypoxia, hypo-/hypercarbia, and acidosis. Hypocarbia and respiratory alkalosis are expected findings in tachypneic patients while normal or elevated pCO2 levels and metabolic acidosis are markers of impending respiratory failure. Although blood gas results can aid in identifying respiratory failure, they should be used in conjunction with a patient’s clinical status to determine the need for intubation. While venous and arterial blood gases are equivalent in their ability to assess pCO2 and pH, venous blood gases are less painful to obtain and, therefore, may be preferred unless accurate pO2 levels are necessary.

Chest radiography: Chest x-ray (CXR) is not routinely indicated for patients with acute asthma. In most cases, the CXR is normal or shows hyperinflation or atelectasis, and the results would not affect any therapeutic decisions. It can aid in identifying/excluding alternative diagnoses such as pulmonary edema or pneumonia. Additionally, it can be useful if a complication such as pneumothorax or pneumomediastinum is suspected.

Peak flow measurements: These can be useful bedside tests to aid in the assessment of disease severity and response to treatment as well as in final disposition decisions They are measured using a peak expiratory flow rate (PEFR) meter or a handheld spirometry machine that determines the forced expiratory volume in one second (FEV1). Both devices measure velocity of air flow and degree of airway obstruction. Although these devices are simple and inexpensive to use, they are effort dependent. As a result, they may have limited utility in pediatric patients and others who are unable to perform the test. If used, serial measurements should be obtained (e.g., upon initial presentation and 1 hour after each SABA treatment). Measurements during an acute exacerbation can be compared to a patient’s baseline, if known. Normal predicted peak flow rates are based on age, gender, and height. Tables of normal predicted peak flow rates are easily available online. Peak flow measurements should only be used in conjunction with other indicators of clinical status to make therapeutic and disposition decisions.

Therapy is determined by the severity of the exacerbation based on vital signs, work of breathing, and PEF (peak expiratory flow) or FEV1 (forced expiratory volume 1 sec). Mild exacerbations are characterized by normal vital signs (including pulse oximetry > 90%), mild wheezes and minimal work of breathing, and PEF or FEV1 > 70% of predicted. Patients with moderate exacerbations demonstrate an elevated heart rate and respiratory rate with pulse oximetry > 90%, increased work of breathing, and PEF or FEV1 40-69% of predicted. Those with severe acute asthma present with abnormal vital signs including pulse oximetry < 90%, significantly increased work of breathing, altered mentation, and PEF or FEV1 < 40% of predicted.

The goals of treatment of acute asthma include:

Correction of significant hypoxemia
Rapid reversal of airflow obstruction
Reduction of the likelihood of relapse

Patient with mild to moderate exacerbations may only require inhaled SABAs and ipratropium and steroids while those with severe exacerbations may also benefit from IV magnesium. Those in more severe distress may need NIPPV or intubation.

Individual treatment options are discussed below.

β2-adrenergic agonists: SABAs (most commonly albuterol) are first line therapy for acute asthma. They can be delivered via nebulizer or metered-dose inhaler (MDI) plus spacer. MDIs with spacers are as effective as nebulizers although MDIs without spacers require more supervision to ensure proper usage. Nebulized albuterol is usually given 2.5-5 mg every 20 minutes for up to 3 doses, followed by 2.5-10 mg every 1-4 hours as needed. Continuous nebulized albuterol may be used in patients with severe exacerbations. The dose of “continuous” albuterol is 10-15 mg/hr (0.5 mg/kg/hr in children). Onset is 5-15 minutes with peak effect within 2 hours. Adverse effects may include tremor and tachycardia. Additionally mild hypokalemia may occur due to potassium being shifted intracellularly.

Levalbuterol is another SABA that can be used to treat acute asthma. However, it does not provide any clinical advantage over albuterol and is more costly.

Although important in maintenance therapy, long-acting beta agonists (e.g., salmeterol) do not have a place in acute exacerbations.

Anticholinergic agents (ipratropium): Inhaled ipratropium is used in moderate to severe exacerbations. Studies have shown that combining ipratropium with SABAs provides an advantage over using it as a single agent. Due to its anticholinergic effects, it may inhibit airway secretions. It can be combined with albuterol in a nebulized form (Duoneb) or in an MDI (Combivent). It is administered as 500 microgram (2.5 mL) every 20 minutes up to 3 doses, followed by 2.5 mL every 6 hours as needed. There is no apparent benefit beyond 3 back-to-back treatments.

Corticosteroids: These are another fundamental component of acute asthma treatment. They are administered to reduce airway inflammation and obstruction as well as to decrease the rate of relapse. Early steroid administration is correlated with decreased rates of hospitalization, perhaps in part due to the delayed onset of action (4-6 hours). Steroids may be given orally or intravenously (IV) with equal efficacy. In general, the oral form is preferred unless a patient’s clinical condition warrants IV administration (e.g., inability to swallow or tolerate oral medications, severe respiratory distress). All steroids can produce similar side effects (i.e., hyperglycemia, hypertension, decrease in potassium, fluid retention, and even mood symptoms) although short courses of steroids convey little risk of serious adverse events.

Common oral steroids include prednisone, methylprednisolone, prednisolone, and dexamethasone. Dexamethasone, hydrocortisone and methylprednisolone are frequently encountered IV forms. The optimal dosage and duration of therapy is somewhat controversial although prednisone 40-80 mg/day orally or methylprednisolone 40-80 mg/day IV are common. The initial dose is usually followed by a 3-10 day “burst” of continued steroids depending on the severity of the exacerbation. Dexamethasone can be administered once in the ED and once in the next 1-2 days with equivalent effect to a 3-5 day burst of prednisone.

Although inhaled corticosteroids are not recommended for acute asthma, they are useful to help prevent acute exacerbations. While they are not currently recommended in an acute asthma exacerbation, they should be considered in patients with frequent exacerbations or frequent need to use SABAs.

Epinephrine: The beta-agonist activity of epinephrine causes bronchodilation. It is useful as an adjunct therapy in severe acute asthma, especially if not responsive to initial treatment with SABAs. Although epinephrine can be administered intramuscularly (IM) or subcutaneously (SC), studies have shown that IM epinephrine provides faster and more consistent delivery of medication than SC. The adult and pediatric doses of 1:1000 are 0.3-0.5 mg of 1:1000 IM and 0.01 mg/kg (up to 0.3-0.5 mg) IM, every 20 minutes for up to 3 doses.

Magnesium: Although magnesium sulfate has shown some benefit in severe asthma exacerbations, the literature does not support its routine use, especially in mild to moderate flares. It appears to work through relaxation of the smooth muscles in the airways. The usual dose is 2 gm IV over 20 minutes, and must be given with continuous albuterol nebulization.

Heliox: This is a helium-oxygen mixture (most commonly 80:20 or 70:30) and may be used as adjunctive therapy in severe exacerbations. Because helium is less dense than oxygen, it can travel through smaller airways with more laminar flow, resulting in increased oxygen or inhaled medication delivery. In turn, this is thought to decrease the work of breathing. Hypoxic patients may not tolerate heliox in light of its lower oxygen concentration.

Agents without routine benefit in acute asthma: Antibiotics should be reserved for patients with evidence of bacterial infection as routine antibiotic dosing provides no therapeutic benefits.

Theophylline is not recommended in the treatment of acute asthma as it does not provide any additional clinical benefit and is associated with adverse effects such as tremors, nausea, anxiety, and tachydysrhythmia. If a patient is already taking theophylline, a serum level should be measured since the drug has a narrow therapeutic index.

Non-invasive positive pressure ventilation: NIPPV can be helpful in severe acute asthma by decreasing the work of breathing and improving recruitment of alveoli. Another theory is that positive pressure helps push albuterol in the periphery, and thus further help with opening of the smaller airways. Although the use of NIPPV in acute asthma appears promising, further study is needed to determine its optimal role in acute asthma management.

Intubation: Mechanical ventilation may be required in patients with severe asthma exacerbations and respiratory failure (including hypoxia and/or hypercarbia despite intervention)/arrest, respiratory fatigue, or altered mentation. It is important to remember that mechanical ventilation is not used in isolation but in conjunction with the other above-mentioned therapies. Ketamine may be useful as an induction agent due to its bronchodilatory effects, although anticipate increase in secretions in using this induction agent. Consider using glycopyrrolate. Managing an intubated asthmatic presents several challenges because mechanically-ventilated asthmatics can develop high lung pressures due to breath-stacking. This may result in barotrauma, pneumothorax or hypotension (due to decreased venous return). Permissive hypercapnia and prolonged expiratory phase in mechanical ventilation may help avoid this pitfall.

Disposition: The decision to discharge or admit a patient with acute asthma is based on their clinical course in the ED, response to treatment, and ability to access outpatient medications and obtain outpatient follow-up. Patients with persistent tachypnea, increased work of breathing, hypoxia, and/or PEF or FEV1 < 70% of predicted should be considered for hospitalization. It is important to recognize the transient hypoxia immediately after treatment with albuterol. This should improve upon brief observation. Persistent hypoxia is concerning.

If patients are deemed safe for discharge, they should go home with appropriate follow-up and a written asthma action plan, including instructions on the appropriate use of medications, and removal of any environmental precipitants. They should also have access to SABAs and receive a prescription for continued steroids (most commonly a steroid “burst” as described above).

Pearls and Pitfalls

“Not all that wheezes is asthma, and not all asthma wheezes.” The differential diagnoses for acute asthma includes COPD, ADHF, acute coronary syndrome, pulmonary embolism, pneumonia, pneumothorax, and airway foreign body. Furthermore, patients with severe asthma may not move enough air to be able to produce wheeze.
Acute asthma is a clinical diagnosis, and laboratory tests and adjunctive studies are not routinely required unless there is a diagnostic dilemma or a complication is suspected
Objective measures of lung function such as PEF and FEV1 can be useful bedside tests to aid in the assessment of disease severity and response to treatment as well as in final disposition decisions
Mainstays of treatment include SABAs and corticosteroids. Concurrent inhaled ipratropium may provide additional benefit. Consider early administration of steroids as they have a delayed onset of action.
Adjunctive therapy for severe exacerbations may include magnesium sulfate, epinephrine, heliox, and/or NIPPV.
Most patients can be managed medically. Consider intubation if the patient is in respiratory arrest or if the patient has impending respiratory failure and has failed other therapies. If intubation is necessary, permissive hypercapnia may help avoid the complications of barotrauma and hypotension.

The patient receives 3 rounds of nebulized albuterol and ipratropium as well as 50 mg of oral prednisone . Initially she remains tachypneic although her work of breathing improves and pulse oximetry is 94% on room air. On re-evaluation, she has persistent wheezing, so additional albuterol nebulizer treatments are ordered. After 5 hours in the ED, she has occasional scattered wheezing, a normal respiratory rate, and 98% room air saturation. She is able to ambulate in the ED without any respiratory distress or hypoxia. She is discharged home with a refill for her albuterol MDI, a prescription for 5 additional days of oral prednisone, a written action plan, and follow up with her primary care physician.

Camargo CA, Rachelefsky G, Schatz M. Managing Asthma Exacerbations in the Emergency Department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. Proc Am Thorac Soc. 2009; 6: 357-66. (PMID: 19675345)

Hodder R, Lougheed D, Rowe BH, FitzGerald JM, Kaplan AG, McIvor A. Management of Acute Asthma in Adults in the Emergency Department: Nonventilatory Management. CMAJ. 2010; 182: E55-E67. (PMID: 19858243)

Rodrigo GJ, Rodrigo C, Hall JB., Acute Asthma in Adults. Chest. 2004; 125:1081-1102. (PMID: 15006973)

Schauer SG, Cuenca PJ, Johnson JJ, Ramirez S. Management of Acute Asthma in the Emergency Department. Emerg Med Pract. 2013;15:1-28. (PMID: 24040898)

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Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

Hilary Pinnock 1 ,
Elisabeth Ehrlich 1 ,
Gaylor Hoskins 2 &
Ron Tomlins 3

npj Primary Care Respiratory Medicine volume 24 , Article number: 14063 ( 2014 ) Cite this article

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Health care

A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals

The self-management abilities test (SMAT): a tool to identify the self-management abilities of adults with bronchiectasis

Improving primary care management of asthma: do we know what really works?

A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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Received : 23 June 2014

Revised : 15 July 2014

Accepted : 15 July 2014

Published : 16 October 2014

DOI : https://doi.org/10.1038/npjpcrm.2014.63

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Asthma Attack!

By Hollie L. Leavitt

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This interrupted case study follows the progress of a pediatric patient who experiences an acute asthma exacerbation brought on by an environmental trigger. Students completing the case will synthesize their understanding of respiratory system anatomy and physiology with the clinical treatment of an obstructive lung disorder. Topics reviewed include bronchoconstriction and dilation, pulmonary ventilation, air flow, gas exchange, respiratory volumes, the oxygen-hemoglobin dissociation curve, pCO2, pO2, and the effects of medications used to treat asthma. Students should have an understanding of the respiratory system before starting the case and thus it is best used at the end of the respiratory system unit as a way for students to apply what they have learned to a real-world situation. The case was developed for an anatomy and physiology class for majors taught through the “flipped” method at a community college, but would also work well for students in a pathophysiology course or in pre-professional programs in health care. It may also be suitable for high school students in an advanced or honors anatomy and physiology program.

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Describe the anatomy of the respiratory passageways.
Understand respiratory system function including air flow and gas exchange.
Determine the effects of bronchoconstriction and bronchodilation on air flow.
Describe the pressure gradients required for pulmonary ventilation.
Understand respiratory volumes and how they are used clinically to assess disease.
Know how to use the oxygen-hemoglobin dissociation curve.
Predict how pCO2 and pO2 are affected by an obstructive lung disease.
Describe pathological changes in the airways and environmental factors that can lead to an acute asthma exacerbation.
Understand the effects of some of the medications used to treat asthma.

asthma; respiratory anatomy; respiratory physiology; respiratory system; lung pathology; respiratory volumes; oxygen-hemoglobin dissociation;

Subject Headings

EDUCATIONAL LEVEL

High school, Undergraduate lower division, Undergraduate upper division, Professional (degree program)

TOPICAL AREAS

TYPE/METHODS

Teaching Notes & Answer Key

Teaching notes.

Case teaching notes are protected and access to them is limited to paid subscribed instructors. To become a paid subscriber, purchase a subscription here .

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The PowerPoint presentation below includes optional slides for in-class review before presenting the case.

asthma_attack_sup.ppt (~634 KB)
How Does Asthma Work? This animated video gives an overview of asthma, including why people get it, and how it can be deadly. Running time: 5:09 min. Produced by TED-Ed, 2017.

StatPearls [Internet].

Muhammad F. Hashmi ; Maryam Tariq ; Mary E. Cataletto .

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Last Update: August 8, 2023 .

Continuing Education Activity

Asthma is a chronic disease of the air passages characterized by inflammation and narrowing of the airways. Symptoms of asthma include shortness of breath, cough, and wheezing. It commonly presents in childhood and is usually associated with conditions such as eczema and hay fever. This activity outlines the evaluation and treatment of asthma and explains the role of the interprofessional team in managing patients with this condition.

Review the epidemiology of asthma.
Identify the typical patient history of asthma.
Summarize the use of pulse oximetry and peak flow measures in the bedside evaluation of asthma.
Outline the importance of collaboration and communication among the interprofessional team members to improve outcomes in patients affected by asthma.
Introduction

Asthma is a common disease and has a range of severity, from a very mild, occasional wheeze to acute, life-threatening airway closure. It usually presents in childhood and is associated with other features of atopy, such as eczema and hayfever. [1] [2] [3]

Asthma is a very common childhood illness leading to multiple hospital admissions and increased healthcare costs. The key feature is airway hyper-responsiveness, which can be triggered by many factors. If not treated promptly, asthma has a high mortality. [4]

Asthma comprises a range of diseases and has a variety of heterogeneous phenotypes. The recognized factors that are associated with asthma are a genetic predisposition, specifically a personal or family history of atopy (propensity to allergy, usually seen as eczema, hay fever, and asthma). [5] [6]

Asthma also is associated with exposure to tobacco smoke and other inflammatory gases or particulate matter.

The overall etiology is complex and still not fully understood, especially when it comes to being able to say which children with pediatric asthma will carry on to have asthma as adults (up to 40% of children have a wheeze, only 1% of adults have asthma), but it is agreed that it is a multifactorial pathology, influenced by both genetics and environmental exposure.

Triggers for asthma include:

Viral respiratory tract infections
Gastroesophageal reflux disease
Chronic sinusitis
Environmental allergens
Use of aspirin, beta-blockers
Tobacco smoke
Insects, plants, chemical fumes
Emotional factors or stress
Epidemiology

Asthma is a common pathology, affecting around 15% to 20% of people in developed countries and around 2% to 4% in less developed countries. It is significantly more common in children. Up to 40% of children will have a wheeze at some point, which, if reversible by beta-2 agonists, is termed asthma, regardless of lung function tests. Asthma is associated with exposure to tobacco smoke and inhaled particulates and is thus more common in groups with these environmental exposures. [7] [8]

In childhood, asthma is more common in boys with a male to female ratio of 2:1 until puberty when the ratio becomes 1:1. After puberty, the prevalence of asthma is greater in females, and adult-onset cases after the age of 40 years are mostly females. Asthma prevalence is greater in extreme of ages due to airway responsiveness and lower levels of lung function. [9]

Of all the asthma cases, about 66% are diagnosed before the age of 18 years. almost 50% of children with asthma have a decrease in severity or disappearance of symptoms during early adulthood. [10]

Pathophysiology

Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration.

Airway obstruction occurs due to the combination of:

Inflammatory cell infiltration.
Mucus hypersecretion with mucus plug formation.
Smooth muscle contraction.

These irreversible changes may become irreversible over time due to

Basement membrane thickening, collagen deposition, and epithelial desquamation.
Airway remodeling occurs in chronic disease with smooth muscle hypertrophy and hyperplasia.

If not corrected rapidly, asthma may become more difficult to treat, as the mucus production prevents the inhaled medication from reaching the mucosa. The inflammation also becomes more edematous. This process is resolved (in theory complete resolution is required in asthma, but in practice, this is not checked or tested) with beta-2 agonists (e.g., salbutamol, salmeterol, albuterol) and can be aided by muscarinic receptor antagonists (e.g., ipratropium bromide), which act to reduce the inflammation and relax the bronchial musculature, as well as reducing mucus production. [11]

Toxicokinetics

The only relevant toxicokinetics in asthma relates to its management as the absorption and systemic side effects of the beta-2 agonists must be monitored. Typically these will be removed from the body in 2 to 4 hours if salbutamol and albuterol, 18 to 24 hours if salmeterol, or 48 to 72 hours if clenbuterol, which is no longer used in the management of asthma.

The side effects of the beta-2 agonists include tachycardia, flushing, sweating, and other signs of sympathetic system overdrive. There is also the chance of iatrogenic hypokalaemia, which must be monitored.

History and Physical

Patients will usually give a history of a wheeze or a cough, exacerbated by allergies, exercise, and cold. There is often diurnal variation, with symptoms being worse at night. Patients may give a history of other forms of atopy, such as eczema and hay fever. There may be some mild chest pain associated with acute exacerbations. Many asthmatics have nocturnal coughing spells but appear normal in the day time

Physical exam findings will depend on whether the patient is currently experiencing an acute exacerbation.

During an acute exacerbation, there may be a fine tremor in the hands due to salbutamol use, and mild tachycardia. Patients will show some respiratory distress, often sitting forward to splint open their airways. On auscultation, a bilateral, expiratory wheeze will be heard. In life-threatening asthma, the chest may be silent, as air cannot enter or leave the lungs, and there may be signs of systemic hypoxia.

Children with imminent arrest may appear drowsy, unresponsive, cyanotic, and confused. Wheezing may be absent, and bradycardia may occur, indicating severe respiratory muscle fatigue.

Life-threatening asthma is a type of asthma that does not respond to systemic steroids and beta 2 agonist nebulization. It is necessary to identify it early as it may lead to high mortality. It has the following characteristic findings on examination

Peak expiratory flow less than 33% of personal best
Oxygen saturation less than 92%
The normal partial pressure of carbon dioxide
Silent chest
Feeble respiratory effort
Bradycardia
Arrhythmias
Hypotension
Confusion, coma

In near-fatal asthma, the partial pressure of carbon dioxide is raised, or mechanical ventilation is required with raised inflation pressures.

Pulse oximetry can be useful in assessing the severity of an asthma attack or monitoring for deterioration. Note that pulse oximetry lag, and the physiological reserve of many patients means that a falling pO2 on pulse oximetry is a late finding, indicating a severely unwell or peri-arrest patient.

Peak flow measures also can be used to assess asthma and should always be checked against a nomogram as well as the individual patient's normal baseline function. The different severities of acute asthma attacks have an associated peak flow measurement, recorded as a certain percentage of expected peak flow.

Urea and electrolytes (kidney function) should be taken if the patient has a high dose or repeat salbutamol, as one of the side effects of salbutamol is to cause potassium to shift into the intracellular space transiently, which can induce a transient, iatrogenic hypokalaemia. Eosinophilia is common but is not specific for asthma. Recent studies show that levels of sputum eosinophils may guide therapy. In addition, some patients may have an elevation of serum IgE.

Arterial blood gas may reveal hypoxemia and respiratory acidosis. Studies indicate that periostin may be a marker for asthma, but its clinical role remains unsettled.

An ECG will reveal sinus tachycardia, which may be due to asthma, albuterol, or theophylline.

A chest x-ray is an important test, especially if patients have a history of risk of the potential foreign body or possible infection. A Chest CT scan is done in patients with recurrent symptoms who do not respond to therapy.

Special Tests

Spirometry is the diagnostic method of choice and will show an obstructive pattern that is partially or completely resolved by salbutamol. Spirometry should be done before treatment to determine the severity of the disorder. A reduced ratio of FEV1 to FVC is indicative of airway obstruction, which is reversible with treatment. Reversibility testing is done by giving the patient inhaled short-acting beta 2 agonists, and after that, the spirometry test is repeated. If there is a 12% or 200ml improvement in FEV1 from the previous value, then it shows reversibility and diagnostic for bronchial asthma. Peak expiratory flow measurement is common today and allows one to document response to therapy. A limitation of this test is that it is effort dependent.

In some patients, a methacholine/histamine challenge may be required to determine if airway hyper-reactivity is present. This test should only be done by trained individuals.

Exercise spirometry may help identify patients with exercise-induced bronchoconstriction.

Treatment / Management

Conservative Measures

Measures to take include calming the patient to get them to relax, moving outside or away from the likely source of allergen, and cooling the person. Removing clothing and washing the face and mouth to remove allergens is sometimes done, but it is not evidence-based. [12] [13] [14]

Environmental control is vital if one wants to avoid recurrent attacks. Allergen avoidance can significantly improve the quality of life. This means avoiding tobacco, dust mites, animals, and pollen.

Weight reduction in obese asthmatics leads to improved control.

Allergen immunotherapy remains controversial. Large studies have not shown any significant benefit, and the technique is prohibitively expensive.

Monoclonal antibody therapy is indicated for patients with moderate to severe asthma who have a positive skin test. The treatment can lower IgE levels, which in turn decreases histamine production. However, the cost of the injections is high.

Bronchial thermoplasty is a relatively new technique that delivers thermal energy to the airway wall and reduces the narrowing of the airways. Several studies show that it can reduce emergency visits and days missed from school.

Medical management includes bronchodilators like beta-2 agonists and muscarinic antagonists (salbutamol and ipratropium bromide respectively) and anti-inflammatories such as inhaled steroids (usually beclometasone but steroids via any route will be helpful).

There are five steps in the management of chronic asthma; treatment is started depending on the severity and then escalated or de-escalated depending on the response to treatment. [15]

Step 1: The Preferred controller is as needed low dose inhaled corticosteroid and formoterol.

Step 2: The preferred controllers are daily low dose inhaled corticosteroid plus as-needed short-acting beta 2 agonists.

Step 3: The preferred controllers are low dose inhaled corticosteroid and long-acting beta 2 agonists plus as-needed short-acting beta 2 agonists.

Step 4: The preferred controller is a medium-dose inhaled corticosteroid and long-acting beta 2 agonist plus as-needed short-acting beta 2 agonists.

Step 5: High dose inhaled corticosteroid and long-acting beta 2 agonist plus long-acting muscarinic antagonist/anti-IgE.

Indications for admission

If a patient has received three doses of an inhaled bronchodilator and shows no response, the following factors should be used to determine admission:

The severity of airflow obstruction
Duration of asthma
Response to medications
Adequacy of home support
Any mental illness

Patients with life-threatening asthma are managed with high flow oxygen inhalation, systemic steroids, back to back nebulizations with short-acting beta 2 agonists, and short-acting muscarinic antagonists and intravenous magnesium sulfate. Early involvement of the intensive care team consultation helps to reduce mortality. In the case of near-fatal asthma, early intubation and mechanical ventilation are needed.

There is no surgical input into the management of typical asthma.

Other/Long Term

Weight loss, smoking cessation, occupational change, and self-monitoring are all important in preventing disease progression and reducing the number of acute attacks.

Differential Diagnosis

The main differential for an acute, life-threatening asthma attack is an anaphylactic reaction. In this case, the patient may also present with orofacial swelling, a rash, and itching. The patient will partially respond to salbutamol and steroids, but intramuscular adrenaline is the lifesaving medication needed to manage these patients.

Other differentials include vocal cord dysfunction, tracheal or bronchial obstruction due to foreign body or tumor, heart failure, gastroesophageal reflux, chronic sinusitis, and chronic obstructive pulmonary disease.

Chronic asthma is usually classified as follows:

Intermittent
Mild persistent
Moderate persistent
Severe persistent

Acute asthma is classified as below:

Acute severe asthma
Life-threatening asthma
Near-fatal asthma

Asthma is not a benign illness and accounts for 1 death per 100,000 people in some countries. The mortality is related to lung function and is exacerbated by smoking. Factors that affect mortality include age more than 40 years, cigarette smoking more than 20 pack-years, blood eosinophilia, FEV1 of 40-70% of predicted, and greater reversibility. [16] Asthma leads to loss of time from work and school; it also leads to multiple hospital admissions increasing the cost of healthcare. Poorly controlled asthma can be disabling and leads to poor quality of life.

Postoperative and Rehabilitation Care

Patients with asthma need life-long follow up for monitoring of the disease, quality of life, and functional status. At each visit, compliance with medications should be emphasized.

Asthma is not a curable disorder, and patients need life long monitoring. Patients should be educated about the need for monitoring of the disease and compliance with medications. The patient should be given a written asthma action plan.

Consultations
Pulmonology consultation.
Involvement of the intensive care unit early in cases of severe persistent asthma and life-threatening asthma.
Deterrence and Patient Education

Patient education about the disease and modifying behavior is vital. The patient should also be encouraged to change lifestyle and control the environmental trigger factors.

Patients should be asked to maintain healthy body weight as evidence reveals that the disorder is more difficult to control in overweight individuals.

Patients should avoid tobacco and use of beta-blockers, aspirin, and sulfites.

Pearls and Other Issues

Disposition

If the patient requires nebulized salbutamol and is not ordinarily on home nebulizers, he or she should be admitted. Anyone who has presented with severe or life-threatening asthma should usually be monitored to ensure that the disease does not return when the medication has worn off.

Issues include forgetting to remove the nebulizer mask once the nebulizer is done (thus leaving the patient on only 6L of 02/min, rather than changing them to 15 L/min via a non-rebreather mask), not assessing inhaler technique, and neglecting to stress the importance of maintenance therapy with inhaled steroids even when the patient is well.

Enhancing Healthcare Team Outcomes

In many countries, including the US, asthma kills one out of every 100,000 persons. The worse the lung function, the higher the mortality. In addition, mortality has also been linked to poor management and lack of medication compliance, especially in young people. Other factors that increase the risk of death include smoking and use of illicit drugs.

Asthma also results in millions of school and workdays lost. In the US alone, close to 2 million asthmatics seek regular care in the emergency department, which also increases the costs of healthcare.

Even though asthma is a reversible disorder, poor lifestyle and lack of management can lead to airway remodeling that leads to chronic symptoms, which are disabling. [17]

The disorder has no cure, and thus life long monitoring is necessary. For best outcomes, an interprofessional approach is recommended.

Evidence-based Medicine

Many guidelines have been published for the diagnosis and management of asthma, but the most critical feature is patient education. The nurses are the last professionals to see the patient before discharge from the emergency department or the floors. Similarly, since most asthmatics are treated as outpatients, pharmacists encounter them regularly. Evidence shows that teaching patients about this disorder and the importance of compliance are critical for good outcomes. The patient should be taught about monitoring techniques, inhaler use, and modifying the environment. A social worker should be involved in the care to ensure that the patient has adequate home support and facilities.

Many evidence-based asthma plans are available for the management of asthma and should be handed out to patients. Finally, nurses also play a vital role in school-based asthma education programs that can help improve self-esteem, knowledge, and self-management behaviors. [18] [19] [20] (Level II)

Management of asthma requires an interprofessional approach. Nurses work with the clinician in providing patient and family education regarding avoiding triggers, regular use of medications and being prepared with rescue inhalers. The pharmacist should assist with the appropriate use of inhalers and encouraging daily medication administration. The pharmacist should carefully examine the current medications and make sure the patient is not taking any medications that may trigger an attack, working with the prescriber to modify the treatment. an interprofessional approach will result in the best outcomes. [Level V]

Despite great awareness of the disease, asthma still results in high morbidity and even mortality. There are universal guidelines on managing the disorder, but patient compliance with medications remains a big problem. Hence, all healthcare workers have a responsibility to encourage medication compliance and close follow up with the primary care physician. [21] [22] (Level V)

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Asthma Pathology. Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms. Contributed by United States-National Institute (more...)

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Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Maryam Tariq declares no relevant financial relationships with ineligible companies.

Disclosure: Mary Cataletto declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Hashmi MF, Tariq M, Cataletto ME. Asthma. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Published: 03 April 2020

Determinants of Acute Asthma Attack among adult asthmatic patients visiting hospitals of Tigray, Ethiopia, 2019: case control study

Melaku Negash 1 ,
Hagos Tsegabrhan 2 ,
Teklit Meles 3 ,
Degena Bahrey Tadesse 1 ,
Gebreamlak Gidey 4 ,
Yemane Berhane 5 ,
Kibrom Berhanu 6 &
Tsgalem Haylemaryam 7

Asthma Research and Practice volume 6 , Article number: 1 ( 2020 ) Cite this article

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Introduction

Acute asthma attack is one of the most common causes of visits to hospital emergency departments in all age groups of the population and accounts for the greater part of healthcare burden from the disease. Despite, Acute asthma attack is an important public health problem that affects not only the patients, but also to the family, health professionals, health care institutions and development of the nation, little is known about the risk factors of acute asthma attack.

Therefore, this study is aimed to investigate the determinants of acute asthma attack among.

The aim of this study was to assess the determinant factors of acute asthma attack among adult asthmatic patients visiting general hospitals of central zone, Tigray, Ethiopia, 2019.

Hospital based unmatched case control study design was conducted in general hospitals of central zone of Tigray, Ethiopia 2019. Data were collected using pretested interviewer administered questionnaire. A total of 289 study subjects (96 cases &193 controls) were selected by systematic random sampling. Data were entered to Epi data version 3.1 then exported to SPSS version 23 for analysis. Bivariate logistic regression was employed to examine the statistical association between dependent and independent variables. Variables with p value < 0.25 in binary logistic regression were entered to multivariable logistic regression model and variables with p value < 0.05 was taken as significant determinants of the outcome variable.

A total of 96 adult asthmatic patients who have acute asthma attack (cases) and 193 adult asthmatic patients without attack (controls)) with 100% response rate were participated in this study. Upper Respiratory tract Infection [AOR = 6.835,95% CI = 3.285,14.222], Season [AOR =2.204,95% CI = 1.011,4.805] kitchen smoke [AOR = 2.307,95%CI1.010,5.272]& sleep apnea [AOR = 9.254, 5%CI =3.563,25.460] were significantly associated with acute asthma exacerbation.

Asthma is a long-term inflammatory disease of the respiratory system which is characterized by wheezing, shortness of breath, chest tightness. Globally it affects approximately 300 million people and is estimated to rise to 400 million by 2025 globally [ 1 , 2 ]. And it is ranked 16th among the leading causes of disability and 28th among the leading causes of burden of disease, as measured by disability adjusted life years (DALYs) [ 3 ].

According to Croatian medical journal 2013, an estimate of asthma prevalence in Africa, was 49.7 million in the age of < 15 years (13.9%), < 45 years 102.9 million (13.8%), and in total population 119.3 million (12.8%) in 2010 [ 4 ].

Asthma exacerbation is defined as a worsening of shortness of breath, cough, wheezing, or chest tightness. If not treated immediately there will be increase in flow resistance causing increased work of breathing, gas exchange inefficiency, respiratory muscle tiredness and finally hypercapnic and hypoxemic respiratory failure [ 5 ]. This implies that acute asthma attack is a significant public health problem that affects patients with their parents or families and the community through labor and school loss, frequent emergency clinic visits, a poor quality of life hospitalizations and finally death [ 6 ]. According to Centers for Disease Control and prevention (CDC) report, More than 11 million people reported having an acute asthma attack [ 7 ].

Despite, in Ethiopia little is known about how risk factors are associated with exacerbation, according to asthma severity and the relative importance of the risk factors. This may be the reason for no policy and strategy to ascertain and acting out of effective intervention in order to reduce the burden of acute asthma attack [ 8 ]. Therefore, this study is aimed to full fill this gap.

Study setting and study design

Hospital based unmatched case control study was conducted in the selected general Hospitals of Central zone of Tigray from November 2018 to July 2019.

Study population and sample size determination

Source population.

All adult asthmatic patients visited to emergency unit who have acute asthma attack.

All adult patients diagnosed as asthma but without acute asthmatic attack who visited the OPD and the regular follow-up unit during the data collection period.

Study population

All selected adult asthmatic patients visited to emergency unit who have acute asthma attack during the data collection period.

All selected adult patients diagnosed as asthma but without acute asthmatic attack who visited the OPD and the regular follow-up unit during the data collection period.

Eligibility criteria

Inclusion criteria.

Adult asthmatic patients who have acute asthma attack during the data collection period.

Adult asthmatic patient without acute asthma attack during the data collection period.

Exclusion criteria

Patients with any history of pulmonary embolism, chronic obstructive pulmonary disease, active pulmonary TB, known congestive heart failure and known mechanical obstruction.

Sample size determination

Sample size was calculated from Previous study conducted in Uganda [ 9 ],using Epi info version 7. sample size was determined based on the assumption of confidence level = 95%; Power = 80%; Odds ratio = 2.132 with case to control ratio = 1:2, proportion of among controls 37.2%, proportion of among cases = 55.8%.

Therefore, the required sample size for cases was =92 where as for the controls =183 and the overall sample size was = 275 then after adding 5% non-response rate, the total sample size was 289. Finally, a sample size for cases was 96 and for controls 193.

Sampling technique and procedure

The total sample size was allocated to each hospital proportionally based on the number of patients who attend in the selected hospitals. A total number of 585(case 165, control.420) patients attended at the selected Hospitals with in 2 months of the previous year (April 1 to May 30–2018). Systematic random sampling method was applied in each hospital to select 289 participants.

Study Variables

Dependent variable.

Acute asthma attack.

Independent variables

Socio-demographic variables.

Age, Gender, Marital status, Residence, Educational level, Employment status and Occupational status.

Behavioral factors

Exercise, vigorous activity Smoking cigarette.

Environmental factors

Humidity, Kitchen smoke, dust, Season.

Medical and Clinical characteristics

URTI, Sleep apnea, Missing follow-up / appointments,

Operational definitions

Those who present with cough, wheezing and difficulty of breathing and diagnosed asthma by physician [ 10 ].

Acute Asthma Attack

Those who present with worsening of wheezing, shortness of breath, cough, chest tightness and diagnosed as acute asthma attack by physician [ 10 ].

Smoker:( daily smoker and non-daily smoker) those who currently smokes or those who quit smoking less than 1 year before the assessment [ 10 ].

Passive smoker: Smoke inhaled involuntarily by non-smokers [ 11 ].

Nonsmoker: Respondents who report never smoke those who quit smoking greater than 1 year before the assessment.

Vigorous activity: participants doing activity more than 10 min continuously, that increases breathing, like carrying or lifting heavy loads, digging or construction work, cutting fire wood [ 11 ].

Data collection tool

Structured questionnaire was used to collect the data which was adapted from different literatures [ 9 , 12 , 13 , 14 ]. The questionnaire contains four parts: socio-demographic, environmental factors, behavioral factors, and Medical &Clinical characteristics.

Data collection procedures

Data were collected from cases and controls using structured questionnaire and checklists through face-to-face interview and from patients chart review respectively.

Twelve BSc nurses as data collectors and three senior nurse supervisors were recruited for the data collection, Then data from cases were collected after they take all the necessary medical care and they recover from their attack whereas from the controls data were collected after they have completed their assessment by physician and at the last record reviews from their chart. Participants were identified as having upper respiratory tract infection and Obstructive sleep apnea from their medical charts which was diagnosed by senior physicians. This is to mean that, it was just suspected clinically by the time of the acute event. The reason we obeyed to use clinically diagnosis for obstructive sleep apnea is that, there is no accesses of modern diagnostic modality like polysomnography in the study area which was Tigray regional state not only in the study area but also in the country Ethiopia as a whole. The evaluation protocol that we use were a single evaluation visit for each case and even those who have follow-up and developed acute asthma attack were included .

Data quality control techniques

Data quality was ensured by training of data collectors and supervisors before data collection period. 5% of the questionnaire was pre-tested in Shire Hospital which was not included in the actual data collection. Based on the findings of the pre-test, questionnaire was modified. The filled questionnaire was checked for completeness and accuracy by data collectors, supervisors and principal investigator each day.. The questionnaire was translated into Tigrigna language for better understanding to both the data collectors and respondents and then back translated into English by another expert to ensure accuracy and consistency.

Data analysis procedures

Data were entered in to Epi data version 3.1 and analyzed using SPSS version 23.0. The degree of association between independent and dependent variables were assessed using adjusted odds ratio with 95% confidence interval. Variables < 0.25 p -value in binary logistic regression were entered to multivariable logistic regression model to control the potential confounding variables. Variables with p-value less than 0.05 in multivariable logistic regression model were taken as significantly associated factors. Variance inflation factor (VIF) was used to assess Multicollinearity between the independent variables. Hosmer and Lemeshow goodness fit model were used to check model fitness.

Ethical consideration

Ethical clearance was obtained from Mekelle University College of health sciences institutional review board (IRB). A subsequent permission was also obtained from Tigray teaching hospitals. Respondents were informed about the purpose of the study and the interview was conducted after receiving the written consent from participants. Confidentiality of the data/information was secured and was not used for other purposes.

Sociodemographic characteristic of study participants

Among the participants, 67.7% (65) of the cases and 60.6% (117) of the controls were females. The median ages of participants were 43 years with interquartile range (IQR) of 26.5 years among cases and 43 median ages with interquartile range (IQR) of 22 for control.

The educational status, one third 33.3% (32) of the cases and 24.9% (48) of the controls were collage and above, where as 14.6% (14) of the cases and 16.6% (32) of the controls were unable to read and write. The majority of the cases 63.5% (61) and 60.1% (116) of the controls were married (Table 1 ).

Behavioral characteristics of study participants

Among the participants, 2.1% (2) of the cases and 1.1% (6) of the controls were smokers.in parallel with this 3.1% of the cases and 4.7% of the control were passive smokers. Regarding vigorous activity 37.5% (36) of the cases and 23.8% (46) of the controls were do vigorous activity. Majority of the participants 72.9% (70) of the cases and 58% (112) of the controls were doing exercise.

Medical & clinical characteristics of study participants

Among the participants, 44.8% (43) of the cases and 13.5% (26) of the controls had Upper Respiratory Tract Infections (URTI) and 29.2% (28) of the cases and few of the controls 5.2% (10) had obstructive sleep apnea.

Among the participants, 31.3% (30) of the cases and 20.7% (40) of the controls had Missing follow up.

Environmental characteristics of study participants

Regarding the seasons of a year, spring season (April, May, June) were the season with high percentage 37.7% (109) of acute asthma attack than the autumn season. Majority of the participants 79.5% (230) were open their window/door while they were cooking. Concerning the kitchen of the participants 32.3% (31) of the cases and 20.2% (39) of the control’s kitchen have no kitchen smoke (chimney) (Table 2 ).

Unmatched case control study with 96 cases and 193 controls was conducted to show the determinants of acute asthma attack among adult asthmatic patients visiting general hospitals of central zone, Tigray, Ethiopia.

Having URTI increases the occurrence of acute asthma attack 6.8 times [AOR = 6.835,95% CI = 3.285,14.222] than those who have not upper respiratory tract infection (URTI) (Table 3 ).

This is consistent with the studies conducted in Gondar, Uganda and Ireland [ 9 , 12 , 15 ].

The association might be due to the mechanism of airway inflammation,mucus hyper secretion, and bronchial hyper responsiveness [ 16 ]. In contrast to this study upper respiratory tract infections was no risk factor for acute asthma exacerbation on the study conduct in Pretoria and New Zealand [ 14 , 17 ]. This difference might be due to difference in health care seeking behavior of the participants in this study.

This study revealed that, sleep apnea was strongly associated with the occurrence of acute asthma exacerbation. Those who have sleep apnea are 9.5 times more likely to run in to acute asthma exacerbation than those who have not sleep apnea [AOR = 9.524, 95% CI = 3.563, 25.460].

This findings is comparable with a study done in Gondar and USA [ 12 , 18 ].

The possible reason is the fact that sleep apnea lead to the worsening of asthma control in patients with concomitant sleep apnea secondary to bronchoconstriction as a result of increase vagal tone while sleeping [ 19 ].

The result of this study shows that the odds of having acute asthma in Spring season was 2.2 times higher than the odds of having acute asthma attack in the autumn season [AOR = 2.204,95% CI = 1.011,4.805]. This is consistent with a study conducted in Canada in which spring season was triggering factor for asthma exacerbation [ 20 ]. Seasonal variation is the risk factors for acute asthma attack especially pollens appearing seasons like spring season exacerbates acute asthma attack. This may be due to the reason that during the spring, tree pollen, mold spores and grass have the power to inflame and narrow the air passages of people who have asthma [ 21 ].

The result of this study was different from a study conducted in Spain which was resulting winter season as higher risk of developing acute asthma attack [ 22 ]. The difference could be arisen from seasonal variation between the study areas, due to the influence of temperature and humidity.

In this study, Kitchen smoke (chimney) is highly associated with risk of acute asthma exacerbation.

Those who have no kitchen smoke in their kitchen were 2.3 times at risk to develop acute asthma exacerbation [AOR = 2.307,95%CI = 1.010,5.2725] than those who have kitchen smoke. This finding is comparable with the study conducted in India [ 13 ]. This is due to the fact that kitchen smoke (chimney) is a way that helps in removing the smokes and fumes from the kitchen and making it clean and smoke free which result in reduction of indoor air pollution and prevents acute asthma exacerbation [ 23 ]. Inhaling harmful smoke can inflame lungs and airway, causing them to swell and block oxygen. This can lead to acute asthma exacerbation [ 24 ]

In this study the determinant factors of acute asthma attack were spring season, presence of upper respiratory tract infection (URTI), having no Kitchen smoke in their kitchen and having obstructive sleep apnea.

Limitations

The diagnosis of respiratory tract infections and sleep apnea was empirical (without laboratory) and all measures used were based on self-reporting, this might end up with social desirability bias. This study may have recall bias, since some of the information was based on the recall of the study participants. Unavailability of studies on acute asthma exacerbation.

Availability of data and materials

The datasets used and analyzed during the current study are presented within the manuscript and available from the corresponding author on reasonable request.

Abbreviations

Adjusted Odds Ratio

Confidence Interval

Crude Odds Ratio

Central Statistical Agency

Interquartile Range

National Health Interview Survey

Out Patient Department

Tigray Region Health Development Agency

Upper Respiratory Tract Infection

Variance Inflation Factor

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Acknowledgments

Authors thanks to public general hospitals of central zone Tigray, Ethiopia for their co-operation, to data collectors, supervisors, for the health staffs of the hospitals and to the study participants for their valuable information.

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Department of adult health nursing ,school of Nursing, Aksum University, Aksum, Ethiopia

Melaku Negash & Degena Bahrey Tadesse

Department of Psychiatric, Mekelle University, Mekelle, Ethiopia

Hagos Tsegabrhan

Adwa General Hospital, Adwa, Ethiopia

Teklit Meles

Department of midwifery, Aksum University, Aksum, Ethiopia

Gebreamlak Gidey

college of medicine and health science, Adigrat university, Adigrat, Ethiopia

Yemane Berhane

Maternity and reproductive health nursing, Mekelle University, Mekelle, Ethiopia

Kibrom Berhanu

Department of Emergency and critical care nursing, Mekelle University, Mekelle, Ethiopia

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Contributions

MN: was made substantially contributions to conceived and designed the study, analysis the data, methodology, data interpretation and wrote the final manuscript.TM, DB, GG,YB, had equally contributed to analysis and interpretation of the data. Whereas HT, TH and KB substantial contribution in reviewing overall the study in analysis, interpretation of data, have drafted the manuscript and substantively revised the work. All authors read and approved the final manuscript.

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Correspondence to Melaku Negash .

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Ethics approval and consent to participate.

Ethical clearance was obtained from Mekelle University College of health sciences institutional review board (IRB). Official supportive letters were obtained from Regional Health Bureau (TRHB) and central zone health office. Respondents were informed about the purpose of the study and the interview was conducted after receiving the written consent from participants. The right of participants to withdraw from the study at any time, without any precondition were secured and participants were informed. Confidentiality of the data/information was secured and was not used for other purposes. No personal identifiers was used on the questionnaire. To maintain confidentiality, data collector was recruited from the study unit.

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Additional file 1..

Annex I: English version structured interview questionnaire.

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Negash, M., Tsegabrhan, H., Meles, T. et al. Determinants of Acute Asthma Attack among adult asthmatic patients visiting hospitals of Tigray, Ethiopia, 2019: case control study. asthma res and pract 6 , 1 (2020). https://doi.org/10.1186/s40733-020-00054-w

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DOI : https://doi.org/10.1186/s40733-020-00054-w

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Acute asthma attack
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Finding the Right Approach to Treating Asthma

A q&a with sandra zaeh, sandra zaeh, md.

Sandra Zaeh, MD , is interested in improving clinical outcomes for patients with asthma. In recent research, she found that current guideline-based asthma treatment is implemented less than 15 percent of the time for moderate to severe asthma due to various factors, including a lack of knowledge about the proper treatment approach.

In the next few months, as a newly promoted assistant professor of medicine in the Yale Department of Internal Medicine Section of Pulmonary, Critical Care, and Sleep Medicine, Zaeh will lead the recruitment of subjects from the Yale Center for Asthma and Airways Disease for a study in collaboration with Brigham and Women’s Hospital. Funded by the Patient-Centered Outcomes Research Institute, the study aims to improve the quality of care for patients at risk of asthma attacks.

In an interview, Zaeh discusses the basics of asthma, different approaches to treating the inflammatory condition, and why controlling asthma is of the utmost importance to asthma physicians and pulmonologists.

What is asthma?

Asthma is a chronic lung disease in which the bronchial airways in the lungs get narrowed and swollen, making it difficult to breathe. People with asthma can feel fine for some time, and then a trigger can cause an asthma attack, which can lead to significant health repercussions. Asthma disproportionately affects Black and Latinx people, low-income populations, and other groups.

How does asthma affect quality of life?

Uncontrolled asthma with frequent exacerbations can cause adults to miss days of work and children to miss school. Asthma can impact your ability to breathe on a day-to-day basis. It can lead to hospitalizations, emergency room visits, and, in some cases, fatality.

How is asthma treated?

For the past several decades, the treatment paradigm for asthma has involved control and relief medications. Controller therapy usually includes an inhaled corticosteroid that you take one to two times a day to control your symptoms. You take a reliever therapy between controller doses to minimize asthma symptoms such as cough, shortness of breath, and wheezing. The traditional reliever therapy has been albuterol, a short-acting bronchodilator that quickly opens the airways.

Interestingly, the data now supports a slightly different management strategy. The big update in asthma management is the introduction of anti-inflammatory reliever therapy for asthma. Current guidelines promote the use of the same inhaler for both control and relief for moderate to severe asthma, with a combination of an inhaled steroid and a quick-acting, long-acting beta agonist called formoterol. This approach is called SMART, or Single Maintenance and Reliever Therapy, because one inhaler does the job that two inhalers used to do.

Tell us about your study involving patients at risk of asthma attacks.

Even though SMART is currently guideline-based care, we’re having difficulty implementing this approach in clinical practice. There are similar, alternative approaches that may be better for certain patients. One of those approaches, which will be tested in this study, is PARTICS, or Patient Activated Reliever-Triggered Inhaled CorticoSteroids. Every time PARTICS patients use their albuterol inhaler, they’re asked to use one puff of inhaled steroid. When they use their albuterol nebulizer as a reliever, they're asked to use five puffs of inhaled steroid. It’s different than SMART because the approach uses more than one inhaler and incorporates the use of nebulizers as relievers.

Many people in the U.S. use an albuterol nebulizer as a reliever because they feel it works more effectively. The PARTICS approach incorporates those individuals.

Studied in Black and Latinx patients with moderate to severe asthma a few years ago, PARTICS was shown to reduce severe asthma exacerbations and improve asthma control and quality of life. Our study compares PARTICS to SMART, the current standard of care. The idea of the study is to test to see if the two approaches are equally effective or if one is more effective than the other.

What do you hope to accomplish through this research?

It’s important to have different asthma management approaches that can be used and tailored for each patient based on needs and preferences. For example, PARTICS is perhaps more appropriate than SMART for people who use nebulizers as their reliever. PARTICS may be more effective or better covered by insurance for some people.

Whether PARTICS or SMART, these approaches are the future of asthma management. By studying these different anti-inflammatory reliever approaches, we can improve implementation and use these therapies more efficaciously.

The more options we have to treat asthma, the better.

The Section of Pulmonary, Critical Care and Sleep Medicine is one of the eleven sections within Yale School of Medicine’s Department of Internal Medicine. To learn more about Yale-PCCSM, visit PCCSM's website , or follow them on Facebook and Twitter .

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Determinants of Acute Asthma Attack among adult asthmatic patients visiting hospitals of Tigray, Ethiopia, 2019: case control study

Introduction

Study setting and study design

Study population and sample size determination

Study population

Eligibility criteria

Exclusion criteria

Sample size determination

Sampling technique and procedure

Study Variables

Independent variables

Behavioral factors

Environmental factors

Medical and Clinical characteristics

Operational definitions

Data collection tool

Data collection procedures

Data quality control techniques

Data analysis procedures

Ethical consideration

Sociodemographic characteristic of study participants

Behavioral characteristics of study participants

Medical & clinical characteristics of study participants

Environmental characteristics of study participants

Limitations

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