Asthma treatment 2: Acute care

So, maybe you’re an author wondering how to write hospital treatment of an asthma attack. Or maybe you’re an asthma patient who’s never been to the ER/A&E before but has had a few times where they think they should have gone but didn’t because they were scared of what would happen. Or maybe you’re someone who is wondering whether or not those difficulty breathing spells they take sometimes are asthma attacks. Or maybe you’re just curious what they can do at an ER/A&E for an asthma attack. This post is for you.

I discussed in a previous post what standard first aid treatment for asthma is, and I also talked about what asthma flareups feel like to me. According to my asthma action plan (I’ll discuss those in a few days – short version is written instructions on how to manage flares from my doctor), severe and above flares that don’t respond to inhaler are ER-worthy. Mild and moderate flares can be handled with watchful waiting, applying my action plan, and seeing if it resolves the flareup. But what actually happens in the ER?

If you have anxiety, or if you’re a person who hates disruptions to their routine (hi), or if you have any of a number of disabilities that make handling new situations more difficult (also hi), the unknown factor might be enough to turn you away from seeking help at the ER. That’s why I’m writing this post: To try to take some of the fear and uncertainty away. Because as scary as it is to go to the ER and acknowledging the existance of ER docs who don’t know how to handle asthma well, the ER is still the safest place for a person to be during a severe attack.

So, let’s say you’re having a bad asthma attack. You’ve never had one this bad before, and your inhaler isn’t helping. You go to the hospital. I suggest bringing someone you trust with you, if possible, because if your asthma is bad, you might not be in good condition to advocate for yourself. I would also recommend bringing a copy of your last lung function tests if you have them and your asthma action plan if you have that (a list of your medications will work just as well for this). Remember to bring your health card or insurance.

The very first thing you’re going to have to do is check in. Look for a sign that says “Check-in” or “Registration” or something that looks like an administrative desk. Usually these have seats beside them and are in a little corner to shield the sound. Some very big hospitals have more than one. If you can’t find it, there should be a nurse monitoring the waiting room to keep an eye on those still waiting. Ask the nurse where to check in.

In check-in, they’ll ask you questions: When did symptoms start? Are you having chest pain? How much asthma medicine have you taken? Do you have any allergies? Etc. They’ll ask you some seemingly-unrelated questions to make sure it is asthma they’re dealing with. Answer all questions honestly, and include any other things you may have taken (even alternative medicine and illicit drugs: Alt med stuff because it can interact with medicines they might give you, and illicit drugs for the same reason. Don’t worry about legal troubles: in most areas, hospitals are not allowed to tell the cops whether you’re on drugs or not). The triage nurse will use these answers and your vitals to assign you a priority in the system.

The triage nurse will take your vitals next. This will probably include probably your temperature, blood pressure, heart rate, and blood oxygen saturation at the registration desk. Temperature should be old hat to anyone who’s used a thermometer before. Blood pressure is a cuff that goes around your arm. They inflate it until they can’t hear any circulation below the cuff, then slowly let the air out until they can first hear your pulse and then hear your venous flow. It shouldn’t hurt but might if you’re sensitive to pressure. It is somewhat uncomfortable. Heartrate is measured either by them holding your wrist and looking at the clock or with a pulse oximeter. The pulse oximeter just goes over a finger (they might have you hold something warm for a few seconds if your hands are cold to ensure an accurate reading). It works by shining a light through the tip of your finger and detecting how much of a certain frequency is absorbed. More absorbance = more oxygen bound to your blood. This test should not hurt at all. If it does, they’re doing it wrong. You will then show insurance and get your hospital bracelet, either at the registration desk or at another desk.

Depending on how severe you seem and how much room they have, they might take you back immediately at this point, or they might send you to the waiting room. If you’re sent to the waiting room, try to be patient and stay calm. If your breathing continues to worsen while in the waiting room, inform the nurse when they check on you. If you feel like you might pass out, inform the nurse immediately.

You will eventually be called to a room when they have a space for your priority. They might have a respiratory therapist visit you to take your lung function. This is essentially a set of specialized breathing exercises into a machine that measures how much air you can move. It might cause more muscle pain if you’re already experiencing chest wall pain from the attack, but the test shouldn’t hurt on its own. In smaller hospitals, they might just have a nurse take your peak flow, which is not as accurate, but is cheaper and faster. Tell the RT or nurse your personal best numbers if you know them and offer a copy of your recent lung function tests if you have them. The RT or nurse can get a more accurate idea of how well you’re breathing with your personal numbers than they can with average charts. If you don’t have that information, they’ll compare your numbers to predicted numbers based on averages for your height, weight, and ethnicity. The doctor who sees you will use this information along with your vitals and their examination to decide what treatment is most appropriate.

If an RT saw you, a nurse might come in and start an IV. Otherwise, the existing nurse might start an IV at this point. They may also draw some blood for blood tests, if the doctor has reason to suspect an infection. Needles obviously hurt a bit. It might hurt more than normal if your blood pressure was low, as that can make it harder to find veins. If your breathing is very bad, they won’t have time to use anesthetic cream or stuff like that if you’re hypersensitive to the pain, unfortunately. If your oxygen saturation was low, they might start you on some oxygen to bring it up to normal, usually with a nasal cannula (this is a tube with prongs that stick up your nose. It’s uncomfortable and might make you sneeze, but it doesn’t hurt).

Next, a doctor will probably come in to examine you. They will listen to your chest with a stethoscope, and they might do some percussion tests (tapping on your chest as they listen through a stethoscope, also doesn’t hurt). The doctor will probably chat with you a bit and might ask some questions you’ve already been asked. They’re not trying to waste your time, they’re trying to get a feel for how short-of-breath you are.

I can’t predict the order of stuff that might happen after this, so I’ll just describe the things that might happen, as how they treat you will depend on how badly you’re breathing and whether or not it’s responding to first line treatment.

They might order a chest X-ray. They will give you a lead apron for your abdomen. Then they will have you stand or sit in front of the backdrop of the X-ray machine. They’ll ask you to raise your arms, take a deep breath and hold it, then they’ll take the X-ray. They will have you turn 90 degrees and repeat the process. This will let them see whether your lungs have the normal shape or whether they’re hyperinflated or collapsed and will let them see whether you have scarring or fluid in your lungs. Chest X-rays don’t hurt at all, but the room and machine are both usually cold.

They will probably give you one or more breathing treatments. This might be through a nebulizer or through an inhaler with a spacer. The nebulizer makes a mist of asthma medicine, which you then breathe in. It might have a mask (which will go over your mouth and nose) or a mouthpiece (which you hold in your mouth). Just try to breathe normally while you’re taking it. Nebs don’t hurt at all.

They might give you steroids, magnesium, or bronchodialators through an IV. These are all strong asthma medicines. Aside from the needle part, it shouldn’t hurt. The steroids will probably make you irritable, emotional, and insomniac. They really suck. I’ve never had magnesium so I can’t say what it’s like. Bronchodialators will make your heart pound and your hands shake.

If your attack is severe, then to get an idea of how tired you’re getting, they’ll measure the levels of different gasses in your blood. To do that more accurately than allowed by a pulse oximeter, they need to get an arterial line – this is a needle that goes into an artery. This does hurt. They will probably bring someone who’s good at it in to make it as painless as possible, but it will hurt.

If none of that works and you’re getting very tired or your blood gases are showing that you’re not moving air well enough, they might put you on BiPAP or CPAP. BiPAP and CPAP are both forms of non-invasive ventilation – they will help you breathe when your muscles are too tired to do it yourself. I haven’t been on it since I was a very little kid and I don’t really remember much except the mask digs uncomfortably into your nose and it feels really weird. Finally, if all of the above fails, they might intubate you and take you to the ICU. You probably won’t be aware of anything, as they will sedate you before they intubate you. Only the most serious of attacks need ventilation, and usually attacks can be turned around at the hospital before it gets to that point.

Most asthma attacks that result in a trip to the ER are treated successfully with breathing treatments and maybe some steroids. Once you start to improve, they will probably keep you for a few hours to make sure the attack doesn’t come back as soon as the bronchodialators start to wear off and they will probably give you a prescription for oral steroids. These come with some not pleasant at all side effects, but the benefits of being able to breathe outweigh the risks, so you should take them. Take them exactly according to the instructions given to you (this will probably include a taper) because if you don’t, you could induce an adrenal crisis.

I hope this helps take away some of the fear, uncertainty and mystery factor surrounding going to the ER for asthma. Hopefully you will never have an asthma attack serious enough to need hospitalization, but if you do, now you know what to expect.

The previous post in this series is here.
The next post in the series is here.

4 thoughts on “Asthma treatment 2: Acute care

  1. ironwing says:

    You’re doing a great job with these asthma info posts. Much of it doesn’t apply to me, since my asthma is severe, atypical, and complicated by neurological quirks. But your honesty and attention to detail will be much more helpful to most people than the useless “asthma tips” offered on many sites.

    • ischemgeek says:

      I’m a moderately severe asthmatic myself, and I was a severe asthmatic as a kid – definitely helps when someone who actually has asthma is writing, I find. 🙂

  2. […] previous post in this series is here. The next post in this series is […]

  3. […] The previous post in this series is here. The next post in this series is here. […]

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