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When asthma escalates to an emergency


In asthma, airway inflammation leads to airway obstruction, which may be chronic or arise as an acute symptom exacerbation. Asthma signs and symptoms range from mild to severe and may proceed to life-threatening complications, including respiratory failure and even death. What’s more, an asthma attack can cause fear and anxiety, which can worsen symptoms.

Approximately 22 million people in the United States have asthma; 6 million are children. Each year, 500,000 people are hospitalized with asthma and 4,000 people die. African-Americans are more likely than whites to be hospitalized and die from asthma. Asthma incidence has risen in the last 20 years, resulting in more emergency department (ED) visits, hospitalizations, and deaths.

Patient assessment

As asthma progresses, the patient may experience shortness of breath, cough, chest tightness, and wheezing. Treatment must be quick and effective to relieve symptoms and prevent further deterioration. Whether the patient presents to the ED or is admitted to the hospital, all nurses should be able to recognize asthma symptoms readily. (See the box below.)

Recognizing asthma quickly
Suspect asthma if your patient has:

  • chest tightness
  • tight, dry cough
  • wheezing with coarse rhonchi
  • increased heart and respiratory rates
  • breathlessness
  • excessive sweating
  • bluish skin and mucous membranes

Confusion and fatigue may indicate respiratory failure. As the attack subsides, the patient may have thick mucus secretions. Between asthma attacks, lung sounds may be clear.

Marcus: A case study

Marcus, age 20, is an African-American male who comes to the ED complaining “I can’t get my breath.” His friend Olivia, who has brought him to the hospital, reports he has a history of asthma. Gina, the triage nurse, quickly escorts them both to a nearby room, where she assesses Marcus. She finds his breathing is labored with audible wheezing and notes that he can speak only in short sentences.

Realizing he needs immediate evaluation and treatment, Gina positions him in high Fowler’s position. His vital signs are temperature 98.7° (37° C), blood pressure 190/88 mm Hg, pulse 122 beats/minute, and respiratory rate 32 breaths/minute. His oxygen saturation (O2 sat) is 88%. Gina administers oxygen 2 L per nasal cannula and places Marcus on a cardiac monitor, which reveals sinus tachycardia. Then she contacts the ED physician.

On arrival, the physician auscultates Marcus’s lungs and finds bilaterally diminished lung sounds with expiratory wheezing in the upper and lower fields. He orders an increase in supplemental O2 to 3 L to attain an O2 sat of 93%, along with a bronchodilator nebulizer breathing treatment and an I.V. corticosteroid to decrease inflammation and ease airway obstruction. As ordered, Gina obtains an arterial blood gas (ABG) sample, chest X-ray, and electrocardiogram. ABG results show an partial pressure of arterial oxygen (PaO2) of 62 mm Hg (below the normal range) and a partial pressure of arterial carbon dioxide (PaCO2) of 42 mm Hg.

During the history and physical exam, Olivia reports Marcus has been healthy except for asthma, which came on during childhood. She states his asthma seemed to be getting worse over the past 6 months, but he has refused to see his primary care provider. Marcus is in college and has been getting his inhaler refilled from a healthcare provider back home. Further questioning reveals Marcus had been using his albuterol inhaler almost daily, but only once a day. He admits he ran out of his inhaled corticosteroid months earlier and hasn’t refilled the prescription. Olivia reports this is his second ED visit for asthma exacerbation in the past year, but states he hasn’t been admitted to the hospital since childhood. She is concerned because his asthma has limited his activity level; he recently had to quit playing recreational college softball. Marcus states he awakens during the night two or three times a week with asthma symptoms. He admits to occasional alcohol use and smoking half a pack of cigarettes per day for the past 2 years.

Important questions to ask

Healthcare providers don’t always ask patients the right questions, which can hinder development of an appropriate treatment plan and care. In 2007, The National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program released evidence-based guidelines, called the Third Expert Panel Report (EPR-3). These guidelines direct healthcare providers to the latest evidence-based practice guidelines to support accurate asthma diagnosis and management.

Healthcare providers should ask patients questions that focus on asthma severity and control with regard to impairment and risk. Questions that focus on impairment include:

  • What were you doing when your symptoms began, or what triggered your attack?
  • How often do you experience asthma symptoms?
  • Do your asthma symptoms affect your normal daily activities?
  • How often do asthma symptoms awaken you during the night?
  • How often do you use your inhaler?
  • •Have you undergone lung function studies recently?

Questions that focus on risk include:

  • How many exacerbations have you experienced in the past 1 or 2 years that required oral corticosteroid treatment?
  • When was your last asthma attack?
  • What kinds of medications were you given to treat the attack?
  • Have you ever been admitted to the hospital for asthma?

Answers to these questions help healthcare providers determine the patient’s asthma severity. EPR-3 classifies asthma into four categories—intermittent, mild persistent, moderate persistent, and severe persistent. For Marcus, the detailed history and physical exam help the healthcare team determine he has moderate persistent asthma, based on his daily inhaler use, nighttime awakenings more than once a week but not nightly, limitations in daily activity, and more than two exacerbations in the past year.

EPR-3 recommends spirometry as the preferred test to determine lung function. It should be done before and after treatment with short-acting bronchodilators. Initial ABG analysis helps the healthcare team determine severity of the exacerbation.

Developing a plan of action

During an acute asthma exacerbation like the one Marcus is experiencing, the initial priority is to stabilize the patient. Treatment goals are to decrease bronchospasms and edema and improve pulmonary function. Inhalation nebulizer treatments used for in-hospital care include beta2-adrenergic agonists (such as albuterol), continued hourly as needed. ED patients with severe or moderate asthma exacerbation may benefit from an anticholinergic bronchodilator, such as ipratropium bromide. This drug is given in multiple doses along with beta2-adrenergic agonists. If the patient doesn’t respond promptly to nebulizer treatment, the healthcare team should consider giving a systemic I.V. corticosteroid or epinephrine I.M. They may give I.V. fluids to help loosen thick secretions and administer O2 by nasal cannula or mask to improve O2 sat. If the patient continues to deteriorate, intubation may be required.

Fortunately, Marcus responds well to albuterol and an I.V. corticosteroid. His lung fields have cleared and he has maintained O2 sat in the high 90s after O2 therapy is discontinued. Further evaluation of his blood work reveals a normal complete blood count and chest X-ray. If either test had suggested an infection or if Marcus had reported a recent respiratory infection, clinicians would have considered antibiotic therapy.

Discharge education

Based on EPR-3 guidelines, Marcus needs to step up his current asthma therapy. Recommendations for patients with moderate persistent asthma include stepping up to step 3, which means continuing a short-acting B2-adrenergic agonist as needed and adding a low-dose inhaled corticosteroid plus a long-acting B2-adrenergic agonist or a medium-dose inhaled corticosteroid. A course of oral corticosteroids should be considered.

For patients with persistent asthma, inhaled corticosteroids are the foundation of therapy, providing the most effective long-term control. Follow-up evaluation is recommended in 2 to 6 weeks. A step-down approach should be considered for patients who achieve good asthma control for 3 months or more. Referral to an asthma specialist also should be considered.

Marcus obviously hasn’t taken his asthma seriously, as shown by his failure to refill his inhaler, worsening asthma, and refusal to see a primary healthcare provider. Also, despite his asthma symptoms, he continues to smokes half a pack of cigarettes daily. What’s more, further questioning reveals that he and his roommate got a cat 6 months ago, and his symptoms got worse shortly afterward. Discharge education for Marcus should focus on smoking cessation counseling, education on proper inhaler technique and use, giving away his cat, and controlling other asthma triggers. (See the box below.)

Potential asthma triggers
Asthma can be triggered by:

  • pollen
  • mold
  • dust mites
  • animal dander
  • sulfite food additives
  • cigarette smoke
  • severe respiratory infection
  • air pollution
  • emotional stress
  • high humidity
  • exercise
  • certain medications, such as aspirin and nonsteroidal anti-inflammatory drugs.

Education on asthma self-management should include information about asthma (such as the role of inflammation), as well as:

  • skills needed to manage asthma
  • self-monitoring (as with a peak flow monitor)\
  • differences between long-acting and short-acting asthma medications, and when and how to use each type
  • action plan that includes both daily management and what to do when asthma worsens
  • importance of getting follow-up care with a primary care provider.

Through effective patient teaching and timely follow-up care, Marcus and other asthma patients can receive the best care possible.

Amanda D. Gaudy is an advanced practice registered nurse and clinical nurse specialist at Total Life Care in Paducah, Kentucky.

Selected references
Evidence-Based Nursing Guide to Disease Management. Ambler, PA: Lippincott Williams & Wilkins; 2008.

National Asthma Education and Prevention Program. Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health Publication Number 08-5846; October 2007. www.aanma.org/advocacy/guidelines-for-the-diagnosis-and-management-of-asthma. Accessed September 2, 2014.

Stoloff SW. Help patients gain better asthma control. J Fam Pract. 2008;57(9):594-602.

Urbano FL. Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm. 2008;14(1):41-9.

Note: All names in clinical scenarios are fictitious.

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