Asthma is an allergic airway disease. Its incidence is increasing with the improvement of people’s living standard. The increase in incidence is especially noticeable in some coastal areas and some humid regions. The disease mostly occurs in children and adolescents. It seriously affects the normal life of patients. If an acute asthma attack is well managed, asthma can be better controlled clinically, thus improving the quality of life of the patient.
I. Acute attack of asthma and inducements
1.Acute asthma attack
Acute attack is the sudden onset of shortness of breath, cough, chest tightness and other symptoms, or a sharp aggravation of the original symptoms, the degree of which varies, and the aggravation of the disease, which can occur within hours or days, and occasionally within minutes that is life-threatening. A person with asthma can have no symptoms, just like a normal person, but due to exposure to some cause, possibly an upper respiratory tract infection or a smell of a specific odor, a sudden onset of wheezing, chest tightness, or shortness of breath. Usually, we call this an acute attack. Or some patients, who usually have some mild symptoms, such as coughing, mild chest tightness, but not obvious, are suddenly aggravated after exposure to similar triggers, which is also called an acute attack.
2, the main trigger of acute attack
The most common is contact with allergens or allergens, such as special odors, pollen or even cold air can induce acute attacks. Another common cause is upper respiratory tract infection. For example, colds, bronchitis, and even pneumonia can also trigger acute attacks in some patients. This is especially true in older patients with lower resistance. The duration of an acute asthma attack can be long or short. Most are relatively short and have an acute onset. However, many patients are able to relieve themselves within a few minutes or half an hour or even a few hours with medication, or even without treatment in some patients. However, some patients can be more severe, with acute attacks lasting for more than 24 hours, called acute persistent asthma. This indicates that the symptoms are more severe, and some patients may even die because of the acute attack.
II. Principles and plans for the management of acute attacks
1. Principles and treatment for patients in general community outpatient clinics or emergency clinics
How should a patient with an acute attack be treated when encountered in an outpatient clinic or emergency room? In principle, there are several points. First of all, the severity of the patient should be judged. There are many criteria for determining the severity of asthma. There is a classification of severity in the stable phase of the disease, and there is also a classification in the acute exacerbation phase. The following is the grading of the acute exacerbation period. The criteria for grading are based on the patient’s vital signs supplemented by a small number of laboratory tests. For example, the patient’s acute exacerbation can be classified into four states: mild, moderate, severe and critical, based on the patient’s shortness of breath, posture, respiratory rate, heart rate and blood gas values. Clarifying the severity of the condition has two implications. First, it can help us to choose different levels of therapeutic drugs. Second, it gives the doctor an initial impression of this patient’s condition and a preliminary judgment of the prognosis, so that he or she can better diagnose and treat the patient more appropriately in the next work.
The aim is first of all to relieve the airway obstruction quickly and in the fastest and shortest possible time. This is because an acute asthma attack is due to some extensive and variable obstruction of the airway. This obstruction is reversible, which is a characteristic of it. Therefore, it is important to use medications to relieve airway obstruction as soon as possible, thus correcting hypoxemia and preventing complications due to hypoxia and hypoxia. After treatment remission, it is necessary to develop a long-term asthma treatment management plan for the patient to prevent frequent exacerbations. This is because with frequent acute exacerbations, asthmatic patients will have irreversible damage to their airways and airway reversibility will decrease unless airway remodeling occurs. Such patients are very difficult to treat.
2. Assessment and treatment of acute asthma attacks of different severity in the community
Firstly, the severity should be assessed. Second, after the assessment, the patient should be given an initial treatment. By initial treatment, the patient should be given several inhalations of bronchodilators for a short period of time. The preferred bronchodilator is a beta2 agonist, such as the commonly used ventolin, which can be inhaled 2-3 times within an hour. These drugs usually work quickly, within 10 minutes. If the response is relatively good and the symptoms are relieved quickly, this means that the patient is suffering from a mild attack. In such a patient, inhalation of beta2 agonists can be continued next. If necessary, a small amount of inhaled glucocorticoid can be used as anti-inflammatory treatment. Continued referral is usually not necessary and treatment can be continued in the community clinic. If symptoms do not return to their pre-onset state, the initial treatment can be escalated and another type of wheezing medication, such as anticholinergics and theophyllines, should be added along with the inhaled beta2 agonist. Some inhaled glucocorticoids can also be added if necessary, and then the efficacy can be further observed. If the treatment is not effective, the patient needs to be referred to a regular hospital for emergency or inpatient treatment. Such patients are usually those with moderate attacks.
If the patient’s symptoms are not significantly relieved or even worsened after the initial treatment, then we call the patient with severe asthma attack. At this time, if possible, the patient should be immediately transferred to the emergency room or ward of a large hospital or to the ICU for treatment. During the referral process, the patient should be given systemic glucocorticoid therapy, either oral or intravenous glucocorticoids. Also immediately add other calming medications on top of repeated beta2 agonists. Then immediately take to the hospital emergency room or ward.
3. In-hospital assessment and treatment
(1) Treatment of mild to moderate patients
The principle is roughly the same as above, but the evaluation means and treatment drugs should be more comprehensive. After the patient arrives, the severity of the seizure should be evaluated based on signs and symptoms, including some laboratory tests. Then 3 or more inhalations of a beta2 agonist should be administered within a short period of time. A more efficient spray device is recommended so that the inhalation is more efficient and the drug can enter the airway more quickly and take effect. If efficacy is good, the patient may continue current therapy.
If, after the initial treatment, the patient does not experience significant remission, the condition is a moderate exacerbation. At this point, systemic glucocorticoids, oral or intravenous, must be used. Generally speaking, the hospital chooses intravenous to be more convenient, the dose is better controlled, and it can also be used simultaneously with some other drugs. Inhaled glucocorticosteroids and beta2 agonists are also needed, as well as theophylline drugs. The amount of inhaled hormones should be larger than the mild amount. At the same time, some antibiotics can be used in small amounts.
(2) Treatment of severe patients
What is the basis for determining a patient with severe seizures? In addition to general signs and symptoms, there are some laboratory indicators, especially blood gas. Blood gases have unique significance in the evaluation of critically ill patients. We know that in a typical asthma attack, the partial pressure of carbon dioxide is low and the partial pressure of oxygen can be normal or low due to hyperventilation and the pH is usually alkaline. This is a typical blood gas in a patient with mild to moderate asthma, or a typical blood gas. If the blood gas shows an increase in carbon dioxide concentration and a decrease in partial pressure of oxygen, the patient has reached a critical level of asthma attack. The respiratory muscles are fatigued because of the intense acquisition of ventilation in the previous period. The patient is no longer able to expel the carbon dioxide from the body. At this point, it means that the patient is a patient with a severe attack. If possible, a request for admission to the ICU should be made for more aggressive treatment. Systemic glucocorticosteroids should be administered intravenously and antiasthmatic medications should be given in adequate doses. If necessary, the patient needs to be ventilated to improve respiratory muscle fatigue and to quickly clear the obstructed airway.
Usually, when the patient first comes to the hospital for consultation, some previous medical history can also prompt us to monitor the patient closely. It is possible that the patient may come in with a minor seizure, but by asking about the past medical history, we learn that there are some special circumstances. This is the time when we have to treat more closely than the general situation. That is, the identification of high-risk groups. What kind of people are called high-risk groups? First, patients who have had mechanical ventilation and near-death asthma attacks in the past. Even if the patient comes in with only a mild attack, we do not need him to stay in the hospital and cannot easily let him go. Number two, patients who have been admitted to the emergency room or hospitalized for asthma in the past year. Third, patients who are on or have just stopped taking oral glucocorticoids. Such a patient indicates that his asthma is in remission, indicating that his attacks are likely to become more severe. The fourth one is a patient with a long history of asthma, but who has not been inhaling glucocorticoids regularly. Such patients often have poor lung function and need close attention. Fifth, the patient’s usual treatment is very irregular, relying excessively on bronchodilators without regular inhalation of glucocorticoids, and such patients are also prone to develop critical asthma, so they also belong to the high-risk group. The following is a patient with psychological problems, who has very poor compliance with treatment, and whose symptoms can still develop, so we should keep such patients under close observation. For these high-risk patients, according to their symptoms and signs, they may not have a moderately severe attack, or even a mild attack, but if they have the above conditions, we should keep them under observation and not let them go easily.