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Tuesday, February 17, 2009

A case study: Does intervention worsen asthma?

I would like to discuss further today the topic of "Fatal Asthma" and the somewhat controversial theory -- although I don't think it is and aim to find proof -- that PURE asthma does not kill. (Actually, books have been published on this topic as you can see by the link above.)

When I first started out as the lone night shift RT a bad asthmatic walked through the doors of the ER. For the purpose of this post I'll refer to her as Cindy.

She walked into the ER one night in SEVERE respiratory distress. However she was awake, alert and orientated and perfectly able to GRASP at the table, hold her shoulders intentionally high, and suck a little bit of air in.

Fortunately for her, her Internist happened to be in the ER along with the ER Dr. While the ER physician proposed lying her flat and intubating her due to progressively worsening blood gas values (the CO2 was creeping up), the Internist decided to give this asthmatic more time.

"This is a risky move," he said to me, "but I'm sending her up to the CCU. If she is not better within a half hour we will have no choice but to Intubate our good friend here."

We were all worried for our asthmatic friend as she gasped and gagged and sucked wind or whatever you want to call it. However, being the consummate professional, THE DOCTOR DID NOT PANIC AND THUS OVER TREAT THE PATIENT. I think this is critical when it comes to treating asthma -- not over reacting and over treating.

I think the Internist gave her only one Epinephrine shot. Now, she did get a continuous breathing treatment with Ventolin, but this treatment has been since proven to be safe and effective. (The Epi, however, is not safe, and I will discuss that tomorrow.)

Yes, that's right, we need to be patient (no pun intended). So, with my ventilator all set up outside Cindy's room, and the Internist standing with me alongside her bed, she all of a sudden looked at me and said, "I think I'm better now."

She was better. I redrew the ABGs a half hour later and they were markedly improved. Thus, the Internist saved the asthmatics life. He did this by staying calm, cool, collective and not panicking.

Now, two weeks later Cindy returned to the ER in the same condition as she was the previous visit. She truly looked the picture of someone who should be intubated. This time the Internist was not in the room, and the ER Dr. decided to intubate.

I wanted SOOOO bad to say to the Dr., "She came in two weeks ago equally bad, and we waited, and she got better." Plus, being a fellow asthmatic, I knew that if I came in like this I certainly wouldn't want the ER Dr. to start thinking Intubation, especially considering I have turned my asthma around on a whim many times before (and of course sometimes with the help of ER docs).

That aside, I did not want to see this patient intubated out of panic. But the ER Dr. decided he wanted the head of the bed down so he could stick a breathing tube in the patients airway. I wanted so bad to say we should wait like the Internist waited, but since I was a new RT I didn't think I was in a spot to say anything (however I definitely should have spoken up).

As soon as the patient was lying flat her panic grew. She was given Succicholine to paralyze her, and she vomited under the mask that was on her face. It was the most disgusting thing. So now, on top of her asthma, she had developed aspiration pneumonia.

She was on the ventilator for over a month. The Internist I referred to earlier met me in CCU with the patient and he ordered a tidal volume of 700. Back then high tidal volumes were in. I swear that as soon as I hooked the vent up to the pt and set in this volume, the alarm went into a hissy fit. The high pressure alarm went off every split second. I had never seen anything like it.
I had no clue what to do, so I lowered the tidal volume WAY down, like say to 100. And, lo and behold, the alarm stopped. I also informed the Internist that he should paralyze this patient because otherwise ventilating her will be next to impossible. So he did. Granted I was a new RT here, so I was grasping at straws -- or, better yet, at the fresh RT wisdom stuck in the niches of my brain.

Of course now I'm sweaty and nervous myself thinking this Dr. thinks I'm an idiot. I'm pretty confident he thought how unlucky he was to have to work with such a fool of a green RT. So, I snuck away from the vent a moment, and nervously called a co-worker of mine to verify what I had done. She said, the way I explained it to her, that I had done all the right things. She said she would have done the same thing.

I said, "Well, the Internist is mad at me. He said he wants his 700 tidal volume, and he thinks the vent is not working."

So my co-worker friend came in to help. You'll never know how relieved I was that she came in. And she basically took over this patient for the rest of the night. This patient was now so sick, and so difficult to ventilate, that she was a one on one all the rest of that night.

At the end of the shift I discussed this case with my co-worker RT. I told her I felt stupid that I called her. She said, "Rick, the fact that you had the common sense to admit you didn't know everything and call me impressed me and the doctor immensely."


"Well," she said, "What you did for this patient is exactly what I would have done. Ventilating asthma patients can be very difficult. And that you sacrificed your pride and called me for my advice is proof that you are not over confident."

Well, I certainly wasn't over confident. I was still upset that this patient was intubated in the first place. I fear that we nearly killed her. Now, this case still bugs me to this very day. And this question still races around in my head for an answer: "If we had not intubated this patient, would she have turned around in the next half an hour or so?"

I will never know. We may never know. And this is why treating severe exacerbation's of asthma -- status asthmaticus -- is such a hard thing to do. Sometimes we think we are doing the right thing by helping them, and many times we do -- but sometimes we cause more harm.

Now I must add that all the Dr.s I mentioned in this post are among the greatest in the profession. I am not questioning their skill. What I am questioning is this: in the future, how should cases of status asthmaticus be treated in the ER? At what point do we take the invasive step and intubate?

Truly this patient had all the right indicators for intubation. She fit well inside all the guidelines. And, if nothing else, this case is a perfect example that perhaps sometimes -- as the Internist did the first time the patient was admitted -- it's important to resort to common sense over the guidelines of an era.

I will discuss this patient further and Fatal asthma further in the days to come.

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