Alternative therapies for status asthmaticus

So you have a really bad asthmatic in the emergency room, and you already have him on a continuous bronchodilator breathing treatment, and the nurse has already given intravenous epinephrine and solumedrol.

Now you, the RN and the doctor are willing to grasp at straws to prevent that person from needing to be intubated. What are some choices you might be able to recommend to the ER physician?

A book called Fatal Asthma and CMAJ list some of the most common "alternative therapies."

1. CPAP: This can be started to help the patient overcome his increased work of breathing. Adding CPAP is also a great technique of overcoming instinsic PEEP that causes hyperinflation. The problem with this is that asthmatics already feel as though they are suffocating, and this might make matters worse.

However, with good equipment, good coaching, and a doctor willing to apply to the patient some sedatives, this might be worth a shot if you have a compliant patient.

2. BiPAP: All the principles of CPAP apply here, except this also applies pressure with inspiraton to help the patient take in a deeper breath, thus allowing the patient to blow off some CO2. This may be of particular use if you suspect impending respiratory failure associated with a rising CO2.

I have seen BiPAP work on at least five asthmatics in the past couple years. Usually if a patient is bad enough to require noninvasive ventilation, we skip CPAP and go right to BiPAP.

3. Heliox: This is a helium/ oxygen mixture that consists of 80% helium and 20% oxygen. With the exception of hydrogen, helium is the lowest density of gas. And, according to medscape.com, since asthma is a disease associated with narrowed passages that result in turbulent flow and increased airway resistance, heliox can help create a more laminar flow, and thus decrease the work of breathing

According to studies, some patients benefit from this and others do not. So, while this is used in some hospitals, the jury is still out on whether it is a cost worthy investment for hospitals.

So now you have a patient in status asthamticus intubated in your emergency room. You have tried all the conventional therapies, and you once again are grasping at straws. What are some options?

4. Bronchiolar lavage: Also known as lung lavage. This is done with a fiberoptic bronchoscope and washing the bronchioles out with normal saline with the intent of clearing the lungs of mucus plugs. This is still not commonly done in a crisis, but remains an option.

5. Anesthetics: These are used to relax airway smooth muscles. According to Fatal Asthma, "Rapid, dramatic improvement is reported, leading to more effective ventilation and in some cases early extubation."

Ketamine is a smooth muscle relaxant and antihistamine, and is given intravenously. Of course this medicine is a known hallucinogenic, and it is a sedative. Many doctors prefer to wait until a patient is intubated to use it, and follow it up with a paralytic, as you can read here.

Isoflurane is an anaesthetic and bronchodilator that has been proven to be efficacious in ventilated patients in status asthmaticus. According to this study, " Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management."

6. Permissive Hypercapnia: This is something I'd wish doctors where I worked would consider more often. We had an asthmatic a few years back who was admitted to CCU, and the doctor ordered a tidal volume of 750. Since I was bagging the patient, and her lungs were stiff, like ventilating a brick. When I finally got her hooked up to the vent the highest tidal volume I could get was 150. The doctor was irate. But I was right. He finally admitted as much.

So, the point with permissive hypercapnia is that you allow a high CO2 and low pH at the expense of low pressures and a lower tidal volume and an appropriate respiratory rate to allow time for the patient to fully exhale to prevent air trapping. You do this while continuously trying to get the patient's airways to open up. In this patient's case, it took two days for this to happen.

As the author's of Fatal Asthma state, "Prolonged severe hypoxemia can cause devastating neurological injury and death, prolonged hypercapnia per se is thought to have no long-term adverse consequences. Use of permissive hypercapnia has become standard practice in many intensive care units and in general has rendered unnecessary other 'heroic' measures in the critically ill asthmatic patient."

Well, those are some of the options available to today's physicians for the treatment of status asthmaticus unresponsive to conventional therapies. Where I work we've used BiPAP and Bronchiolar lavage, although rarely.

I've known about heliox and permissive hypercapnia, but the anaesthetics used to treat status asthmaticus is something new to me. If these medicines were ever used at my facility I'm unaware of it.

If any of my readers know of any other alternative therapies for asthma please share them in the comments below.

All I wanted was the shot

Growing up with asthma: chapter 4
I sat on the edge of the ER cot with my fingernails pressed deep into the edge of the narrow mattress. My shoulders were high and stiff. Breathing was very difficult now.
The nurse, the lady with the white uniform and funny hat, left the room and said, "I'll be right back with doctor Gadget."

That minute quickly turned into a long time. It probably was only a minute, but when you can't breath, a minute is a long time.

A skinny dark haired man wearing what looked like wrinkled green pajamas entered the room carrying a white bag. I watched as he ripped the bag open, turned and scattered the contents onto the counter. I knew now I was going to feel better soon.

He seemed to be taking a long time. I could hear the clicks and clacks as he put his gadgets together.

Where is the needle? I thought. What's this thing he's working on?

My heart skipped a beat as the nurse brushed her way past him, walked around the bed, and stood behind me and rubbed my shoulders. I know she told me her name earlier, but I couldn't remember.

"Try to relax your shoulders, honey," she said.

Her gentle, caring fingers pressed deep into my sore shoulder muscles, and I let my shoulders droop. Easier said than done. I've been trying to relax all night. It was no use. I tensed up. If I could relax my shoulders I wouldn't be here.

She ran her finger along my spine. I let my shoulders droop again. Concentrate. Pretend you are a wet noodle. Go limp. Relax. The words I read in the "Asthma for Kids" book rang out loud in my head. "Breathe in through you mouth and out your nose," she said.

I hated when they said that. I couldn't breath through my nose. I couldn't breath through my nose on a good day. I tried. I sniffed. My nose was full. I wiped it with my arm. I looked at my dad, and he didn't say anything. I looked down at my arm and saw the little streak of snot.

Despite that I couldn't breathe through my nose, I could still smell that clean, fresh hospital smell.

"How long has he been feeling like this?" the doctor said. He was about dad's age, with a big fluffy mustache, and he was standing in front of me pressing his fingers into my neck.

"He woke us up a half 'n hour ago." Dad was sitting in a wood chair by the door. "He was fine before he went to bed."

I thought about how miserable I was at grandmas, and my heart skipped a beat when I thought about how I had decided I was going to tell mom and dad how terrible I felt when we got in the car, but I never did. Dad really doesn't understand. He has no clue. That was the first time I came to that revelation.

"Was he around something he was allergic to?" The doctor asked, and dad shrugged, "Not that I know."

I tried to speak: "I was," gasp, "going to te...," gasp, "tell you last," gasp, "you that--

"Don't try to speak, Rick." The doctor was now poking something into my ear, then he shone a light into my eye. I did not wince. I was a pro at this. I heard air hissing, and noticed the skinny dark haired man was holding something that was steaming.

"Here, hold this," the skinny man said, and he proffered to me that thing that was making steam. It looked like a little cup with a white mouth piece on one end and a white tubing on the other. I had never seen anything like this before. I grasped it in my little hand and stared at it. What am I supposed to do with this? I don't want this. I want that shot. The shot always makes me feel better. "This should make you feel better."

The doctor walked around the bed, and I tried to take as deep a breaths as I could as he listened to me with his stethoscope. I looked at dad and he looked worried. I didn't ever remember seeing him look that way before. Through the doorway I could see the nurses station, but nobody was out there. As far as I knew I was the only patient, which meant that I got all the attention. I didn't' like all these people in the room. I could feel my heart racing.

"My name is Matt, and I'm from respiratory therapy" the skinny man said, "What I want you to do is put this into your mouth, and clench it between your teeth. You can hold it with your hand if you want. I want you to breath normal."

I did what he said. I concentrated on my breathing. I saw everyone was watching me. That made me more nervous than being short-of-breath. I had been short of breath before and I could handle that, but all the attention was new to me.

I watched as the steam disappeared when I inhaled and blew out of the end of the white corrugated pipe when I exhaled. My breaths were short and not very deep, so the steam never completely disappeared before I exhaled again. It was kind of like puff-puff-puff-puff.

"This is what we call a nebulizer. It has medicine in it that should help you breath," he said. "I want you to really concentrate on your breathing."

.The doctor walked around the bed. The man who gave me this neb-you-lizer slid his feet across the floor and moved to the back of the bed. The doctor motioned for me to lie down and he pressed his fingers into my stomach with his gentle hands. As soon as he was done I popped back up to a sitting position. "This should work," he said to my dad more so than to me.

Nobody left the room. They all stared at me as I continued to struggle despite the neb-you-lizer thing. I kept waiting for the relief. The relief never came.

"Give him another one," the doctor said. He patted me on the back. "We'll have you better in no time," he tried to reassure me. I knew this neb-you-lizer wasn't going to work.

I could hear my heart going rap-rap-rap-rap in my head.

The nebulizer started to make a sputtering noise, and the steam was no longer pouring out when I exhaled. Matt from respiratory therapy took the nebulizer from me and walked over to the counter. He reached toward the wall and turned a knob on a flowmeter. The hissing stopped.

He picked up a syringe and a bottle and drew up some of the medicine. He squirted it into the cup. He held up the syringe, eyed it, and squirted some of the liquid into the air. He put the syringe into a second bottle, and squirted that into the cup too. All the while he did this the nurse continued to rub my shoulders and back, occasionally reminding me to "relax, honey. Try to relax your shoulders. Just concentrate on your breathing."

I relaxed my shoulders when I thought of it.

Take a slow breath in, breath out slow. Take a slow breath in, breathe out slow. The words from the asthma book resonated in my head. Take a slow breath in, breathe out slow.

I took a breath in, it wasn't very deep. I blew it out slowly. I repeated this again and again.

"He's pretty calm for someone who can't breath," the nurse said.

I looked at dad. He didn't say anything. He just sat in his chair all relaxed.

I watched as Matt turned the flowmeter on. The air hissed continuously again. The steam was pouring from the neb. He handed it to me. I took it. I clasped it between my teeth, and pressed my palms into the mattress.

"Try to relax." The nurse continued massaging my shoulders. I relaxed as best I could.

"What is this... steam?" I gasped through the mouthpiece.

"It's not steam," Matt said, "It's a mist. You ever go to a waterfall?"

I nodded.

"It's kind of like the moisture that squirts up from the waterfall. It's a mist. What I have in this cup is what I call a magic mist. It usually works fast."

"Not working... fast on me," I assured him.

He turned to look at my dad. "What I have in here is a medicine called Alupent."

"Yeah, he's had these before," dad said.

"I want," breath, "the shot." I didn't care about this thing they made me put in my mouth. My jaw was getting sore.

The doctor looked at my dad, and dad looked back at the doctor as though waiting for the doctor to say something, but the doctor said nothing. The were content to wait, I figured.

"I want the shot!" I said.

"I never heard a kid ask for a shot before," the doctor said. He smiled.

Dad said, "He has responded very well to Susprin in the past. That's what they usually give him when he comes here."

"Oh, really." The doctor listened to me again with his stethoscope. I could hear myself wheezing. I could feel each breath as it didn't want to go in. There was an elephant sitting on my chest. That's the same as I felt since the last time I woke up. I feel worse than I felt last night at grandmas, I decided. Nobody asked me about last night. How could they not ask me? I'm glad, because I don't want them to know.

"All right," the doctor said after what seemed to me to be an eternity. Martha, why don't you prepare 5 of Susprin."

The nurse stopped massaging my back and left the room. I watched as she walked around the nurses station, went out of sight a moment, and then she appeared out of nowhere and re-entered the room with a syringe and a wad of white gauze. I looked at the needle as she held it up to the light and squirted some of the fluid out. It was huge and sharp. I didn't care.

The doctor stepped back and stood next to the chair dad was sitting in. The nurse opened the bottle of alcohol and put the gauze over the opening. The smell of alcohol was strong. That was

The smell of a shot. She rolled up my sleeve and rubbed the cool alcohol onto my shoulder.

"Poke," she said. I could feel the needle as it entered my skin, but I did not jerk this time. I could feel the sting as the medicine entered me. I concentrated on my breathing. I knew it was just a matter of time now. I rush of joy filled my veins. I knew I was going to feel better real soon. It was like a Christmas gift. It was better than a Christmas gift.

"Relax and just concentrate on your breathing," the doctor said. You don't need to tell me that, doc. This is what I wanted all along. Oh, it feels so good.

The nurse was rubbing my shoulders again. I liked it when she did that, but I don't know that it was doing much good. "Breathe slow in through your nose and out your mouth," she said.

I didn't listen to her. I knew what I had to do. I breathed slowly in through my mouth and out my mouth. I felt how hard the air was going in. I felt the agony of each breath. I concentrated on how miserable I was. I wanted to savor the moment, because I knew what was going to happen in...

"It usually takes about 5 to 10 minutes," the doctor said looking down at my dad "Do you feel better yet." He looked at me.

"No." I gasped. I knew it wouldn't be long. I watched the clock on the wall. I don't remember it being there before. It was right over the doctors head. It was so quiet in the room now I could hear it ticking. All eyes were on me.

It was now the five minute mark. I could feel the breath go in half way. It felt so good.

I watched the clock, listened to it tick. Time seemed to go so slow as I watched, waited for my breath to come back. It was now ten minutes since I got the shot. Air was now going in three-quarters of the way.

"This is feeling much better." I smiled.

"Good," the doctor said. "Just concentrate on your breathing."

I continued watching the clock, and concentrated on my breathing. After a few more ticks I took in a deeeeeep breath. It went in all the way.

Finally!

I took in another deeeeep breath.

Yes! It felt so good to breath. I took in several more deep breaths.

"It sure is a great medicine, isn't it?" Mike said, smiling. I looked at dad. He was smiling too.

I took another deep breath. "Yep, I can breathe."

I released my grip on the cot.

"Ahhhhhhh, it's a miracle."

The latest research on Atrovent

As I wrote last night, we have a doctor here at Shoreline who loves to order Atrovent. Even if a patient needs a continuous treatment, it will be Duoneb, Duoneb, Duoneb, Duoneb and Duoneb. And then an hour later it will be Duoneb again.

I graduated from respiratory school in 1997, and was taught that Atrovent should ideally be given QID but never more frequently than Q4. I don't see what it would hurt to give the drug more often than that, but I also wasn't taught that it had any added benefit either.

But now we have Dr. Krane ordering it galore. She even orders Duoneb on pediatrics and Neonates. Umm, I was under the understanding that it was a drug for COPD patients mostly, or at least just adults. National Jewish Medical and Research Center verifies this.

However, I suppose I could be behind the times in my research. And, as I also wrote yesterday, so too are the other doctors behind on their research, because they still follow the old Atrovent routine.

There is one exception, though, and that would be Dr. Kipper on the floor. He's a new Internist who likes to order Q4 Atrovent treatments. My thinking about this is: why not just go with the inhaler.

So, do these doctors know something I don't? If you guys have any research on this, I'd really appreciate it. I've asked RT students that mosey through here and none of them have heard of anything. I figured if anyone would be up on the latest research it would be the RT teachers.

I did manage to find one article on the Internet "Evidence-Based Medicine for Student Health Services" by Dr. Robert J. Flaherty, MD, of Montana State University, which reports:

The addition of a single inhalation of anticholinergics (such as Ipratropium bromide) to a beta2-agonist regimen may improve lung function in children and adults with acute exacerbations of asthma treated in the emergency department. Multiple-dose anticholinergics improve lung function and may avoid hospitalisation in severe exacerbations.

Dr. Flaherty also lists some studies.

I found a second website which states the same: "(Anticholonergic) can be useful adjunct to beta-agonist in exacerbations for both adults and children-- NHLBI guidelines recommend considering in severe exacerbations." He lists several studies.

Another study from the University of Michigan that states Atrovent works on acute asthma exacerbations in children.

So, based on these reports, the excessive use of Atrovent may benefit Asthma patients, but this still doesn't get to the bottom of every treatment including Atrovent as Dr. Krane does.

Now I have absolutely no problem with giving Duoneb more often than Q4. But, if Atrovent is something that will benefit every person in need of a neb, then I want the other docs to know about this too.

Either way, if these studies are credible, then Atrovent should be given to Asthmatics, and multiple Duoneb treatments do work. If this is true, Dr. Krane appears to be up to date on her research.

If you guys know something I don't, let me know. Sometimes we can be behind the times here at Shoreline, and it's my job to catch us up.

When it's asthma it's personal for me

(Two weeks ago)

"I can't breathe! I can't breathe!"

I did not recognize her as Leanne because she looked so miserable. She sat on the edge of the bed, all 300 pounds of her, with her arms to her side holding her shoulders up. She was extremely labored. She was literally gasping for air like a fish out of water.

My first instinct was to get her in bed because I could just see her coding and falling to the ground. Nurse Boo helped me set the bed up and put her feet in bed. Then I started a treatment.

"Go get your biPap," the doctor said. BiPap on an asthma patient? I had heard of it before, but never tried it. I know some asthmatic RTs who contend they would never let someone put a BiPap on them when they were SOB.

It was a rental doctor I had never seen before. "Let's try BiPap!" he ordered again.

He was impressed because I just happened to have my LTV 1200 plugged into the wall right next to the bed. Within a minute I was holding the mask on the patients face. I figured if I attached it to her head she'd feel even more trapped and claustrophobic. In other words, I had a good feeling this BiPap wasn't going to work.

"Put that thing on her!" the doctor ordered, and he grabbed it from me and put the straps around her head. She isn't going to tolerate this, I thought. To my amazement she made no attempt to yank it off.

That was when I realized this was Leanne, and she's only a couple years older than me. She had a history of asthma and did wear a BiPap at home. So that would explain why she tolerated it so well. She also had a history of fluid retention, so I was thinking CHF. And, considering she had audible upper airway congestion, that's kind of what I was thinking.

The doctor disagreed with me. "This is status asthmaticus, he said, "I want you to keep the treatments coming; just give continuous." I did. I set the treatment inline. Nothing we were doing seemed to be doing any good.

"She's really bad," nurse Lee said. "We're going to have to intubate."

I knew from past experiences with nurse Lee that she has a tendency to get over excited in intense situations, and I see too many doctors jumping the intubation gun. I also knew from past experiences that I did not want this patient to be intubated. It was personal. This patient had asthma. I have asthma.

"Let's just be patient," I said, knowing no one was listening. The doctor was already leaning on the airway box. Stay away from that, I thought.
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(Nine years ago)

It was in my first year at Shoreline Hospital. Her name was Erin. She came in with status asthmaticus. I knew her personally as a nurse and because she took care of me when I had my asthma attack and had to stay the night. Her Internist happened to be here that day, gave her all the essential medicines like Epi, Steroids, bronchodilator, etc., and sent her to CCU despite the fact she was still quite labored.

Thirty minutes later she was doing much better, "Looks like she escaped the tube this time," Dr. Peterson said that day.

Two weeks later Erin came back in. She was equally as labored as her last visit. This time, however, Dr. Peterson was unable to come in. Dr. Samson ordered the essential medicines like Epi, Steroids, continuous bronchodilator, etc, and decided to intubate.

Wait!, I thought. Don't intubate this patient. Let's be patient and give her time to recover. Let's give the medicine some time to work. It worked 2 weeks ago when Dr. Peterson was here. I was a new RT at this time. I did not say what I was thinking, what my gut instinct told me to say. I regretted this for years to come.

Erin got intubated. It was a horrible intubation. She fought vigorously and turned blue when we sat her back. As soon as I placed the mask on her I could see vomit building up under it. We set her on her side. She vomited all over the side of the bed. Since she was overweight, she was an awful intubation.

In CCU she fought the vent like no patient I have ever seen since. Dr. Peterson ordered a tidal volume of 700, but the vent breath stopped at 300. The high pressure alarm blared with every breath. I turned the tidal volume to 250, and the high pressure was still barely under 60.

Dr. Peterson was not happy. More than likely I was new and hadn't earned his trust. "I ordered 700."

"I can't give 700."

"Is something wrong with your vent."

"No." I had intensely been studying my machine and nothing was wrong, I was sure of it. The vent was doing its job, I was certain. She was in severe bronchospasm. She had asthma. She was tight. She was airtrapping. She needed low tidal volumes. Why the hell is this doctor insisting I give her 700 tidal volume?

He paralyzed the patient. Still, a low tidal volume was needed. Dr. Peterson was insisting something was wrong with my vent. I was sweating.

I went to the nurses station and called sagacious Jane. I explained the situation. "What do I do," I said. She assured me what I was doing was correct, and then came in to help me.

She ended up doing a 1 on 1 with Erin the rest of the night, that's how bad she was. I felt bad because I wished I had told the ER doctor my recommendation that we not intubate. At least if I had said something and he still intubated, I wouldn't have this on my chest.

She ended up spending a month on the vent. At one point we were told she might have brain damage because we had taken all her sedatives away and she wasn't waking up. It was very sad. We were told she might not make it.

Then one day I walked into her room and her eyes were open. The next day I was explaining to her the weaning process.
------------------------
The doctor decides to intubate Leanne against my wishes. It was actually an easy intubation despite what I had expected. I set the LTV 1200 up to give ventilator breaths and did a blood gas. The ABGs read: pH 7.24, CO2 56, PO2 90 (on 100% FiO2), HcO3 25.

According to this ABG she was starting to fail. That's when I realized the nurse and the doctor were probably right about intubating this patient. I was basing my decision on not to intubate on emotion rather than experience and knowledge. And she was so panicked she might not have turned around had we not intubated. As it was, we had no choice but to intubate.

I suppose we can't be perfect all the time. Two days later she was off the vent and back to her usual cheery self.

While the ER doctor assured me she was "a classic case of status asthmaticus," and I agreed with him, I still suspected a CHF component too, although she wasn't treated as such until she was up in CCU and I was at home sleeping.
--------------------------
(last night)

In report I was told she had been crying. She was scared about going to pulmonary rehab. By the time I enter Leanne's room to give her a treatment she's her usual cheery self, however I see the pulmonary rehab packet on the bedside table.

Leanne had been a regular patient since she spent time on the vent two weeks back. I always tell people working at a hospital is no different from working at a grocery store, you have your regular customers.

She asked me if I read any good books lately, and so we discussed our favorite books. Then somehow we ended up discussing a show she was watching on the history channel and, before we realized it the treatment was no longer misting.

"Oh, I guess that's done," I said. "When I have fun patients I try to make this thing last longer." She smiled. I proceeded to put the neb away while she talked.

I grabbed my clipboard and was standing by the door. "You know," she said, "I'm really leery about going there. I have a 17-year-old at home. I don't want to leave him."

"You know," I said, "I can relate to you here. When I was a kid I was a regular patient, kind of like you right now. I'd spend at least 2 weeks a year in the hospital. When I was 14 I got so bad my doctors didn't know what to do, so they shipped me to an asthma hospital in Denver."

"Really."

"Yep. Only I didn't get to go for just 18 to 24 days. I was initially scheduled to be there 6-8 weeks. It ended up taking them nearly 6 months to straighten me out. And it really wasn't that bad really. I learned a lot about my disease. You see they did all the best asthma research in the world there, and they put me on all the most up to date asthma medicines at the time."

"Wow. That must have been hard to be away from your family at such a young age."

"Really it wasn't so bad. Somehow I knew that making this small sacrifice now was going to make the rest of my life better. And you know what?

"What?" She smiled.

"I didn't go back to the hospital for ten years after I got out.
---------------------------
(This morning)

"You know," Leanne said this morning as I was finishing up her treatment, " I feel much better after talking to you last night. I really think this is the best thing to do."

I said, "I really think this will benefit you."

"I think it is too."

I wrapped up the neb. "Anything I can get for you?"

"No." She hesitated, then said, "I really like you guys and all, but I hope I don't have to see you again for a while."

"In a grocery store. If I see you again I want it to be in passing."

She smiled.