Asthma

[Doc]

What are your thoughts on asthma and what do you use to treat it?

I would like to hear the good, bad, and ugly on this subject as well.

Doc

[medicerik]

I look at asthma as having three parts to treat:

1) Bronchosconstriction
2) Inflammation
3) Excessive mucous production

In the emergent setting, I like 1.25 mg xoponex and 500 mcg atrovent as a combined neb to treat bronchoconstriction, 125 mg solumedrol to treat inflammation, and iv fluid to treat mucous production. In addition, getting some IV fluid on board in the process seems to mitigate the hypotension you get when a real nasty asthma exacerbation breaks. If this isn't doing it, depending on patient age and cardiac history, you can also go to subq epi or terbutaline. In real bad situations with a patient near arrest, 0.3 mg 1:10,000 epi IV can be helpful. I had one asthma patient in full arrest that I had intubated, but could not ventilate until I had epi on board and circulating.

Depending on what you have available to you, you can use albuterol instead of xoponex. albuterol is much less expensive, but seems to cause more tachycardia than xoponex. albuterol is also much more common in prehospital protocols. xoponex seems to be limited to the critical care transport setting outside of the hospital.

Erik

[Doc]

Thanks for your reply.

I like the choice of meds you picked too. Asthma is a multi-faceted disease process and should be addressed as such.

From what I've seen, some HCP's are reluctant to use the proper prophylactic meds with patients in the first place, leaving their patients to experience the exacerbations you are left to treat.

They also allow asthma medicine "holidays" where they take their patients off of their meds in order to give them a break from the routine. My daughter is an asthma (mild persistent type) patient who stays on her meds 365 days a year. She does not use rescue meds more than twice a week. She is a member of the cross-country team at school and does well.

Doc

[medicerik]

Doc,

Have you ever used ketamine for induction in asthma patients who need to be tubed. Seems like it would be great option in the field drug box. Puts the patient into a dissociative state and doesn't really impare respiration. The bronchodilatory effects of the ketamine should also be helpful

Erik

Doc,

I have had asthma all my life. In the olden days (60's), the drug of choice besides Epi was Marax. Still around from what I hear. Many trips to the ER with sometimes up to 6 injections of Epi with the last one being Susphrine (sp?), this along with what I use to call the "Green" machine to assist with the inhalation therapy. Cannot remember what the inhaler was called that I use to carry around as child. Anybody know?

Now days, I use Ventolin prn, usually before I run.

No Singular as I get pnuemonia as a side effect.

Asthma is what kept me from getting in the Army way back when.

Now, here is question for all of you QP's.

Should "controlled" asthma keep an individual from getting into the Army, Rangars, and SF?

[sf-doc]

Originally Posted by MAB32

Doc,

Cannot remember what the inhaler was called that I use to carry around as child. Anybody know?



Asthma is what kept me from getting in the Army way back when.

Now, here is question for all of you QP's.

Should "controlled" asthma keep an individual from getting into the Army, Rangars, and SF?

In response the medication you used was probably Proventil. Usually 1-2 puffs as symtoms start to develop.

Also, AR 40-501 defines the enlistment and retention medical standards. Asthma is a disqualifying condition for enlistment. It is not however disqualifying for retention. This is based on the patients medical history. That is the Asthma has to be adaquately controlled (No exacerbations). The patient must also demonstrate his continued ability to perform his job.
There is a Chapter in AR 40-501 for the medical standards for SF. I do not remember if Asthma is specifically a disqualifying condition (I believe it refers you back to enlistment standards) but a waiver can be requested for most conditions if they are controlled.

Hope this answers your question.

Doc

[Doc]

Originally Posted by medicerik

Doc,

Have you ever used ketamine for induction in asthma patients who need to be tubed. Seems like it would be great option in the field drug box. Puts the patient into a dissociative state and doesn't really impare respiration. The bronchodilatory effects of the ketamine should also be helpful

Erik

No I have not. Interesting thought though.

jasonglh,

Thanks for correcting me on that one. I also will not be learning a new sport/hobby! Thanks all for saving my life and money!

[Sweetbriar]

I'm not a doc, but asthma must be more dangerous than I ever thought before . The husband of a co-worker died of it this week. She sent him off in the ambulance like before, went to take him some clothes in the morning and he was dead. I'm not about to ask her the details, but I see the word "arrest" used above. Will it make your heart stop, or does it become so impossible to breathe that all interventions are overwhelmed?

[jasonglh]

Originally Posted by Sweetbriar

Will it make your heart stop, or does it become so impossible to breathe that all interventions are overwhelmed?

An acute episode of asthma called status asthmaticus is a life threatening event. It often does not respond to prn home meds like Proventil inhalers. People like me are stubborn and do not want to go to the ER if they can get out of it. If an attack does not respond to your normal PRN meds trying to wait it out is a bad idea. Respiratory arrest can occur causing death.

The only way I can describe it would be one minute your wheezing wondering why your damn inhaler is not working then suddenly the wheezing stops. Its not because you suddenly got better but because you are no longer moving enough air to wheeze. Next thing you know someone is coming at you with a laryngoscope.

Having 2 episodes from gradeschool mentioned in my medical record derailed any chance of me getting a waiver to enlist.

I control mine with Accolate and Allegra D for allergies twice a day plus a Proventil inhaler when it hits the fan. Cigarette smoke and felines really set mine off in particular.

[Peregrino]

This thread is something all asthmatics should see. Those who've never had an episode requiring hospitalization, especially those with adult onset that is "mostly" controlled with meds, still live with an "it can't happen to me" attitude. My wife has asthma, most probably as a result of exposure to "something" during the 1st Gulf War, and she's as guilty as any of them. (Apparently there is an unusually high percentage of 1GW vets with respiratory ailments.) Anyway - given the severity of consequences and the (relative) unpredictability of triggers for asthmatic episodes, I can't believe some of the civilian dive training agencies are training and certifying asthmatics. (One of the reasons I've decided to quit instructing - I'm tired of other people trying to force me to accept liability exposure I'm not willing to risk. Pursuit of profit has blinded most of these people to reality. One of my soapboxes - not the biggest anymore either. ) I take the wife's asthma seriously enough that I've got an 80% O2 deco bottle at the house if she ever has an attack that the meds won't handle. Eventually I'll be getting a mask type regulator for it. It's not as good as a dedicated O2 system, but I don't need a prescription to get it refilled. (Just one of the ridiculous things that require a prescription.) My .02 - Peregrino

[medicerik]

Status asthmaticus is actually a little more than an acute exacerbation. We don't consider a patient to be in status unless they don't respond to the initial run of meds to try and open up the airways.

A prolonged asthma attack can most definitely cause a cardiac arrest. It can occur from prolonged hypoxia (not enough oxygen) or can also occur from a pneumothorax. The cardiac arrests from asthma that I've managed have been results of big bilateral pneumothoracies. One was in a 14 year old who's parents sat on her for four days of an acute exacerbation because they didn't have insurance. The other was in a 68 year old male. We found his inhaler laying next to him on the ground. Once the pt's chest was needle decompressed, I got pulses back. The pneumothoracies in these patients can occur for a couple of reasons. These patients develop weak outpouchings of the pleura called blebs. The blebs can rupture causing the pneumothorax.

Fully understand the not wanting to certify asthmatics to dive. The last thing you need is someone 60 feet underwater who suddenly starts wheezing, panics, and bolts for the surface. It's not like you can just pull your regulator out of your mouth for a minute, take a couple of puffs off your albuterol inhaler, and then go straight back to strenuous physical activity.

Erik

Asthma has always been a very sore spot with me. I wanted SF from the time I watched "The Green Berets" with John Wayne as a kid. When I went to sign up at the local Recruiter's office I signed a contract for at least a Ranger spot (if my mind serves me). I did however choose to not tell the Reqruiter that I had Asthma. He found out anyway (still a mystery to me) and gave me the "standard" two options. I chose the smarter of the two and became a Cop instead. I would of been much more comfortable being a "career" soldier than a career Law Dog.

Years later I am reading "Blackhawk Down" and find out that Keni Thomas had Asthma and the Army turned the other cheek. Not only during basic but all the way through Ranger Training and Somalia. I guess it just wasn't meant to be and I have to accept that even though it angers me from time to time.

I had a "severe" attack a number of years ago and ended up going into A-Phib. Had to be Cardio-converted under a max dose of Verced. I wasn't asleep like the doctor thought, and, well, you all know the rest of that story. The cause was too much Ventolin and not enough "gray matter" at the time. I have not made that same mistake again. Asthma and the meds to treat it are a double edged sword. Prednisone, Depo-Medrol and Kenalog were also popular back then, but with these meds came mood swings and weight gains (Cushings Type).

Oh, and by the way, the inhaler back then was called Alupent I believe(?).

I have yet to try any diving, so I am not sure if the pressure differences and/or the breathing underwater would cause me to have an attack. All I know is that my Asthma is more prone to happen around very cold air (winter) and
Cigarrette smoke. Also, in my case Cats are a my biggest worry/threat to my ability to breath. I usually take three puffs of Ventolin 15 minutes before I go jogging and I am good to go for 3-5 miles at a steady jog. I will also take it at work every four hours so I am not caught off guard as of recent my Asthma has seem to become more and more "exercise" induced rather than an allergy antagonist induced.

Back about a two decades ago, Asthma went through a very "lethal" period in time for people who had it. The drug of choice was Alupent(?) and it was being abused because people would have an attack and the normal two puffs (max dose) would not do the trick so more was better. It went from being OTC to script and back again under the name of Primatene I believe. Asthma meds, especially the "Beta-selective adrenergic agonists" can be a double edged sword as I found out. But I don't know of any Asthmatic who enjoys Cyanosis much.

[Doc]

Originally Posted by jasonglh

An acute episode of asthma called status asthmaticus is a life threatening event. It often does not respond to prn home meds like Proventil inhalers. People like me are stubborn and do not want to go to the ER if they can get out of it. If an attack does not respond to your normal PRN meds trying to wait it out is a bad idea. Respiratory arrest can occur causing death.

The only way I can describe it would be one minute your wheezing wondering why your damn inhaler is not working then suddenly the wheezing stops. Its not because you suddenly got better but because you are no longer moving enough air to wheeze. Next thing you know someone is coming at you with a laryngoscope.

Having 2 episodes from gradeschool mentioned in my medical record derailed any chance of me getting a waiver to enlist.

I control mine with Accolate and Allegra D for allergies twice a day plus a Proventil inhaler when it hits the fan. Cigarette smoke and felines really set mine off in particular.

Two terms that come to mind are "controllers" and "relievers".

[Michelle]

Great thread... great information. My father died from an asthma attack at the age of 62. Even though I poured over the autopsy report and learned it was from cardiac arrest, I didn't quite understand the mechanism of how/why until now.

Quick question: Although not an asthmatic myself, I have twice in my life had "asthma-like" symptoms, both times were when I was in very hot, dry temps (triple digits, no humidity). Is that abnormal? I see someone else here posting cold weather as a trigger.

Thanks,

m1