Tag: airway obstruction

Bronchial Foreign Body Aspiration (2024)

~ iEM Education Project Team ~ Leave a comment

by Elhaitham Ahmed & Khalifa Alqaydi

Authors
Listen

You have a new patients!

Patient 1

A 72-year-old male was brought from an inpatient stroke rehabilitation center to the emergency department for a cough lasting the past ten days. Along with the cough, the patient was noted to have blood-tinged sputum, which is sometimes foul-smelling. His vital signs are as follows: temperature of 38.4°C, blood pressure of 138/78 mmHg, heart rate of 103 bpm, respiratory rate of 26 breaths/min, and oxygen saturation of 93% on room air. On physical examination, the patient exhibits tachypnea, dullness on percussion, bronchial breathing, egophony, and increased vocal fremitus upon examining the right side of his lung.

The image was produced by using ideogram 2.0.

Patient 2

Thirty minutes later, the nurse calls you regarding a 5-year-old boy brought in by his mother, presenting with stridor and an ongoing cough. The mother mentions that she found her child playing with her wallet while she was in the next room and discovered him in this condition. The child is tachypneic, saturating at 90% on room air with subcostal retractions. Examination of the right lung revealed wheezing with decreased air entry.

a-photo-of-a-5-year-old-male-patient-(the image was produced by using ideogram 2.0)

What do you need to know?

Importance

Tracheobronchial foreign body aspiration (FBA) can be a potentially life-threatening event. FBA in children may be suspected based on a choking episode if such an episode is witnessed by an adult or remembered by the child. In contrast, the clinical presentation of unwitnessed FBA may be subtle, requiring careful review of the history, clinical assessment, and judicious use of radiography and bronchoscopy for diagnosis. Flexible and rigid bronchoscopy have become the cornerstone of both diagnosis and treatment in patients with suspected airway foreign bodies, which are most commonly seen in patients with FBA [1].

Epidemiology

FBA is more common in children than in adults. Data from the National Security Council report that approximately 80 percent of cases occur in patients younger than 15 years of age, with the remaining 20 percent presenting in those older than 15 years. Overall, death from FBA is the fourth leading cause of accidental home and community deaths in the United States, with over 5,000 fatal episodes of FBA reported during 2015. Death from FBA peaks in children under 1 year old and in adults over 75 years [2].

Pathophysiology

In children, nuts, seeds, and other organic material account for the majority of foreign bodies. However, in adults, the nature of inhaled objects is highly variable, ranging from organic to inorganic material. The type of foreign body significantly impacts the degree of tissue reaction in the airway. For example, some inorganic materials, such as metal or glass items, may cause little tissue inflammation but can result in direct airway injury if they are sharp. In contrast, some organic materials, such as nuts and a variety of pills, can cause significant inflammation, granulation tissue formation, and airway stenosis. Aspirated organic material can also expand from airway moisture, worsening obstruction. Aspiration of medications in pill form, such as iron tablets, aspirin, and potassium chloride, can also cause severe airway inflammation and ulceration [2].

Medical History

Clinical presentation can range from chronic nonspecific respiratory complaints to acute airway obstruction. In most cases of aspiration, the presence of a foreign body can be suspected after a thorough history. Patients with airway foreign bodies may present with noisy breathing, inspiratory stridor, rhonchi, vomiting, changes in voice, and hemoptysis [3]. Some patients may report a history known as penetration syndrome, which includes a choking sensation accompanied by wheezing and coughing. Coughing may not completely expel the foreign body but may instead cause its impaction in the subglottic region. Therefore, coughing after suspected aspiration should prompt a search for a foreign body, even if symptoms improve [4].

In pediatric patients with suspected foreign body aspiration, the sudden onset of choking or intractable cough associated with wheezing and respiratory distress occurs in more than 63% of cases [5,6]. In addition to coughing and choking, stridor is a frequent symptom. The absence of early coughing and choking is associated with delayed diagnosis and chronic presentations, such as recurrent pneumonia [4]. The sudden onset of dyspnea and odynophagia may indicate an impacted subglottic object. If the object is sharp and thin, the emergency clinician should suspect embedding between the vocal cords or in the subglottic region, resulting in partial obstruction [7].

Other components of the history can assist in diagnosing and characterizing foreign bodies in patients with aspiration of nonfood objects. Many types of items may be aspirated by children exploring their environment. Another at-risk population includes individuals who habitually store small items in their mouths for quick access; examples include construction workers (nails) and seamstresses (pins). The presentation of patients with a retained airway foreign object may involve only infectious complications. A foreign object can lead to a retropharyngeal abscess. Patients with atypical or recurrent pneumonia may have pulmonary infections caused by the persistence of a foreign object serving as a focus of infection [6].

Physical Examination

Physical findings depend on the degree of airway obstruction and the duration of the object’s presence. Depending on the size and location of the foreign body, the examination may reveal a normal patient, one with cyanosis and respiratory arrest, or any condition between these two extremes. Patients may exhibit stridor or hoarseness with upper airway foreign objects, and intercostal or sternal retractions may be observed in patients with high-grade obstruction caused by tracheal foreign bodies [8]. Hypoxemia may be present; however, normoxia does not rule out the presence of a foreign body. Patients with secondary infections may present with fever.

Oropharyngeal examination may reveal a foreign body posteriorly or donor sites of fractured teeth. The examination should also include a search for fractured or missing dental prostheses. Oropharyngeal examination can often be supplemented by indirect or direct laryngoscopy or nasopharyngoscopy, but these procedures should be performed only if the procedural stress does not pose an undue risk of airway compromise.

Coughing may result from local irritation caused by bronchial foreign bodies. Localized or apparently generalized wheezing is frequently auscultated in patients with lower respiratory tract foreign bodies [9]. Complete obstruction of a mainstem bronchus may result in absent ipsilateral breath sounds; however, breath sounds can sometimes be transmitted across the thorax, and the only physical abnormality may be asymmetric chest rise. Occasionally, a foreign body acts as a one-way valve, allowing air into the lung during inspiration but preventing its exit during expiration. The affected lung becomes hyperexpanded, which may be detected as hyper-resonance on percussion [6].

Alternative Diagnoses

The selected differential diagnoses for airway foreign bodies include anaphylactic reactions, acute pharyngitis, acute epiglottitis, retropharyngeal abscess, neck tumors, pulmonary carcinomas, pneumonia, bronchitis, bronchiolitis, and tuberculosis.

Acing Diagnostic Testing

Imaging should not delay intervention in cases of suspected acute asphyxiation but is indicated for stable patients [10].

Findings on imaging depend on the type and location of the material aspirated and the time elapsed. In practice, plain films of the neck and chest are often performed simultaneously and can be followed by site-specific CT if suspicion remains. The majority of foreign bodies are radiolucent and not easily identified on plain film. If obstruction of the upper airway (oropharynx and upper trachea) is suspected, initial imaging should include anterior-posterior and lateral soft tissue views of the neck [11]. If these tests are negative and suspicion for FBA persists, further imaging with CT may be indicated. When FBA of the lower airways (below the vocal cords) is suspected, a chest radiograph should be the initial radiographic test to look for an obvious radiopaque airway lesion. Negative scans may prompt further evaluation with CT. The reported sensitivity of chest radiography is approximately 60 to 80 percent in children, and clinical experience suggests similarly poor sensitivity in adults [12].

Given its widespread availability, flexible bronchoscopy is often the diagnostic procedure of choice for non-life-threatening FBA in adults, particularly in cases involving smaller foreign bodies in the lower airway. Flexible bronchoscopy allows precise identification and localization of foreign bodies and facilitates the selection of instruments necessary for retrieval [13]. Additionally, flexible bronchoscopy enables removal of the foreign body during the diagnostic procedure if the operator is skilled in these techniques. Standard diagnostic or therapeutic flexible bronchoscopes are usually adequate for the management of FBA in adults [6].

Risk Stratification

Risk factors in adults include loss of consciousness due to trauma, drug or alcohol intoxication, or anesthesia. Additional risk factors in older adults include age-related slowing of the swallowing mechanism, medication use (impairing cough and swallowing), stroke-related dysphagia, and various degenerative neurologic diseases such as Alzheimer’s or Parkinson’s disease [2].

Management

In a conscious adult, data support the efficacy of chest thrusts, back blows or slaps, blind finger sweeps, and abdominal thrusts in relieving complete foreign body airway obstruction [6, 14]. In cases of life-threatening asphyxiation, initial support should focus on treating airway obstruction and respiratory failure. Once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed immediately to diagnose and retrieve a supraglottic or glottic foreign body. If a foreign body is not seen, rigid bronchoscopy is generally the procedure of choice for suspected asphyxiating foreign bodies located in the trachea or major bronchi. In patients with non-life-threatening FBA, flexible bronchoscopy is typically performed [15].

When large foreign bodies completely or almost completely obstruct major upper airways (glottis, supraglottis, trachea), it is critical to ensure the patient is oxygenated and the airway is secured [16]. Support measures may include bag-valve-mask ventilation and endotracheal intubation. If ventilation is unsuccessful, an emergent cricothyrotomy or tracheotomy may be required if the foreign body is suspected to be above the vocal cords. Once the airway is secured, immediate inspection of the oropharynx (glottis, supraglottis) is indicated, as one-third of FBA cases presenting as acute asphyxiation are located in the supraglottis. Retrieval of the foreign body with Magill forceps can be safely performed using direct laryngoscopy (glottis, supraglottis) or with smooth or alligator forceps during rigid or flexible bronchoscopy (large central foreign body in the trachea or major bronchus) [17].

The choice of procedure for foreign body removal depends on the type of presentation, characteristics of the inhaled foreign body, its location, the duration it has been in the airway (if known), and local expertise. Anti-inflammatories and antibiotics are not routinely administered to patients with suspected or documented FBA. Antibiotics are indicated only in cases of clinically, radiologically, or microbiologically documented respiratory tract infections. However, their use should not delay foreign body extraction, even if pneumonia or sepsis is suspected [2].

Figure 1 - Approach to Upper Airway Foreign Body. Original Image can be found here: White JJ. Upper Airway Foreign Bodies: Emergency department presentation, Evaluation and Management. emDOCs.net - Emergency Medicine Education. April 12, 2021. Accessed May 9, 2023. http://www.emdocs.net/upper-airway-foreign-bodies-emergency-department-presentation-evaluation-and-management/.

Special Patient Groups

In the pediatric age group, moderate or high suspicion of FBA is suggested by any of the following:

  • Witnessed FBA, regardless of symptoms.
  • History of choking, with any subsequent symptoms or suspicious characteristics on imaging.
  • A young child with suggestive symptoms without another explanation, especially if there are suspicious characteristics on imaging. Suspicious symptoms include cyanotic spells, dyspnea, stridor, sudden onset of cough or wheezing (often focal and monophonic), and/or unilaterally diminished breath sounds.

The tracheobronchial tree should be examined in all cases with moderate or high suspicion of FBA, using rigid bronchoscopy (or, in some cases, computed tomography [CT]). On occasion, the adjunctive use of a flexible bronchoscope may be helpful. Normal chest radiographs are not sufficient to rule out FBA [19], primarily because most foreign bodies are radiolucent. Morbidity and mortality may increase if bronchoscopic evaluation is delayed.

When To Admit This Patient

Most patients improve clinically following FBA removal. Those with imaging abnormalities should undergo follow-up imaging six weeks to three months after extraction to confirm resolution. Patients presenting with a delayed presentation and belonging to high-risk groups should be admitted for management of complications and FBA retrieval and removal.

Revisiting Your Patients

The elderly patient, given his history of a recent stroke and being in a rehabilitation center, is at risk of FBA. His presentation with chronic cough and fever raises suspicion of pneumonia; however, the emergency medicine clinician should maintain a broad differential diagnosis based on further history, including foul-smelling sputum and nursing staff observations of difficulty swallowing and previous admissions for pneumonia. Such delayed presentations of FBA can occur in this age group. The patient’s management began with initial stabilization using oxygen support, along with workup for infection. Imaging modalities started with a chest plain film, which showed right lower lobe opacities but no clear foreign body. With suspicion for FBA still high, a chest CT scan was performed and revealed evidence consistent with FBA. The patient was started on broad-spectrum antibiotics, and bronchoscopy was scheduled as the definitive management for FBA. Follow-up bronchoscopy identified distal fragments of nuts impacted in the right lower lobe bronchus.

In the pediatric patient, the presentation is more acute and requires securing the airway. After placing the patient on a non-rebreather mask with 15L of oxygen, his saturation improved to 100%. Given the history of playing with a wallet, suspicion of coin aspiration was considered. A chest radiograph with posteroanterior and lateral views was performed, showing a rounded radiopaque structure in the right main bronchus. Airway support and supplemental oxygen should be provided until bronchoscopy is performed and the coin is retrieved.

Authors

Picture of Elhaitham Ahmed

Elhaitham Ahmed

Zayed Military Hospital, AbuDhabi

Picture of Khalifa Alqaydi

Khalifa Alqaydi

Zayed Military Hospital, AbuDhabi

Listen to the chapter

References

  1. Ruiz, F.E. (2022) Airway foreign bodies in children, UpToDate. Available at: https://www.uptodate.com/contents/airway-foreign-bodies-in-children?search=airway+foreign+bodies+in+children&source=search_result&selectedTitle=1~83&usage_type=default&display_rank=1 (Accessed: 08 May 2023).
  2. Shepherd, W. (2023) Airway foreign bodies in adults, UpToDate. Available at: https://www.uptodate.com/contents/airway-foreign-bodies-in-adults?search=adult+forign+body+&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3 (Accessed: 08 May 2023).
  3. Bajaj D, Sachdeva A, Deepak D. Foreign body aspiration. J Thorac Dis. 2021;13(8):5159-5175. doi:10.21037/jtd.2020.03.94
  4. Dabu J, Lindner M, Azzam M, et al. A Case of Chronic Cough and Pneumonia Secondary to a Foreign Body. Case Rep Med. 2017;2017:3092623. doi:10.1155/2017/3092623
  5. Mîndru DE, Păduraru G, Rusu CD, et al. Foreign Body Aspiration in Children-Retrospective Study and Management Novelties. Medicina (Kaunas). 2023;59(6):1113. Published 2023 Jun 9. doi:10.3390/medicina59061113
  6. Goodloe JM, Soulek J. Foreign Bodies . In: Rosen’s Emergency Medicine Concepts and Clinical Practice. 10th ed. Elsevier; 2023:666-681.
  7. Hazra TK, Ghosh AK, Roy P, Roy S, Sur S. An impacted meat bone in the larynx with an unusual presentation. Indian J Otolaryngol Head Neck Surg. 2005;57(2):145-146. doi:10.1007/BF02907672
  8. Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am. 2001;11(4):861-872.
  9. Kazmerski T, Dedhia K, Maguire R, Aujla S. Chronic Esophageal Foreign Body Presenting as Wheezing and Cough in a Toddler. Pediatr Allergy Immunol Pulmonol. 2014;27(3):151-153. doi:10.1089/ped.2014.0370
  10. White JJ, Cambron JD, Gottlieb M, Long B. Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting. J Emerg Med. 2023;64(2):145-155. doi:10.1016/j.jemermed.2022.12.008
  11. António P, Raffaella C, Luigia R. Plain Film and MDCT Assessment of Neck Foreign Bodies. 2014;1007/978-88-470-5406-6_1.
  12. Svedström E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?. Pediatr Radiol. 1989;19(8):520-522. doi:10.1007/BF02389562
  13. Turk D, Moslehi MA, Hosseinpour H. Role of Flexible Fiberoptic Bronchoscopy in the Diagnosis and Treatment of Pediatric Airway Foreign Bodies: A 5-Year Experience at a Tertiary Care Hospital in Iran. Tanaffos. 2022;21(3):354-361.
  14. Pavitt MJ, Swanton LL, Hind M, et al. Choking on a foreign body: a physiological study of the effectiveness of abdominal thrust manoeuvres to increase thoracic pressure. Thorax. 2017;72(6):576-578. doi:10.1136/thoraxjnl-2016-209540
  15. Bodart E, Gilbert A, Thimmesch M. Removal of an unusual bronchial foreign body: rigid or flexible bronchoscopy?. Acta Clin Belg. 2014;69(2):125-126. doi:10.1179/2295333714Y.0000000006
  16. Davis RJ, Stewart CM. Complete Glottic Obstruction by an Unusual Foreign Body. Otolaryngol Head Neck Surg. 2019;160(5):935-936. doi:10.1177/0194599818824298
  17. Singh GB, Aggarwal D, Mathur BD, Lahiri TK, Aggarwal MK, Jain RK. Role of magill forcep in retrieval of foreign body coin. Indian J Otolaryngol Head Neck Surg. 2009;61(1):36-38. doi:10.1007/s12070-009-0031-7
  18. White Upper Airway Foreign Bodies: Emergency department presentation, Evaluation and Management. emDOCs.net – Emergency Medicine Education. April 12, 2021. Accessed May 9, 2023. http://www.emdocs.net/upper-airway-foreign-bodies-emergency-department-presentation-evaluation-and-management/.
  19. Pinto A, Scaglione M, Pinto F, et al. Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography. Radiol Med. 2006;111(4):497-506. doi:10.1007/s11547-006-0045-0

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Asthma (2024)

~ iEM Education Project Team ~ Leave a comment

by Mohamed Elamin Salama & Ahmed Norain 

Authors
Listen

You have a new patient!

A 40-year-old female with a known case of asthma presents to the emergency department (ED) with complaints of cough, difficulty breathing, chest tightness, and audible wheezing. She has had fever and flu symptoms for three days, which she believes she caught from a colleague at work. She has taken her prescribed home medications with no relief. Her symptoms got worse over the last 2 hours. Her vitals were BP 140/90 mmHg, HR 122 bpm, RR 42 bpm, and SpO2 92% on room air. The physical exam revealed the use of accessory muscles for respiration, expiratory wheezing, and decreased breath sounds with expiratory rhonchi bilaterally. 

a-photo-of-a-40-year-old-female-(image produced by using ideogram2.0)

Nebulized short-acting beta2-agonists (SABA) and systemic corticosteroids were ordered. Peak expiratory flow (PEF) measurements before and after treatment were 125 and 360, respectively. Auscultation after initial treatment revealed much-improved airflow. The patient was discharged following clinical improvement, with a prescription of oral corticosteroids in addition to her current medications.

What do you need to know?

Importance

Asthma is characterized by recurrent symptoms of reversible airway obstruction that range in severity, including bronchial hypersensitivity, hyperresponsiveness, bronchospasm, inflammation, and bronchial hypersensitivity [1,2]. While the exact causes of asthma, a complex chronic disease of the airways, are still not fully understood, researchers continue to study the condition. The high cost of managing and treating asthma is a barrier to effective asthma management. Lack of access, non-compliance with asthma treatment, and excessive reliance on emergency rooms significantly impact asthma morbidity and mortality [1].

Epidemiology

The prevalence of asthma is higher in children than in adults, in women than in men, and in Puerto Ricans and African Americans than in whites or other Hispanics. Adults aged 65 and older have been reported to have the highest death rates, while children 0 to 4 years old have the lowest rates. Asthma deaths were 1.3 times more common in women than in men. The mortality rate from asthma was 2.5–3 times higher among African Americans than among whites [1].

Pathophysiology

Asthma can be divided into allergic and non-allergic based on the presence or absence of immunoglobulin E (IgE) antibodies to common environmental antigens (pollen, dander, mites) and microbiologic antigens (bacteria, viruses). The presence of airway T-helper cells, which release cytokines like interleukin [IL]-4, IL-5, and IL-13 to promote basophil, eosinophil, mast cell, and leukocyte migration to the airways and increase IgE production, is a characteristic of all types of asthma. The outcome is an exacerbation of the inflammatory response in the airways and, over time, irreversible remodeling of the airways. Clinical manifestations of these intricate cellular interactions include bronchospasm, mucus production, airway edema, and airflow restriction [1].

Medical History

Initial history inquiries should include potential triggers, symptom onset, and severity, particularly compared to prior exacerbations. Physicians should also identify comorbidities, particularly those that might be worsened by systemic corticosteroids, like diabetes, peptic ulcer disease, hypertension, and psychosis. All current asthma medications and the times and dosages taken recently should be highlighted. Moreover, any potential asthma aggravators, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), beta-blockers (including topical agents used for glaucoma), and angiotensin-converting enzyme inhibitors, should also be noted. The use of beta-blockers, both cardioselective and nonselective, increases emergency room visits and hospitalizations. There is a variance in dyspnoea perception among asthmatics with the same degree of airway narrowing. Patients with poor perceptions of their dyspnoea are more likely to require emergency room visits and hospital stays and experience near-fatal and fatal asthma attacks [1].

Physical Examination

Asthma is characterized by classical symptoms such as cough, shortness of breath, and wheezing. Additional clinical features often observed in asthma patients include tachypnea, tachycardia, chest tightness, and cyanosis. In more severe cases, patients may present with the use of accessory muscles for breathing, a “silent chest” (indicative of minimal airflow), altered level of consciousness, or even collapse, highlighting the potential severity of this respiratory condition.

The physical examination findings and some bedside test results for asthma patients vary depending on the severity of the acute asthma attack [3].

For moderate asthma, patients may exhibit increasing symptoms with a peak expiratory flow (PEF) of 50–75% of the predicted value, but they show no physical signs of acute severe asthma.

In acute severe asthma, physical examination may reveal a PEF of 33–50% of the predicted value, a respiratory rate ≥25 breaths per minute, a heart rate ≥110 beats per minute, and an inability to complete sentences in one breath due to shortness of breath.

For life-threatening asthma, physical findings can include altered consciousness, exhaustion, cyanosis (bluish discoloration of the skin), a silent chest (indicative of critically reduced airflow), arrhythmias, and hypotension. Measurements include a PEF of less than 33% of the predicted value, oxygen saturation (SpO₂) below 92%, and normal arterial partial pressure of carbon dioxide (PaCO₂) between 4.6–6.0 kPa, despite the severity of the attack.

In the case of near-fatal asthma, the physical exam may demonstrate poor respiratory effort, and the condition is characterized by elevated PaCO₂ levels or the need for mechanical ventilation with raised inflation pressures, reflecting a critically severe respiratory compromise.

These findings collectively aid in categorizing the severity of asthma attacks and guiding appropriate management.

Alternative Diagnoses

When treating acutely breathless patients, it is imperative to consider aetiologies other than asthma. The differential diagnoses include pneumonia, COPD exacerbation, upper airway obstruction, foreign body aspiration, pulmonary embolism, congestive heart failure, allergic anaphylactic reaction, and gastroesophageal reflux disease. Any of these diagnoses can present concurrently with asthma [1,3].

Acing Diagnostic Testing

In the evaluation and management of acute asthma exacerbations, several diagnostic tools can aid in assessing the severity of the condition and guiding treatment decisions:

Peak Expiratory Flow Rate (PEFR)

Peak Expiratory Flow Rate (PEFR) should be measured in all asthma patients presenting with acute exacerbations as it provides an objective assessment of airway obstruction severity. If a patient is unable to perform the PEFR test, this inability is a critical indicator of severe airway obstruction and necessitates urgent management. PEFR is most valuable when compared to the patient’s previous personal best measurement, as it reflects their baseline respiratory function. In cases where the personal best measurement is unavailable, the predicted PEFR percentage, calculated based on the patient’s age, sex, and height, serves as a practical alternative to estimate the severity of the airway obstruction. Regular monitoring of PEFR can assist in early detection of exacerbations and guide treatment adjustments.

Pulse Oximetry

This non-invasive method is crucial for determining the effectiveness of oxygen supplementation, especially in children or other patients unable to perform PEFR. The target SpO₂ is 94%-98%, with levels below 90% signaling the need for more aggressive therapy.

Capnography

Capnography is valuable for monitoring hypercapnia and respiratory failure in asthma patients. Waveform capnography provides continuous monitoring, showing changes in airway diameter and improvements during acute asthma management.

Blood Gas Analysis

Routine arterial blood gas (ABG) analysis is not typically indicated in acute asthma exacerbations. However, ABG testing should be considered when SpO₂ is below 92% or when PEFR is less than 50% of the patient’s personal best or predicted value, to identify hypercapnia and guide critical care.

Other blood testing

Routine blood testing is not recommended for acute asthma exacerbations. However, in older patients with cardiovascular comorbidities, B-type natriuretic peptide (BNP) levels may be useful to detect unrecognized congestive heart failure.

A chest radiograph (CXR)

Although not routinely required, a chest X-ray may be warranted in cases of suspected complications such as pneumonia, pneumothorax, pneumomediastinum, subcutaneous emphysema, or congestive heart failure.

Electrocardiogram (ECG)

ECG is helpful for assessing patients with chest pain or cardiovascular disease, where the asthma exacerbation may act as a physiologic stressor. In severe asthma, ECG may show a reversible right ventricular strain pattern. Continuous cardiac monitoring is advised for patients with severe hypoxemia.

Point of care ultrasound (POCUS)

Increasingly used in emergency settings, POCUS aids in diagnosing complications like pneumothorax and heart failure in patients with acute dyspnea, offering rapid, bedside insights [4].

Risk Stratification

There are several risk stratification tools for asthma, particularly for the pediatric population. MDCalc offers various tools to evaluate asthma severity and predict future exacerbations. One such tool is the PEFR (Peak Expiratory Flow Rate) estimator, which provides expected PEFR values based on the patient’s age, height, and ethnicity. Additionally, this tool allows clinicians to input the patient’s measured PEFR and offers management suggestions tailored to the patient’s condition. These tools, among others, can assist physicians in managing asthma patients more effectively.

However, in time-sensitive situations, there may not be enough time to use such tools, requiring immediate recognition of risk factors for death from asthma [1,5], which include:

  • History of sudden severe exacerbations
  • Prior intubation for asthma
  • Prior asthma admission to an intensive care unit (ICU)
  • Two or more hospitalizations for asthma in the past year
  • Three or more emergency department (ED) care visits for asthma in the past year
  • Hospitalization or an ED care visit for asthma within the past month
  • Use of more than two MDI short-acting beta-2 agonist canisters per month
  • Current use of or recent withdrawal from systemic corticosteroids
  • Difficulty perceiving severity of airflow obstruction.
  • Comorbidities such as cardiovascular diseases or other systemic problems
  • Serious psychiatric disease or psychosocial problems
  • Illicit drug use, especially inhaled cocaine, and heroin

Management

Effective management of acute asthma exacerbations involves a combination of pharmacological and non-pharmacological interventions tailored to the severity of the patient’s condition. Below is a detailed explanation of these management strategies:

Oxygen Therapy

Oxygen supplementation should be provided to all hypoxemic patients to maintain oxygen saturation (SpO₂) within the target range of 94%-98%. Adequate oxygenation is critical for preventing further respiratory compromise.

Beta-2 Agonist Bronchodilators

Short-acting beta-2 agonists, such as albuterol, are first-line agents for treating acute asthma attacks and should be initiated promptly. Albuterol can be administered via nebulization at a dose of 2.5–5 mg or with a metered-dose inhaler (MDI) delivering 6–12 puffs. The use of an MDI with a spacer provides comparable benefits to nebulization in both adults and children in emergency settings [6]. For patients who cannot use inhaled therapy effectively, intravenous (IV) or subcutaneous beta-2 agonists may be considered, although evidence supporting their use in ventilated or critically ill patients remains limited.

Anticholinergic Agents

Anticholinergic medications, such as ipratropium, are less potent than beta-2 agonists and have a slower onset of action, so they should not be used alone for acute attacks. However, combining a short-acting beta-agonist (SABA) with ipratropium is particularly beneficial in moderate to severe exacerbations, reducing hospitalizations and improving peak expiratory flow rates (PEFR). The initial adult dose of ipratropium is 250–500 mcg.

Corticosteroids

Corticosteroids are essential in the early management of acute asthma exacerbations. Both oral and intravenous (IV) corticosteroids are equally effective, with no additional benefit from adding inhaled corticosteroids to systemic therapy. The recommended oral dose is 50 mg of prednisone, while IV therapy typically involves 125 mg/day of methylprednisolone in one or two divided doses.

Magnesium

Magnesium sulfate is a bronchodilator that relaxes bronchial smooth muscles, making it particularly useful in severe asthma attacks. It is recommended for adults with PEFR <25% of the predicted value, adults and children with persistent hypoxia after initial treatment, and children with PEFR <60% after one hour of care. Magnesium has been shown to reduce hospital admission rates in these patients.

Epinephrine

For asthma patients with concurrent angioedema or anaphylaxis, epinephrine should be administered intramuscularly at a dose of 0.3 mg. This is an adjunct to standard asthma therapies.

Heliox (Helium-Oxygen Therapy)

Heliox reduces airway resistance and enhances the bronchodilatory effects of albuterol [7]. It also reduces respiratory muscle workload and improves ventilation by facilitating carbon dioxide diffusion. Heliox may be considered in severe airflow obstruction (PEFR <30% predicted), rapid onset of symptoms within 24 hours, a history of labile asthma or prior intubation, or in cases where mechanical ventilation is inadequate.

Ketamine

Ketamine, an IV dissociative agent with bronchodilatory properties, is a valuable adjunctive therapy in refractory status asthmaticus when standard treatments are insufficient [8].

High-Flow Nasal Cannula (HFNC)

HFNC delivers high concentrations of oxygen, reduces work of breathing, and provides continuous positive airway pressure. While its role in adults with asthma is not well-defined, small studies suggest it may alleviate respiratory distress in children.

Non-Invasive Ventilation (NIV)

NIV may benefit select patients with severe and resistant asthma. However, it is not a substitute for endotracheal intubation and mechanical ventilation when these are indicated.

Intubation and Mechanical Ventilation

Approximately 2% of all asthma exacerbations, and 10%-30% of cases requiring ICU admission, necessitate intubation. Indications for intubation include altered consciousness, coma, respiratory or cardiac arrest, paradoxical breathing patterns, refractory hypoxemia, and failure of NIV.

Extracorporeal Membrane Oxygenation (ECMO)

In patients with asthma refractory to conventional ventilator management, ECMO may be considered as a last resort to provide oxygenation and ventilation support.

These therapeutic approaches, used in a stepwise manner based on severity, help optimize outcomes for patients experiencing acute asthma exacerbations. Early intervention, combined with evidence-based management, remains critical in preventing complications and reducing mortality.

Special Patient Groups

Pediatrics

For pediatric patients, the recommended initial dose of albuterol is 0.15 mg/kg/dose (0.03 mL/kg/dose), with a maximum dose of 5 mg via nebulization. Alternatively, administering 4–12 puffs of a short-acting beta-agonist (SABA) via a metered-dose inhaler (MDI) with a spacer provides equivalent bronchodilation compared to nebulized therapy. The initial dose of ipratropium bromide depends on the child’s weight: 250 micrograms for children weighing less than 20 kg and 500 micrograms for those over 20 kg.

In terms of corticosteroids, dexamethasone is an effective alternative to prednisone for managing acute asthma in the emergency department, offering comparable efficacy with fewer doses, less vomiting, and improved compliance. For moderately to severely ill children, continuous nebulized albuterol, corticosteroids, magnesium sulfate, and parenteral SABAs form the cornerstone of management.

Admission to the Pediatric Intensive Care Unit (PICU) is indicated for children with continued severe respiratory distress, altered mental status, or the need for advanced interventions such as intravenous SABAs, non-invasive ventilation (e.g., BiPAP), or mechanical ventilation.

Geriatrics

In elderly patients, asthma symptoms may go unreported as they may attribute their shortness of breath to aging, obesity, or comorbid cardiovascular conditions. It is essential for physicians to inquire about all home medications, including eye drops, and carefully consider potential drug interactions to avoid complications.

Pregnancy and Breastfeeding

Asthma exacerbations during pregnancy should be treated in the same manner as in nonpregnant patients. There are no contraindications to using any asthma medication in breastfeeding patients, making treatment decisions more straightforward and ensuring both maternal and infant safety.

When To Admit This Patient

Relapse rates among asthmatic patients discharged from the emergency department (ED) vary significantly, ranging from 11% within 3 days to 45% at 8 weeks.

The Emergency Department Disposition Decision-Making Guidelines assist in determining the appropriate care site for asthmatic patients based on their peak expiratory flow (PEF) percentages and response to treatment [1]. Below are the key details for each category:

Good Response

  • PEF (% predicted/personal best): Approximately 60% or higher.
  • Disposition Site: Patients with a good response are typically discharged home. Hospitalization is not necessary.

Incomplete Response

  • PEF (% predicted/personal best): Between 40% and 60%.
  • Disposition Site: The decision to send patients home or hospitalize them depends on the presence of risk factors outlined in Box 1. A careful evaluation is required to decide the appropriate course of action.

Poor Response

  • PEF (% predicted/personal best): Less than 40%.
  • Disposition Site: Patients in this category are not discharged home and require continued therapy in the emergency department. Hospitalization is necessary if the facility is available and appropriate.

Additional Factors Increasing the Likelihood of Admission

  • Female sex, older age, and non-white race.
  • Use of more than 8 beta-agonist puffs in the past 24 hours.
  • Severity of exacerbation, such as the need for rapid medical intervention upon arrival, respiratory rate >22, oxygen saturation <95%, and final PEF <50% predicted.
  • Past history of intubations or asthma-related hospital admissions.
  • Previous use of oral corticosteroids (OCS).
    These guidelines ensure that patients receive care tailored to the severity of their asthma exacerbation and associated risk factors.

The risk factors for death from asthma can be categorized into asthma history and other factors [1]:

Asthma History:

  • A history of near-fatal asthma that required intubation and mechanical ventilation.
  • Hospitalization or emergency department (ED) visits for asthma in the past year.
  • Current or recent use of oral corticosteroids, which is a marker of event severity.
  • Not currently using inhaled corticosteroids.
  • Overuse of short-acting beta-agonists (SABAs), particularly using more than one canister per month.
  • Poor adherence to asthma medications or a lack of adherence to a written asthma action plan.

Other Factors:

  • Presence of psychosocial problems.
  • Psychiatric diseases.
  • Food allergies in individuals with asthma.

Revisiting Your Patient

The patient in the case presentation is a 40-year-old female with known asthma. She presented with asthma exacerbation due to upper respiratory tract infection with sick contact at work. In the history, asking for any other potential triggers of an acute exacerbation, including potential allergen, onset of symptoms, and severity, is useful. Physical examination should focus on signs that help categorize the disease’s severity and guide a management plan. Like any other emergency, initial evaluation and management should highlight the “ABCDs” assessment (Airway, Breathing, Circulation, and Disability), along with imitation of the appropriate and time-sensitive diagnostic and therapeutic interventions (in our case, initiation of SABA and systemic steroids).
Additionally, Peak Expiratory Flow Rate (PEFR) should be performed for all asthmatics presenting with acute exacerbation who can perform the test. Patients who are unable to perform the test should be considered to have severe airway obstruction. If the patient is fit for discharge, prescription medications and appropriate follow-up appointments should be initiated, with strict return precautions to the emergency department as needed.

Authors

Picture of Mohamed Elamin Salama

Mohamed Elamin Salama

Dr. Salama is currently a Specialty Registrar in Emergency Medicine at the Thames Valley Deanery, Oxford School of Emergency Medicine. He completed his emergency medicine training at Zayed Military Hospital and has obtained both the Arab and Emirati Board certifications in Emergency Medicine. Dr. Salama is dedicated to advancing his clinical practice and actively sharing the most current developments in medical knowledge. His professional interests encompass trauma, resuscitation, sports medicine, and the promotion of public health initiatives.

Picture of Ahmed Norain

Ahmed Norain

Emergency Department, Zayed Military Hospital, Abu Dhabi

Listen to the chapter

References

  1. Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 10th edition. Elsevier; 2023.
  2. Gary T Kitching, Jason B Lee. Asthma in Adults. RCEMLearning. Accessed March 8, 2023. https://www.rcemlearning.co.uk/reference/asthma-in-adults/#1568193285479-ef3b01a0-b2ab
  3. Global Initiative for Asthma. GLOBAL STRATEGY for ASTHMA MANAGEMENT and PREVENTION Updated 2022.; 2022. https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-FINAL-22-07-01-WMS.pdf
  4. Zanobetti M, Scorpiniti M, Gigli C, et al. Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED. Chest. 2017;151(6):1295-1301. doi:10.1016/j.chest.2017.02.003
  5. D’Amato G, Vitale C, Molino A, et al. Asthma-related deaths. Multidiscip Respir Med. 2016;11:37. Published 2016 Oct 12. doi:10.1186/s40248-016-0073-0
  6. Krylov V, Greuel J. Are bronchodilator nebulizers superior to MDIs for the treatment of acute asthma exacerbations? Evidence-Based Practice. 2018;21(6):3. doi:https://doi.org/10.1097/01.EBP.0000545148.85715.aa
  7. Kress JP, Noth I, Gehlbach BK, et al. The utility of albuterol nebulized with heliox during acute asthma exacerbations. Am J Respir Crit Care Med. 2002;165(9):1317-1321. doi:10.1164/rccm.9907035
  8. Ueoka m, antonette subia g, lai hipp c, tawata w, chung-esaki h. Ketamine infusion for refractory status asthmaticus: a case series. Chest. 2021;160(4):a5. doi:https://doi.org/10.1016/j.chest.2021.07.062

Additional Resources

 

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

More asthma content on iem-student.org