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Serious lung disorders
Asthma
Asthma is a hyperresponsive disease of the airways and lungs that involves episodes of coughing, shortness of breath, wheezing, and increased secretions in the bronchi. Generally, most people will know that they are prone to asthma attacks; however, a first-time episode might occur during an allergic reaction, on exertion or exposure to cold, or as a result of emotional stress. In most cases, the mechanism is the same: narrowing and spasm of the small airways, with increased mucus production. Asthma is often accompanied by inflammation of the airways. The victim has difficulty breathing, with wheezing during exhalation (most common), during inspiration, or both. Coughing is a major feature. The victim might become quite anxious (“air hunger”). Severe cases lead to rapid respiratory deterioration, cyanosis (blue discoloration of the skin), and the use of accessory muscles of respiration (the victim sits upright and attempts to expand the chest wall by contracting neck muscles and using body movements, or sits forward and appears agitated). When the attack is extreme, wheezing might diminish, because the lungs become so “tight” that there is not enough air movement to create the abnormal breath sounds. The victim might tire out and become drowsy. Worrisome signs that indicate a severe asthma attack are very rapid (greater than 30 breaths per minute) or very slow breathing rate, and inability to speak or lie down. Diminished or poor feeding in an infant might indicate severe asthma. Conditions that mimic asthma are acute allergic reaction, inhalation of a foreign body, pulmonary embolism (see page 53), heart failure (see page 54), and vocal cord dysfunction. If a pulse oximeter is available (see page 41) and the oxygen saturation is below 90%, that is worrisome.
Treatment for severe asthma
- 1.
Administer oxygen (see page 431). Remove trigger. If cold weather precipitated the attack, try to get the victim into a warmer climate.
- 2.
Administer an inhaled (aerosol or “micronized”) bronchodilator such as albuterol (Ventolin). Bronchodilators (airway openers) are drugs that carry the advantages of minimal side effects and direct delivery to the site of action. They are available in metered-dose handheld inhalers from which the victim takes therapeutic puffs (See page 485).
- A
The most effective technique for metered-dose inhalation is discharging the contents through a spacer clamped between the lips. The drug should be released (canister pressed down or “triggered”) at the beginning of a deep inspiration. After inhalation, the recipient should attempt to hold their breath for 10 seconds.
- B
In an acute moderate to severe asthma attack, start with four puffs of a short-acting bronchodilator and consider going up to 10 puffs as needed.
- C
Young children have difficulty using the inhaler and may require nebulized albuterol (difficult in the wilderness); ensuring ability to comply with an inhaler with a spacer is imperative prior to wilderness travel with an asthmatic child.
- D
A person with asthma might also be carrying their own long-acting bronchodilator, such as salmeterol or formoterol or an inhaler that combines budesonide (steroid) and formoterol.
- A
- 3.
Administer a corticosteroid . Asthma is often accompanied by inflammation of the airways. The patient should be given a steroid such as dexamethasone, 0.6 mg/kg body weight (oral or intravenous, maximum dose 16 mg), followed by a second equivalent dose 24 hours later. This recommendation is for both pediatric and adult age patients; refer to page 486 for steroid conversion. If a person with asthma improves greatly (e.g., feels completely normal) after an inhaled bronchodilator, steroid administration is not absolutely necessary, but in general, it is a very helpful intervention.
- A
If a victim is carrying their own steroid (glucocorticoid) inhaler, such as beclomethasone, budesonide, ciclesonide, or fluticasone, have them use it. Similarly, if they are carrying their own ipratropium (which helps to open the airways), this can be self-administered.
- A
- 4.
Administer epinephrine (adrenaline) if the victim remains in severe distress after inhalation of a bronchodilator. For a severe asthma attack that is not remitting, epinephrine can be given via an EpiPen autoinjector or in a proper dose of 0.01 mg/kg intramuscular (maximum dose 0.5 mg) every 20 minutes for 3 doses. Drug information and administration of epinephrine is discussed on page 469.
A person with asthma who is in more than minimal distress, does not achieve great improvement with these basic pharmacologic maneuvers, or who requires epinephrine should be transported rapidly to the nearest medical facility. Great care should be taken to keep them well supplied with oxygen and as exertion-free as possible.
Newer therapies are drugs (“biologics”) that combat aspects of the type of airway inflammation seen in persons whose asthma does not improve with corticosteroids. These are prescribed by pulmonologists, who specialize in lung diseases.
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