Emergency care in bronchial asthma

Clinical presentation

A typical bronchial asthma attack is often preceded by prodromal symptoms: nasal congestion and itching, sneezing, or a mild cough. A sudden feeling of air hunger soon develops.

At the height of the attack, the following are observed:

• Expiratory dyspnea (expiration is specifically impaired).
• Forced position: the patient sits leaning forward with hands on the edge of the bed or knees to engage accessory respiratory muscles.
• Remote wheezing audible from a distance ("music in the chest").
• Paroxysmal cough with thick, difficult-to-expectorate glassy sputum.
• In severe cases — cyanosis, tachycardia, and diaphoresis.

Examination reveals a hyperresonant percussion note (sign of hyperinflation), and auscultation reveals disseminated sibilant wheezes on prolonged expiration. The end of the attack is marked by the discharge of liquid sputum and eased breathing.

Emergency care algorithm

Actions during an acute asphyxiating attack must be rapid and consistent.

1. Primary measures: ensure a supply of fresh air. If possible, initiate oxygen therapy (it must not delay drug administration).
2. Inhalation therapy: if the patient has not yet used their inhalers, administer bronchodilators (salbutamol, berotec, astmopent, etc.). Important: do not exceed a dose of more than three puffs in a row.
3. Intravenous therapy: administer 2.4% aminophylline (10 ml) in isotonic sodium chloride solution (10 ml).
4. Special cases (HR > 90 bpm or combination with cardiac asthma):
5. Additionally administer cardiac glycosides intravenously (strophanthidin, corglycon, or digoxin) in saline.
6. Administer 0.1% adrenaline subcutaneously or 5% ephedrine intramuscularly.

Caution: Before administering adrenaline or ephedrine, be sure to find out how many times the patient has already used their pocket inhaler before the arrival of medical staff. Many inhalers contain sympathomimetics, and their overdose can drastically worsen the condition.

Efficacy assessment and further management

With proper treatment, the attack is usually relieved within 15–60 minutes: dyspnea subsides, wheezing decreases, and sputum discharge transitions from viscous to more liquid.

If there is no improvement, it is necessary to:

• Administer prednisolone intravenously (60–90 mg).
• Mandatorily initiate oxygen therapy.

If the attack is successfully relieved at home, the patient can be left under outpatient observation with referral to the district general practitioner. However, if the attack occurred in a public place, hospitalization is mandatory for all patients.

Status asthmaticus

A prolonged attack lasting more than 24 hours that fails to respond to standard therapy progresses to status asthmaticus. This is a life-threatening condition accompanied by escalating respiratory failure and can lead to respiratory arrest, loss of consciousness, and death.

After first aid, patients in status asthmaticus must be urgently transported to a hospital (ICU or pulmonology ward) strictly in a semi-sitting position, or handed over to a specialized resuscitation team.

Class and exam questions

What else to study on this topic

• Pathogenesis of bronchial hyperreactivity and chronic inflammation
• Aspirin-exacerbated respiratory disease and the effect of NSAIDs on arachidonic acid metabolism
• Rules for stepping down baseline therapy (inhaled corticosteroids)
• Phenotypes of bronchial asthma and association with atopy
• Comorbid conditions: allergic rhinitis, nasal polyposis, GERD

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.