Status Asthmaticus

Introduction 
During an asthma attack, also called an asthma exacerbation, airways become swollen and inflamed. The muscles around the airways contract, causing breathing (bronchial) tubes to narrow.

·         People (including children) with therapy resistant severe asthma. These are people who are unable to reduce their asthma symptoms and have frequent worsening of asthma symptoms and asthma attacks, despite taking multiple asthma medicines.

·         People (including children) who are not therapy resistant but who have poorly managed difficult asthma.

Presentation

Signs and symptoms 

·         Severe shortness of breath, chest tightness or pain, and coughing or wheezing

·         Low peak expiratory flow (PEF) readings

·         Worsening symptoms despite use of a quick-relief (rescue) inhaler

·         Severe breathlessness or wheezing, especially at night or in the early morning

·         The inability to speak more than short phrases due to shortness of breath

·         Having to strain your chest muscles to breathe

·         Low peak flow readings when you use a peak flow meter

·         Bluish tint to your lips

·         Agitation, confusion, or an inability to concentrate (Mayoclinicorg, 2015)

Causes

Common asthma attack triggers include:

·         Pollen, pets, mold and dust mites

·         Upper respiratory infections

·         Tobacco smoke

·         Exercise

·         Inhaling cold, dry air

·         Gastro esophageal reflux disease (GERD)

 Food allergies rarely cause asthma yet they can cause a severe life-threatening reaction. The most common foods associated with allergic symptoms are,

·         Eggs

·         Cow's milk

·         Peanuts

·         Tree nuts (such as almonds, pecans, walnuts)

·         Soy

·         Wheat

·         Fish

·         Shrimp and other shellfish

·         Food preservatives

·         Dried fruits or vegetables

·         Potatoes (packaged and some prepared)

·         Wine and beer

·         Bottled lime or lemon juice

·         Shrimp (fresh, frozen, or prepared)

·         Pickled foods

Symptoms of food allergy can include hives, rash, nausea, headache, vomiting,sneezing and nasal congestion. Some people may experience wheezing or anaphylaxis  a swelling of the throat that can cut off the airway.

Management

Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications

·         Inhaled corticosteroids. These anti-inflammatory drugs include fluticasone (Flovent HFA), budesonide (Pulmicort Flexhaler), flunisolide (Aerobid), ciclesonide (Alvesco), beclomethasone (Qvar) and mometasone (Asmanex).

·         Leukotriene modifiers. These oral medications including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) help relieve asthma symptoms for up to 24 hours.

·         Long-acting beta agonists. These inhaled medications, which include salmeterol (Serevent) and formoterol (Foradil, Perforomist), open the airways.

·         Combination inhalers. These medications such as fluticasone-salmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera) contain a long-acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-acting beta agonists, they may increase your risk of having a severe asthma attack.

·         Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily pill that helps keep the airways open (bronchodilator) by relaxing the muscles around the airways. 
(Uptodatecom, 2015)

Quick-relief (rescue) medications

·         Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex) and pirbuterol (Maxair). Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer.

·         Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts quickly to immediately relax your airways, making it easier to breathe.

·         Oral and intravenous corticosteroids. These medications which include prednisone and methylprednisolone relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term.

·         Intubation, mechanical ventilation and oxygen (Asthmaorguk, 2015)

Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

·         Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens.

·         Omalizumab (Xolair). This medication, given as an injection every two to four weeks, is specifically for people who have allergies and severe asthma. It acts by altering the immune system.

·         Allergy medications. These include oral and nasal spray antihistamines and decongestants as well as corticosteroid and cromolyn nasal sprays.

References 

Uptodatecom. 2015. Uptodatecom. [Online]. [7 May 2015]. Available from: http://www.uptodate.com/contents/treatment-of-severe-asthma-in-adolescents-and-adults

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [7 May 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/asthma-attack/basics/symptoms/con-20034148

Asthmaorguk. 2015. Asthma UK. [Online]. [7 May 2015]. Available from: http://www.asthma.org.uk/advice-severe-asthma