Asthma in the Emergency Department - By: Carl Davidson

Treat the causes. We want them to be bronchospastic. We want to treat them while they are making "NOISE." NOISE is a pneumonic for the treatment of asthmatics when they come in and are sick. N is nebulizers where there is Albuterol and Atrovent. O is oxygen. I is intravenous fluids. Remember, these people are breathing quite fast and breathing causes humidity to leave the lungs, and these people can become dehydrated. S is steroids. I would again give you the pearl that any patient who presents with an acute exacerbation of asthma should be put on steroids in one form or another, whether it is oral or intravenous, or even given an intramuscular injection. If they are put on steroids, they do have a tendency to bounce back. E is epinephrine. In the extreme states, you can give them a subcutaneous or intra-muscular injection of epinephrine. As an instructor in the advanced cardiac life support for experienced provider course, life-threatening asthma is discussed at length. Some of the not-as-well-established yet-still-potential-treatment regimens have to do with morphine, aminophylline, and terbutaline. Once again, these are all options in refractory asthma where you are in a position to say that we will either intubate this person or have to pull out medications that are not as well established yet may prevent intubation. Ketamine is a hypnotic that is used at times for pretreatment of asthma, and it does have some bronchodilatory effects and may be helpful. I can say clinically that two different times I have had patients who were so sick with asthma, I thought they needed to be intubated. I initially started giving them magnesium IV which is 2 mg over 10 minutes. Magnesium is a smooth muscle relaxer and has been used at times as a tocolytic or used in premature labor to try and relax the uterus so they don't have the baby too soon. Two different times where I have had refractory asthma in my career, I have given magnesium, and the patient felt subjectively better and clinically did better. I will swear that it saved me two intubations from asthma in my humble career. Now, asthmatics do not do very well on a ventilator, so we want to do everything we can to keep them off the ventilator, and I think magnesium is a great medication that is outside the typical medications we use for asthma. One last note about asthma….it is very important with asthmatics to make a note of how they have responded to treatment in the past. If you have an asthmatic who presents having been admitted to the hospital multiple times before, one time intubated in the intensive care unit, the provider needs to have a very low threshold to admit them to the hospital with pulmonary follow up and close observation.

"NOISE" is a mnemonic for the treatment of asthmatics when they come in and are sick.

N is nebulizers where there is Albuterol and Atrovent. O is oxygen. I is intravenous fluids. Remember, these people are breathing quite fast and breathing causes humidity to leave the lungs, and these people can become dehydrated. S is steroids. I would again give you the pearl that any patient who presents with an acute exacerbation of asthma should be put on steroids in one form or another, whether it is oral or intravenous, or even given an intramuscular injection. If they are put on steroids, they do have a tendency to bounce back. E is epinephrine. In the extreme states, you can give them a subcutaneous or intra-muscular injection of epinephrine.

As an instructor in the advanced cardiac life support for experienced provider course, life-threatening asthma is discussed at length. Some of the not-as-well-established yet-still-potential-treatment regimens have to do with magnesium, aminophylline, and terbutaline. Once again, these are all options in refractory asthma where you are in a position to say that we will either intubate this person or have to pull out medications that are not as well established yet may prevent intubation.

Ketamine is a hypnotic that is used at times for pretreatment of asthma, and it does have some bronchodilatory effects and may be helpful.

I can say clinically that two different times I have had patients who were so sick with asthma, I thought they needed to be intubated. I initially started giving them magnesium IV which is 2 mg over 10 minutes. Magnesium is a smooth muscle relaxer and has been used at times as a tocolytic or used in premature labor to try and relax the uterus so they don’t have the baby too soon. Two different times where I have had refractory asthma in my career, I have given magnesium, and the patient felt subjectively better and clinically did better. I will swear that it saved me two intubations from asthma in my humble career. Now, asthmatics do not do very well on a ventilator, so we want to do everything we can to keep them off the ventilator, and I think magnesium is a great medication that is outside the typical medications we use for asthma.

One last note about asthma….it is very important with asthmatics to make a note of how they have responded to treatment in the past. If you have an asthmatic who presents having been admitted to the hospital multiple times before, one time intubated in the intensive care unit, the provider needs to have a very low threshold to admit them to the hospital with pulmonary follow up and close observation.

About the Author

How do you treat the urgent presentation of asthma, or reactive airway disease? I say, treat them while they are making "NOISE." Nebulizers, Ozygen, IV Fluids, Steroids, Epi. Options. To learn other critical information on the pulmonary patient, visit my pulmonary patient website. For more information on the pulmonary patient, visit http://www.emergencymedicineseminars.com/The-Pulmonary-Patient.html

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