Pearls of Wisdom: Near-Fatal Asthma Attacks
Joey is a 19-year-old man with mild asthma who was recently required intubation during what he described as a “serious asthma attack.” At his most recent follow-up appointment, he asks how he could have experienced such an attack, given his mild asthma.
A. Joey must have been misdiagnosed. He actually had moderate-to-severe asthma.
B. The attack was unrelated to Joey’s asthma.
C. The intubation was not required, and was performed by mistake.
D. Asthma deaths are essentially evenly distributed amongst persons with mild, moderate, and severe disease.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
ANSWER: Asthma deaths are essentially evenly distributed amongst persons with mild, moderate, and severe disease
Some 5000 asthma-related deaths occur each year. Why do some patients die from asthma? Common sense suggests that patients with the most severe asthma are the most likely to die, but this is not the case. In fact, the number of deaths from asthma are essentially equally divided amongst people with mild, moderate, and severe asthma.
Pediatric Asthma Deaths: Mild Patients Are Also At Risk1
The Research
To further examine why this is the case, researchers conducted a study of 11 participants who experienced near-fatal asthma attacks, 11 patients with asthma who had not experienced near-fatal attacks, and 16 control subjects.2 Qualifications for “near fatal asthma” included individuals with asthma who had had to be intubated at their most recent asthma admission.
Once the study participants were back to baseline status, researchers assessed participants’ respiratory responses to hypoxia and hypercapnia by artificially increasing respiratory resistance and altering ambient oxygen status. During the evaluations, researchers asked the participants about how they felt, scoring their perceived dyspnea on the Borg scale.
The Results
Overall, researchers found that perceived dyspnea was significantly lower in patients who had experienced near-fatal asthma attacks. In other words, there appears to be a select group of people with asthma who—when incurring derangements in respiratory resistance, hypoxemia, or hypercapnea—do not register the level of respiratory imbalance that other patients experience, providing a false reassurance to both them and their clinicians about the degree of distress.
What’s the “Take-Home?”
For patients with acute asthma, you cannot rely solely on the patient to report their relative level of distress. Many emergency care settings have protocols that include minimum levels of FEV1, PEFR, required before discharging a patient with asthma from the ED.
Reference:
1.Robertson C, Rubinfeld AR, Bowes G. Pediatric asthma deaths in Victoria: The mild are at risk. Pediatric Pulmonology. 1992;13:95-100.
2. Kikuchi Y. Chemosensitvity and perception of dyspnea in patients with a history of near-fatal asthma. N Engl J Med. 994;330:1329-1334.