Scenario 1 The Head Cold - Practice Exercises: Asthma

Content provided by the Faculty of the Harvard Medical School

Scenario 1: The head cold

Imagine that your asthma has been generally well controlled. Your controller medicine is a steroid inhaler (two puffs twice daily). Most days you do not need your quick-relief bronchodilator (albuterol inhaler) at all. Other days you use it perhaps once or at most twice in a day, although you always carry it with you.

Last week you and other members of your family had a head cold. You had a low-grade fever for two days, with sore throat and nasal congestion. Earlier this week your cold seemed to improve, but you started coughing a lot. Last night you were awakened repeatedly with coughing and slept much of the night propped up on pillows. You used the albuterol inhaler twice overnight with some relief.

Today you are still coughing and raising clear phlegm that resembles egg white. In addition, you find yourself short of breath after even light exertion, such as walking 50 feet. You use your albuterol inhaler again, but it doesn't seem to help for more than about five minutes. You check your breathing capacity with your peak flow meter. You are dismayed to find that your peak flow is only 180 L/min, less than half of your usual 400 L/min. What do you do next?

Management options

The first point is to recognize that this episode is more than just a bad cold. It is a severe asthma attack. It is not normal for a routine chest infection to cause shortness of breath when you walk only a short distance. In this example a head and chest cold has triggered a flare-up of the underlying asthma. The low peak flow value, less than half of the usual best value, confirms that this is a severe attack.

If you have a nebulizer at home, this would be a good time to use it to deliver a quick-relief bronchodilator (such as albuterol) by continuous mist. If you don't have a nebulizer, use your quick-relief bronchodilator inhaler with a spacer (to maximize delivery of the medication to the airways) and take four puffs, waiting one minute between puffs. If you don't have a spacer with you, use the inhaler as carefully as you can without one. You can continue to take your quick-relief bronchodilator (by nebulizer or by inhaler) every 20 minutes for an hour or two if needed.

It would be a mistake to rely solely on your bronchodilator medicine for treatment of a severe asthma attack. If you continue to have intense asthma symptoms after using your bronchodilator two to three times, you can be certain that a major part of the problem is swelling of the bronchial tubes and accumulation of mucus in the tubes. The air passageways are severely inflamed, and no amount of bronchodilator alone will treat this part of the problem. To treat swelling and inflammation of the bronchial tubes, turn to steroids.

For a severe attack like this one, it is generally necessary to take steroid tablets such as prednisone or methylprednisolone. Call your doctor (or a physician covering for him or her) immediately to discuss your condition and get a prescription for oral steroid tablets. It is particularly helpful if you can tell your physician what your peak flow value is. This information will help him or her to gauge how severe this attack is and how best to respond to it.

If you have had a severe attack of asthma in the past, your doctor may already have prescribed steroid tablets for you to keep at home. If so, take the dosage prescribed (usually 30–60 mg). Then notify your doctor that you are having an asthma attack and that you have begun taking the steroid tablets.

Steroid tablets usually take six or more hours to take effect. You can continue to use your bronchodilator (for example, albuterol inhaler) as often as every hour while waiting for the steroids to start working. You should rest and relax as much as possible while waiting for the medication to take effect. As long as your breathing and peak flow are steady or improving during this time, you will be fine.

On the other hand, if your breathing is getting worse despite frequent use of your bronchodilator, seek emergency help. Quickly get to a nearby urgent care center or emergency room. A severe asthma attack can be dangerous, especially if you are getting worse in spite of initial self-help measures. In particular, the following types of symptoms are signs that it is time for you or a family member to call 911 for an emergency rescue team:

• You are unable to speak more than a word or two because of shortness of breath.

• You pass out or nearly pass out.

• Your lips and skin have a bluish discoloration due to lack of oxygen.

• Your peak flow is less than 100 L/min.

Last updated:	September 27, 2007