By Dr Swathi Rao

March 25: A severe attack of asthma also known as “Status asthmaticus” is an asthma attack that doesn’t get better with standard treatments based on out-patient care. It makes it hard to breathe and is a life-threatening emergency. 

How do you know it is severe?

When a child, whether previously diagnosed as asthma or not feels difficult to breathe, progressing to the point where he/she might not be able to eat or speak very well is should be considered as severe. It also might keep your child from sleeping.

How fast can it progress to severe stage? 

Status asthmaticus can come on over a few days or just a few hours. 

What is asthma? 

Asthma in children has become a common entity now. In children less than five years we usually don’t label them as asthma, since wheeze can be triggered by common viral or bacterial infections without any long-term problems. If the child has recurrent wheezing without an underlying infection we start the treatment like asthma. If the wheeze/cough is disturbing his/her day-to-day activities and increasing the school absenteeism we should have a high index of suspicion for asthma.

In children with asthma, triggers like smoke, allergens and physical activity can cause their airways to swell and fill with mucus.

What’s the difference between asthma and status asthmaticus?

Asthma is respiratory condition where the airways are reactive to common allergens resulting in cough and difficulty in breathing that gets relieved by oral medicines. Whereas an asthma attack is characterized by severe and continuous cough and breathlessness that does not get relieved by standard outpatient treatment. A minor asthma attack can be usually managed with nebulisation and other medicines with a brief stay in the hospital. 

Status asthmaticus is a severe asthma attack that doesn’t get better with first line treatments and requires hospitalisation for a longer duration. The children generally require admission to the Paediatric Intensive Care Unit where continuous monitoring of the child is done along with advanced therapies.

What are the symptoms of status asthmaticus (acute severe asthma)?

The symptoms of status asthmaticus are as follows and generally develop over hours or days: 

• Severe shortness of breath. 
• Inability to speak or eat.
• Wheezing.
• Coughing.
• Fast heart rate.
• Dizziness.
• Confusion
• Bluish fingers, lips or skin.

What causes status asthmaticus?

Children with asthma have high risk of tightening of airways (bronchospasm), swelling up (inflammation) and production of a lot of mucus on exposure to allergens. The bronchospasm can be reversed by nebulisations; however, it is the inflammation and mucus that cause the most hard-to-control asthma attacks.

What are the triggers for status asthmaticus?

Common triggers for asthma include:

Dust, Mite, Smoke, fragrances or cold air.

Physical exercise.

Emotional stress.

Infections, like colds, the flu

Certain medications.

What area the risk factors for a severe asthma attack?

Non-compliant inhaler use

Underlying skin allergy/ allergic rhinitis 

Improper use of inhalers resulting in incomplete delivery the medication to the lungs.

Exposure to cold air, dust.

Flu or other viral respiratory infections. 

What are the complications of status asthmaticus?

Acute severe asthma can lead to serious complications, including:

Low oxygen levels in blood

Respiratory failure.

How is status asthmaticus (acute severe asthma) diagnosed?

Status asthmaticus is diagnosed mainly based on the symptoms and clinical examination. Sometimes, an X-ray and few blood tests might be done. 

How is status asthmaticus (acute severe asthma) treated?

Once your child is diagnosed to have severe asthma the treatment is started right away to get his/her breathing under control. Oxygen will be started if your child’s oxygen levels are low. Nebulisations containing various medicines will be started immediately to relieve the bronchospasm.

Specific medications used to treat status asthmaticus:

• Inhaled bronchodilators. This includes beta-2 agonists (albuterol or levalbuterol) and anticholinergenics (ipratropium bromide).
• Intravenous (IV) corticosteroids (hydrocortisone or methylprednisolone).
• IV bronchodilators (magnesium sulfate).

If your child does not get better with these medications, invasive procedure of intubation and ventilator support might be required until the child’s airways get better. Other supportive measures are IV fluids for hydration and antibiotics/antivirals if there is evidence of underlying infection. 

Can you prevent status asthmaticus (acute severe asthma)?

You can reduce your risk of severe asthma attacks by:

Appropriate use of inhalers.

Seeking medical attention before the asthma attack becomes severe. 

Knowing the triggers and doing your best to avoid them.

Note from KMC Hospital:

Not being able to get a breath is scary. You might feel anxious when your child gasps and wheezes. KMC Hospitals Children’s asthma experts are here to help them (and you) breathe easier.

Try to remain calm and call for help. If your child has asthma, work with your provider to understand and manage your condition. Know when and how to treat worsening symptoms before they become a severe asthma attack. Making a plan ahead of time can help you keep calm and get help if you need it.

(Dr Swathi Rao is a Pediatric Intensivist at KMC Hospital, Dr B R Ambedkar Circle, Mangaluru)