Asthma is a considerable management issue for paramedics as every asthmatic patient is vulnerable of developing acute severe asthma. Asthma is a pulmonary emergency whereby; bronchial smooth muscle contraction and hypersecretion of mucous cause an airflow obstruction. McCance and Huether (2010) define asthma as a common inflammatory disease that comprises of periodic episodes of severe but reversible bronchial obstruction. As a result of the inflammation, bronchial plugging cause oedema and a hyper inflammatory response, which occurs within the bronchial wall of the pulmonary tract as a result from histamine release (Sanders, 2007). As the bronchioles constrict the muscle fibres that encompass the tract are starting to contract causing more of a blockage in the airway. Severe asthma can lead to the constriction of airways, lung hyperinflation, ventilation perfusion imbalance, and increased work of breathing and thus leading to ventilatory muscle fatigue and life-threatening respiratory failure (Schreck, 2006).
It is crucial to make a diagnosis of asthma and to exclude other diagnoses. Considering the diagnosis of anaphylaxis is important in situations like this. Anaphylaxis mimics asthma in a way that it presents with tachycardia and bronchospasm (Sanders, 2007). Paramedics can undertake a secondary survey so to immediately rule out an allergic reaction. Also, a laryngoscopy can precede a secondary survey to check for the presence of laryngeal or epiglottic oedema that would normally be present in a patient suffering an anaphylactic reaction. In this case there was no angio-oedema or urticaria accompanying the inability to ventilate, so anaphylaxis was unlikely. Research has shown that anaphylaxis very rarely presents as just bronchospasm (Linton & Watson, 2010). However, respiratory arrest and coma, or severe dyspnoea with silent chest on auscultation comprise the basic clinical picture for asthma. 'Silent chest' is an outcome of hyperinflation as there is a decrease of inspiratory flow (Holley& Boots, 2009).
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Foreign body aspiration can also masquerade as asthma as one of the signs of aspiration is diminished breath sounds wheezing and coughing and could cause immediate asphyxia (Qureshi & Behzadi, 2008). As children are more prone to develop foreign body aspiration, asthma seems more likely to be the culprit. Also, performing a laryngoscopy to rule out any upper airway obstruction can be another effective assessment and method used to exclude other diagnoses. In asthma a wheeze is typically heard in both lung fields on expiration. While a wheeze that is localized and only in one area generally signifies foreign body obstruction (Fulde, 2009).
Another differential diagnosis for this patient is tension pneumothorax as the patient does have poor perfusion and diminished breath sounds. Nevertheless there is no pattern of injury that would indicate tension pneumothorax, there was no barotrauma and the patient has a past history of asthma and thus the diagnosis of tension pneumothorax is highly unlikely. While with asthma, there is a profound change in the cardiovascular function and status of a patient having an acute, severe asthmatic episode. Patient that has severe asthma can become unconscious; as there is gas trapping and increase in intrathoratic pressure and there is an increase in oxygen demand to the brain and surrounding tissues. Furthermore, there is also hyperinflation of the lungs that causes the systemic venous return to declines drastically (Hodder, Lougheed, Rowe, Fitzgerald, Kaplan & McIvor, 2010). In addition, the lack of oxygen can cause an increase in the patient's metabolic waste output, thus the monitor is reading sinus tachycardia signifying the compensatory mechanisms being initiated by the patient. Also tachycardia is a stress response of not being able to breathe and a normal reaction to hypoxia (Sanders, 2007).
After making a determinant on what the patient's condition is, treatment must quickly follow. The best way to assist this patient is via the use of pharmacological intervention management and reversing the subsequent bronchospasm. Since the issue is bronchoconstriction, Salbutamol, which is a bronchodilator should be the first medication to be administered, followed by Ipratropium Bromide, Adrenaline and corticosteroids (Ambulance Victoria, 2009). help by opening the airways slightly but do not assist with the formation of the mucosal plugging and oedema caused by the hyper inflammatory response (Sanders, 2007). So upon administration of these drugs, assisted ventilation is needed until the patient is transported to definitive care.
Other forms of treatment and management that could be introduced to Victoria ambulance guidelines in the future are Heliox and Magnesium sulphate. Heliox is a mixture of helium and oxygen; it flows through constricted airways more efficiently than oxygen because it is low density (McGarvey & Pollack, 2008). It was discovered 73 years ago and a large number of studies advocate its use. During exacerbations of asthma, increased secretions and bronchospasm occur and thus causing increase work of breathing. These changes cause flow to be more chaotic. The effectiveness of nebulised bronchodilator can be impeded by turbulent flow. Heliox mixtures decrease turbulent flow and act as a protracting agent allowing bronchodilator or anti-inflammatory agents to attain their peak activities. There is a myriad of case articles that support its use in conjunction with conventional medications of treatment in asthma. Research has shown that Heliox has been shown to rapidly improve ventilation and decreases airway resistance and shortness of breath in patients with acute severe asthma (Ho, Lee, Karmakar, DionChung & Contardi, 2003).
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Heliox comes in the same cylinders as oxygen and therefore can be easily stored on the side of the ambulances. Also, it does not require any extra training as it is used the same way as oxygen. Furthermore, Heliox is nontoxic and research has shown little evidence of any adverse reactions on patients and thus can be safely used in the majority of patients. Patients with asthma suffer from a range of symptoms including dyspnoea; hypoxemia and ultimately respiratory muscles become weakened due to exhaustion (Venkataraman, 2006). Heliox has shown to decrease all these symptoms, and therefore prevents patients going into respiratory failure which may necessitate intubation.
Magnesium sulphate is a sulfur salt of magnesium with a formula of MgS04 that has various medical uses. One of them is inducing smooth muscle relaxation and as such it has been identified as an anti-inflammatory agent in patients with asthma. Magnesium sulphate has been shown to decrease histamine release and inhibit smooth muscle contraction (Bichara & Goldman, 2009). The use of magnesium sulphate in status asthmaticus has gained support recently. According to several reviews and studies, magnesium appears to be of benefit to patients both adults and children with severe exacerbations of asthma who are unresponsive to standard treatment with anticholinergic drugs, beta agonist and corticosteroid medications (Mohammed & Goodacre, 2007).
The Guidelines advise taking into consideration intravenous MgSO4 for patients with life threatening exacerbations of asthma. Furthermore, the 2008 Global Initiative for Asthma recommends intravenous administration of magnesium sulphate in adults with severe airway obstruction who do not respond promptly to bronchodilators. In addition, research has shown that patients that receive nebulisers of ventolin mixed in magnesium sulphate instead of in saline get a much greater benefit (Aggarwal, Sharad, Handa, Dwiwedi & Irshad, 2006). Magnesium is safe; no life-threatening side-effects noted in any of the trials, inexpensive and has shown benefit in the severe asthmatic subgroup. Magnesium sulphate comes in ampoules, so it can easily fit in the drug bag and since it is already in liquid form, it is easy to draw up without it taking too much of the paramedic's time. Research has shown that magnesium sulphate decreases debilitating symptoms of asthma in patients who do not responded to other treatments and as such would be of great value to paramedics (Rowe & Camargo, 2006).
Considering differential diagnoses, we can conclude that the patient is suffering from respiratory failure with the underlying cause being acute severe asthma. Given the evidence presented above, the use of Heliox and magnesium sulphate should certainly be considered by Ambulance Victoria, as it presents paramedics with more effective and uncomplicated treatments that will improve patient outcomes in those suffering from severe asthma.