Bronchial Asthma-The Sudden Catastrophic Death! Are you ready in case of an acute emergency?

I had just graduated from UCLA’s Medical School, June 1983, when I decided to take a trip to Sinaloa’s Sierra Madre. Once in the wilderness, Guadalupe De Los Reyes, my uncle developed a precipitous asthma attack (status asthmaticus). Fortunately, we were just a few steps away from a small government run clinic. The doctor was as “green” as I was, and he said to me, “I don’t know how to treat asthma; I heard you’re also a doctor; you’re going to have to treat him.” By then, my uncle was turning blue and was gasping for air. It was a medical emergency. Fortunately I remember two life saving drugs, Corticosteroids and Epinephrine 1:l000.

I first treated him with Epinephrine 1:1000 .3 ml SC followed by intravenous Methylprednisolone @ 2 mg/kg (125 mg total loading dose). I repeated the Epinephrine dose at .3 ml SC every 20 minutesX3 total. An hour later, he was relatively well. A few hours later, we continued our hike through the forest.

He was the first asthmatic I saved.

What must an asthmatic always have readily available to him (or her)?

1. An oral corticosteroid, like Prednisone tablets or suspension (5 mg/5ml) that may be dosed at 1 mg to 2 mg/kg (maximum daily dose 30 to 60 mg ÷ tid or qid); a three-day’s supply. Pregnant women with asthma might be better off taking Prednisone (as opposed to DEXAMETHASONE) because the placenta may deactivate it. Dexamethasone is not inactivated by the placenta’s 11ß-hydroxysteroid dehydrogenase (N ENGL J MED 2033 349;8) and may “suppress the secretion of sex steroids by the fetal adrenal gland.” An inhaled corticosteroid is not a “rescue drug” nor is Singulair®. For patients with hypertension seizure disorders, heart failure, I treat their asthma almost exclusively with DEXAMETHASONE since it is non-salt retaining.
2. ALBUTEROL (Maxair®; Proventil®; Ventolin®) is a selective ß-2-Adrenergic agonist with properties similar to those of TERBUTALINE (Brethine®). Terbutaline is commonly used to stop premature labor (tocolytic agent) and is readily available and can be used if ALBUTEROL is not available. The ß-2-agonist LEVALBUTEROL (XOPENEX HFA®) is available as brand only, is expensive, and, according to the Medical Letter, is not better than the inexpensive and short acting Albuterol. Students should know that the bronchial smooth muscle receptors are largely ß-2. ß-1 and Alpha-1-adrenergic receptors are found in heart and vascular smooth muscle.
3. Epinephrine is a nonselective ß-1, ß-2 and alpha-1 receptor agonist. For this reason, the more specific agonists, like Albuterol are preferred. Epinephrine’s use, in saving an asthmatic, merits some mention. In status asthmaticus, the bronchial constriction can be so severe that the proper delivery of Albuterol to the targeted ß-2 receptors may be suboptimal. This week, September 19, 2007, I had to rescue an asthmatic seriously ill for the second time in a year. If I had performed an arterial blood gas, it would have probably revealed CO2 retention-an ominous finding.

In conclusion, 4,000 to 5,000 asthmatics die yearly in the United States. These are preventable deaths. No patient of mine has died under my care. Certain drugs are of little utility in the treatment of asthma, like Cromolyn sodium (Intal®). Cromolyn sodium, paradoxically, can cause bronchospasm (bronchoconstriction). I have not prescribed Theophylline to patients with asthma for over 15 years. Advair® (GlaxoSmithKline), for some reason, has been associated with laryngeal spasms and death. Immunotherapy is of little use, in my experience, but it is lucrative. Cats (via a hair protein) can cause severe asthma in susceptible patients. Before renting or buying a home, susceptible patients must investigate if the previous tenant had cats. Even after a cat owner moves, the cat allergen may be around the house for months.

Do antibiotics play a role? They often do. In my intense study of the subject, most middle ear infections are due to allergic rhinitis (hay fever). Bacterial pneumonia is a common complications associated with asthma (or sinusitis with aspiration).

I rarely recommend that asthmatics be monitored as tightly as are diabetics. There are many patients with mild asthma that never see a doctor. I ask my patients to first use the Albuterol inhaler, when symptomatic, and to wait 5 to 10 minutes before they use their corticosteroid inhaler.

My asthma patients have a three-day supply of Prednisone or Dexamethasone as well as Albuterol in case I am away, and they experience an asthma crisis. I encourage all asthmatics to discuss this topic with their doctors before an emergency develops.

Luis Lomeli MD/Beta

Duration : 0:4:33

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