Updated 12/11/23
ASTHMA
Asthma is a chronic inflammatory disease of the airways. During an asthma attack, muscles in the wall of the breathing airways (bronchi) constrict (bronchospasm), thereby limiting the ability of air to enter and exit the lungs. Further narrowing is caused by mucus plugs and/or swelling of the bronchial lining. The effect of all of these changes is an obstruction to airflow making it hard for the sufferer to breathe effectively.
Asthma is very common, with over 5 million people in the UK suffering from the condition. It can affect people at any age. Once they understand the issues, the majority of people can live normal active lives with asthma, and may go months or years without a serious attack, so the seriousness of the disease can easily be forgotten. However, some people are very poorly controlled and struggle to even climb a flight of stairs.
A bad asthma attack can be life threatening. Three people die of asthma in the UK each day (figures from Asthma UK). Because most asthma sufferers routinely carry a reliever inhaler, if we are called to an asthma attack, it is likely to be serious and should not be underestimated.
An asthma attack can be a frightening experience. It often starts with the sufferers feeling a pain in their chest before the obvious symptoms of an attack become apparent. It feels like something is starting to squash their lungs. This is followed by a decreasing ability to get air to and out of the lungs. It can feel almost like there is something stuck in their throat stopping them drawing air in, and at the same time, as if something is tightening around their lungs compressing them. They struggle increasingly hard to get air in, yet only a little will go in, and over time, the effort of trying to force air in and out exhausts them.
Symptoms develop at different speeds ranging from several days to a few hours. Fear and anxiety can build and play a significant role in exacerbating an attack. This can cause them to adopt a poor breathing pattern, typically a rapid breath in and shallow breaths. By helping to reassure and calm them down, you can help them to improve their breathing.
ESSENTIALS
What Triggers an Asthma Attack?
Asthma attacks can be triggered by problems inside the body or from something outside that irritates the lungs. Common examples are:
Inhaling allergens such as pollen, dust or pet dander (including search dogs!)
Inhaling smoke
Exercise
Some drugs e.g. Beta blockers, NSAIDs, aspirin, and penicillin
A common cold or illness
Chest infection (usually viruses)
Anxiety
Going from a hot to cold environment quickly
Remember – A casualty with asthma is likely to have suffered attacks before, and will be able to identify that an attack is starting. Sometimes they can feel the attack coming on before the signs and symptoms become apparent. Some will even be able to tell you how serious the attack is likely to be.
If there is no clear history of asthma, it is very unlikely that someone will suffer their first attack on a mountain. Consider other causes of breathing difficult and bronchospasm such as anaphylaxis and spontaneous pneumothorax.
General Points for Assessment
History
Ask the casualty if they:
Are a known asthmatic
Take any drugs regularly for asthma (ask for the names or colours of their inhaler)
Carry a reliever inhaler (ask for the name, colour or to look at the device)
Have taken it today?
Did it work?
When was their last attack?
Have previously been admitted to hospital for asthma?
Have ever been admitted to intensive care for treatment?
There has been any change in their condition and is it getting better or worse?
When did their symptoms start and how long did they take to develop?
If they tend to wake up around 5-6 am with a cough or difficulty in breathing (this indicates that their control is poor)
Signs and Symptoms
This is what a bad asthma attack may look and sound like.
Look for:
Shortness of breath, feel like they can’t get enough air in
Short breath in
Longer exhalation, when the wheeze will be audible. NOTE: the wheeze may not be audible if the casualty is so exhausted that they can hardly breathe.
Reduced SpO₂ (NB this occurs late)
Coughing
Raised respiratory rate
Raised heart rate
Use of accessory muscles around the neck to breathe
Inability to complete sentences normally (this is a very serious sign)
Sitting hunched over
General Principles of Management
Stop exercise
Sit up
Keep them calm and reassure them
Bronchodilator drugs by inhaler or nebuliser (salbutamol and ipratropium bromide (atrovent)
Supplementary oxygen adjusted to give SpO2 of 94-98%
Encourage them to breathe
using their diaphragm
pursing their lips on exhalation
Keep warm to minimise oxygen demand
Severity of Asthma Relevant to Mountain Rescue
Asthma attacks can range from mild to life-threatening:
Moderate
Acute severe
Life threatening
Use the number of words a casualty can say, the respiratory rate, heart rate and SpO₂ level to help differentiate between these.
Moderate
Usually self managed. If MR is called, the casualty’s condition is likely to be more severe or they don’t have their own inhaler. If they improve, they may be able to go home with continued monitoring of symptoms.
Signs & symptoms
Any one of the following:
Able to talk (can complete a sentence)
Respiratory rate less than 25 breaths per minute
Pulse less than 110 bpm
SpO₂ 92% or above, on air
Management
Stop exercise
Sit up
Keep calm and reassure
Pursed lip breathing on exhalation
Bronchodilator drugs. Get the casualty to take 2-4 sprays from a salbutamol inhaler. Alternatively, use a nebuliser to deliver the drugs. The dose can repeated after five minutes.
Keep warm
Acute Severe
Signs & symptoms
Any one of the following:
Cannot complete sentences
Respiratory rate greater 25 per min or more
Pulse rate 110 per min or more
SpO₂ 92% or above, on air
Management
Do not allow them to lie down as it can induce a respiratory arrest. Keep the casualty sitting up (they will usually want to do this anyway).
Bronchodilator drugs. Give 5 mg of salbutamol (two ampoules) via the oxygen-driven nebuliser at 6-8 litres per minute (see delivery of drugs section below for details). The dose can be repeated after five minutes.
If the first dose of salbutamol has no effect, give 500 micrograms ipratropium (atrovent) via the oxygen-driven nebuliser along with a second dose of salbutamol (the drugs can be mixed together) at 6-8 litres per minute. Only give one dose of atrovent.
When not giving bronchodilator drugs, give oxygen via a non-rebreathing mask to maintain their SpO2 at 94-98%. Reduce the flow rate from 15L/min to 10L/min if the gas supply will not last the duration of the evacuation. NB Increase the flow if the reservoir bag collapses. It is better to give lower flow for longer than high flow for a short period and then just air.
Keep warm
Will need assessment at hospital
Life Threatening
Life threatening attacks are extremely rare in mountain rescue because they generally take many hours to reach this stage.
Signs & symptoms
Any one of the following:
Single or no words
Exhaustion
Drowsiness, confusion or coma
Silent chest, feeble respiratory effort, cyanosis (blue dislouration of the lips)
Hypotension (low blood pressure)
Slow heart rate
SpO₂ less an 92% on air (there is an imminent threat to life if the Sp0₂ reading is less than 92% on oxygen) & no or minimal response to oxygen.
Management
As for Acute Severe.
If they prove unresponsive to treatment and are deteriorating, or there is a risk they could be suffering from anaphylaxis, give them IM adrenaline via an EpiPen /Jext. See Anaphylaxis section.
Remember – Do NOT lie them down. This will cause a respiratory arrest.
Signs of Improvement
Look for:
Feels less breathless
Ability to complete sentences returns
Breathing pattern becomes easier
Respiratory and heart rate fall towards normal
Patient feels better
Wheezing decreases
SpO2 improves if previously low
Remember - symptoms may return as bronchodilator drugs wear off. Repeated treatments may be necessary.
What else could it be?
Asthma shares a number of signs and symptoms with anaphylaxis and spontaneous pneumothorax. Always consider other causes of breathing difficulties and bronchospasm, especially if there is no previous history of asthma.
A simple way of distinguishing asthma and anaphylaxis is the speed of onset. Asthma generally develops slowly over several hours, whereas anaphylaxis develops rapidly in the space of minutes, up to an hour following contact with a trigger. If symptoms have developed rapidly, you should consider the possibility of anaphylaxis first and treat with immediate adrenaline if you suspect it is the cause. The adrenaline will relieve the symptoms of asthma anyway, if it is the real cause of their symptoms.
Techniques for Delivery of Asthma Drugs
We can give salbutamol in two ways:
self-administered via an inhaler. We carry a salbutamol (ventolin) inhaler in the gases sac. This is difficult to do correctly if the asthma is severe.
via a mask and oxygen-driven nebuliser (one dose of ipratopium (atrovent) can also be mixed with the salbutamol and be given this way)
Inhaler
How to use an inhaler (the casualty will almost certainly know how to use it and won’t need coaching).
However, some people have a poor technique, particularly when under stress.
Nebuliser
Nebulisers are machines that turn the liquid form of a reliever drug (salbutamol and/or atrovent) into a fine mist. The casualty then breathes this in via a facemask. The nebuliser unit is kept with the oxygen masks in the Medical Sac.
Nebulisers are more effective than normal inhalers with a spacer in people who are very tired with their breathing and very breathless as they require no co-ordination or effort to use.
In addition, they are powered by oxygen, meaning the casualty gets the benefit of supplemental oxygen whilst taking the drug.
Nebulisers are mainly used for severe attacks of asthma when large doses of inhaled drugs are needed. Both salbutamol and atrovent can be given at the same time. Salbutamol can be repeated but only give one dose of atrovent.
How to set up and use the nebuliser.
Remember - check the device label for the correct oxygen flow rate. This is 6-8 litres per minute for the nebulisers we carry.
Jext
In life threatening cases of asthma where they have failed to respond to salbutamol and atrovent, adrenaline can be used to relieve the symptoms. For speed, our first choice route of administration is via an Jext. See video for administration under Anaphylaxis.
Positioning - Sitting up
The best position for anyone with breathing problems is sitting up. Whether they sit bolt upright or slightly reclined (45-60 degrees) will depend on the terrain and the patient. The knees can be either bent or straight. Sitting up improves breathing in a number of ways including reducing pressure on the chest from abdominal contents pushing upwards and a better position for the diaphragm.
Personal experience with asthma suggests around 45 degrees feels most comfortable as it’s hard to sit up when you’re exhausted, but this can vary from patient to patient. There aren’t any high backed chairs on the fell but we may be able to provide a back support for the patient with rucksacks. Remember to support the patient’s head too. In all cases, be guided by the patient coupled with clinical observations that indicate whether improvement or deterioration is occurring.
Remember - Never lie a casualty with severe or life threatening asthma down.
Pursed Lip Breathing
A technique known as controlled or pursed lip breathing has been shown to be very effective in improving the quality of breathing in asthma and chronic lung disease (COPD). As asthma can be a very scary experience, there can be an element of panic involved that causes them to try to breath faster. Pursed Lip breathing technique can also help to get them into a more controlled steady slow rhythm.
The aim isn’t to get them to breath deeply, it’s to get them to breath in an effective, controlled and steady manner.
The technique involves the following:
Ask them to sit up straight.
Try to relax their neck and shoulders.
Breathe in through their nose for two seconds. Ask them to try to keep their mouth closed when they breathe in through their nose.
Then out through their mouth for four seconds. Ask them to pucker or ‘purse’ their lips (as if you are about to whistle) as they breath out. This gives slight resistance to the outflow of air.
They may find it helpful for them to count ‘one, two’ as they breathe in, and ‘one, two, three, four’ as they breathe out.
Then repeat.
They should not hold hold their breath between breathing in and out.
If they are having difficulty either breathing in for two seconds or out for four seconds, try to get them to make their out breath twice as long as their in breath.
Most asthmatics will be familiar with this technique and will have been coached through using it when they were children. A gentle hand on the upper back or shoulders will offer reassurance and let them know they have your support. Counting the in- and out-breath times with them will help to take their focus off the attack and concentrate them on their breathing helping to relieve some of the fear and anxiety associated with an attack.
Breathing from the Diaphragm
The diaphragm is a large muscle under the lungs (represented by the green line of the diagram below). When you breath in, it pulls the lungs downwards expanding the airways and creating negative pressure to allow air to flow in. When you breathe out, it pushes up decreasing the lung volume and helping to expel stale air and carbon dioxide from the lungs.
During an asthma attack people tend to forget to use this muscle, often using the accessory muscles at the top of the chest and shoulders instead. Breaths taken using the upper chest muscles are more shallow and more tiring. Breathing this way causes you to breathe faster and feel more breathless, compounding the problems created by the asthma attack. Therefore if you can encourage them to breath from their diaphragm it will help them to get more air in.
You can check if they are using their diaphragm by feeling just below the sternum (breastbone) at the top of their abdomen (belly) just as we do when counting the respiratory rate. You should feel the belly move outward as they breath in and inward as they breath out.
To get the casualty to breath from their diaphragm ask them to:
Relax their shoulders.
Place one hand on their chest and the other on their belly.
Get them to inhale through their nose for about two seconds.
As they breathe in, their belly should move outward more than their chest. If it isn’t, ask them to concentrate on moving it.
As they breathe out slowly through pursed-lips, their belly should move in. If it isn’t, ask them to gently press on the belly as they breath out. This will push up on their diaphragm to help them to get air out.
Repeat.
Diaphragmatic breathing is not as easy to do as pursed-lips breathing. However many asthmatics will already be familiar with it and as with pursed lip breathing getting them to concentrate on breathing correctly will help with their symptoms, fear and anxiety.
References
British Guidelines on Management of Asthma. British Thoracic Society - Scottish Intercollegiate Guidelines Network, 2019.
Randomised controlled trial of high concentration versus titrated oxygen therapy in severe exacerbations of asthma. Perrin K et al. Thorax. 2011 Nov;66:937-41.