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Michael Wechsler, MD: Hello. I'm Dr Mike Wechsler. Welcome to Medscape's InDiscussion series on moderate to severe asthma. Today we'll be discussing emergency management of asthma with Dr Joshua Kosowsky. Josh is the clinical director in emergency medicine and vice chair of clinical affairs at Brigham and Women's Hospital and Harvard Medical School. Josh, welcome to InDiscussion.
Joshua M. Kosowsky, MD: Thanks, Mike. Good to be here.
Wechsler: It's great to have you. I've known you for a long time. I think it's been close to 38 years; we met in college and we both managed to make our way through medical school. I remember that back then I used to beat you in basketball and squash. You ended up choosing a path toward emergency medicine after medical school. Why did you choose a path of emergency medicine?
Kosowsky: Some of your younger viewers may not know that emergency medicine is, believe it or not, a relatively new specialty. Not that we're old or anything, but in the mid-1990s, very few people went into emergency medicine, especially from our medical school. The premise was that if you didn't find anything that you liked but kind of liked everything a little bit, that's what you would end up doing. Sure enough, 38 years later, I still enjoy the pace. I enjoy the diversity, and not knowing what to expect is a lot of fun for me.
Wechsler: I remember also around that same time, the show ER was out. I wonder if that influenced your or anyone else's decision to go into that field, because there was a lot of drama associated with that show as well.
Kosowsky: Honestly, we probably watched ER together. Back in the day, it was pretty realistic in terms of the types of medical terminology that they used, and the scenarios were — at least up until about season seven — relatively realistic. When they started doing heart transplants in the ER, that's when I kind of lost my patience with it. But it was a good show.
Wechsler: That's true. I didn't see heart transplants when I was doing my residency and practicing in the emergency room either. I recognize that there's a lot of asthma out there. In the United States there are about 25 million Americans or more who have asthma, and every year they have over one and a half million emergency room visits.
When I get called down to the emergency room every so often, to see either some of my patients or other patients, these patients are generally very uncomfortable. They're huffing and puffing, and they seem like they're in real respiratory distress. Can you describe how you see these asthma patients when they get into the ER and what sort of symptoms they have?
Kosowsky: The cases you get called about are the most severe because they've been there for some time. They've been triaged to a higher level of acuity, and they're just still not getting better. The vast majority of patients who present with asthma are presenting with more mild to moderate symptoms.
The vast majority of patients get discharged and you may not even hear about them until the next day. The ones who are sick enough to call a pulmonologist or get admitted are patients who have typically been through several rounds of bronchodilator treatments. They've been given IV steroids, they've been given some supplemental treatments as well, and they still have not turned around and are quite sick. They probably represent about 10%-15% of our overall population.
Wechsler: What's on the differential diagnosis when you see someone who presents saying, "I have asthma"? What are some of your other concerns when you see them in the emergency room?
Kosowsky: It's a great question, particularly for patients who present with what would appear to be a first-time asthma exacerbation. It's sort of a red flag in our minds that there can be very many other diagnoses. Some that come to mind in an older patient might be congestive heart failure (CHF), pneumonia, and other, more obscure lung diseases.
But most patients who have asthma and come in with an asthma attack are pretty well familiar with the types of symptoms. They'll even be able to tell you that this is exactly like the last time they had an asthma exacerbation. They may even know exactly what precipitated it. For the vast majority of patients, it's not a major differential diagnostic dilemma.
Wechsler: What kind of workup do you do when they come in, just to make sure that it is asthma and it isn't something else? How do you distinguish between asthma and chronic obstructive pulmonary disease (COPD), for instance?
Kosowsky: The workup mostly is a clinical diagnosis. It's taking a history and doing a physical exam. There may be a role for a chest x-ray in some of these patients, particularly if they're sick enough to get admitted. But the average patient with asthma probably doesn't need a chest x-ray.
If they're really sick, you're probably going to get some blood work. Particularly, getting a venous blood gas would be important, to see if they're retaining CO2. As far as distinguishing between asthma and COPD, you know better than I that there's a spectrum of folks. Younger patients tend to have asthma; older patients, particularly if they've had a smoking history, tend to have COPD; and there are lots of patients in the middle who carry some kind of a diagnosis of asthma/COPD. I have to say, as an emergency physician, we don't get too involved in making that distinction. For the most part, most of our treatments are going to be the same.
Wechsler: There are a lot of people who may come in wheezing, and it may not be asthma or COPD. They may have a valvular issue. What else comes to mind, and when you see these patients with your medical students or residents, what do you tell them to be on the lookout for?
Kosowsky: You're alluding to the famous saying, "All that wheezes is not asthma." That is very true, and particularly for patients who either don't have a history of asthma or have a history of other comorbidities, particularly cardiac comorbidities, hypertension, valvular disease like you mentioned, risk factors for heart failure, or volume overload in general.
It's very important that we keep an open mind about what their differential diagnosis is. The last thing that you want to do for a patient who's coming in with a CHF exacerbation is to just bombard them with beta-agonists and give them fluids because you think that they're dehydrated.
Again, take a good clinical history, a good physical exam, supplemented in select cases by a chest x-ray and some labs. Bedside ultrasound is becoming something that we're getting much more facile with in almost all of these patients. Between those modalities, it's pretty straightforward, in most cases, to identify the patients who don't have asthma.
Wechsler: When you see these patients, a lot of times they're going to say, "I was exposed to this or that." What are some of the things that patients will tell you that makes you think, "Okay, this sounds like it was triggering your asthma"?
Kosowsky: That's something I emphasize with patients. Asthma, by its nature, is a chronic disease that has triggers. If you're struggling to figure out what the trigger was, then maybe this isn't really asthma. The vast majority are triggered by either a viral illness or something environmental.
This time of year it would be seasonal allergies, but it could be something else in the environment — smoke or what have you. If you can't find a trigger, I always pause to think I wonder if this really is asthma or if there's something else going on.
Wechsler: I agree with you. I think it makes sense to take a good history and see if there's an environmental thing, whether it's an allergen, pollen, or even something in the air. Recently there's been a lot of news about all of the smoke from the wildfires, and that can trigger asthma in a lot of patients.
These patients come in to the emergency room; they're short of breath, they've got chest tightness, they've got coughing, they're wheezing. About 30 years ago, when I first started to train, we used to just give them some bronchodilators and we'd put these people on an aminophylline drip. What has changed over the past 30 years or so, and how are we treating these patients these days who come in for an asthma exacerbation?
Kosowsky: You're bringing us way back to the days of aminophylline. I think that even precedes my day, but you're quite a bit older than me, Mike, so that probably explains it. In terms of first-line and even second-line therapies, not a whole lot has changed, maybe with the exception of not using aminophylline drips.
Our go-to agents are still short-acting beta-agonists, whether in isolation or together with ipratropium, whether given as discrete nebulizer treatments or given as continuous nebulization vs in metered-dose inhalers. It's the same medicine but different ways of giving it. That's still our first-, second-, and third-line treatment for all of these patients.
There's really not a huge role for parenteral beta-agonists. Very rarely would we use that, except in cases of anaphylaxis, and then IV steroids or oral steroids, although you don't see the impact of them right away. We know that giving steroids earlier in an asthma exacerbation — ideally within the first hour — can prevent the need for hospitalization and further exacerbation.
Between beta-agonists and steroids, that's pretty much 90% of what we do. We can talk about some of the adjuncts that we may use in certain cases, and obviously patients who are in extreme respiratory distress and need ventilatory support is a different discussion. For the vast majority of patients, not a whole lot has changed.
Wechsler: When you give these bronchodilators, the beta-agonists — you're giving albuterol, you're giving ipratropium — how frequently are you able to give it, and do you see any adverse effects from giving the bronchodilators?
Kosowsky: It's an area that has been studied a lot. There are many different protocols out there, as I've alluded to. There's stacked nebulizer treatments vs continuous nebulizer treatments, vs iterative, based on response to each treatment and looking at things like peak flow.
Overall, the main side effect that you're looking for in the immediate term would be tachycardia, and in some cases that does limit your ability to continue to give bronchodilator treatments, particularly patients who may have underlying coronary disease. Then, over time, if you give enough beta-agonist, you have to worry about hypokalemia as well.
But the bottom line is, if a patient is getting benefit and needs more bronchodilator therapy, we would just generally continue it.
Wechsler: And at what point do you start getting concerned that the patient isn't responding?
Kosowsky: With asthma, because it tends to be fairly acute in terms of presentation, which makes it a little different from COPD, patients usually have some reserve when they come in. They're usually not retaining CO2 when they first present. They may be working hard to breathe, but if they're young, they can work pretty hard for a while before they tire out.
It's when we see patients tiring out that we really start to be worried. When their venous PCO2 starts to get above normal, even slightly above normal; when their respiratory rate starts to fall, that's when we start to be concerned that this patient is going to need some kind of supplemental ventilatory support.
Wechsler: I assume that you're also looking at use of accessory muscles and paying attention to the physical exam to see what's going on with them physically, in addition to slowing down of their respiratory rate. Because the slowing down could suggest either that they're doing better or that they're doing worse. So how do you distinguish between those two?
Kosowsky: That's a great point. You need to be following these patients over time. The patient who is working hard to breathe but is young and healthy, even though they're using accessory muscles, if you think that you can break them with another nebulization or give them some time for the steroids to kick in, that's fine.
But you do need to be monitoring these patients continuously. You want to catch the first sign that their work of breathing is slowing down — not because they're getting better and their pulse ox is not improving, but their work of breathing is still high and they're now starting to tire. That really is a clinical assessment. You don't want to wait for them to start retaining CO2. You want to identify those patients earlier rather than waiting for them to crash.
Wechsler: You mentioned hypoxemia. When is that a signal? Most of the time, patients with asthma have normal oxygen saturation.
Kosowsky: True. Patients will continue to increase their respiratory rate and work of breathing to maintain a normal oxygen saturation. But a low oxygen saturation is a red flag, and we can certainly supplement it while we're waiting for those patients to improve. If you see the supplemental oxygen requirements increasing, that will be another red flag that this patient is heading toward admission or possibly even the ICU.
Wechsler: Let's talk about those patients with severe presentation. So, patients come in, you treat them with bronchodilators, they aren't seeming to get better. When do you consider admission to the ICU or noninvasive ventilation such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), and when do you consider even intubation for those acutely ill, severe asthma cases?
Kosowsky: It's going to be a clinical decision that's going to be made over time. Unless the patient comes in crashing, you usually have some time to make that decision. You don't have to rush into it, particularly recognizing that noninvasive ventilation, and certainly intubation, is not without significant hazards in some of these patients with asthma. The issue is not necessarily that they don't have ventilatory function; it's that they're trapping air and they can't get expiration accomplished. Simply putting them on positive pressure could potentially make the problem worse if you don't have the settings correct, and intubating makes it even more compounded because you're adding resistance to their circuit. Those are sort of last-ditch efforts to save a patient. Our goal is to try to prevent intubation at all costs. Some additional therapies we might try would be magnesium, which has a role in bronchodilation. We might turn to something like heliox to improve ventilation if the patient's oxygenation can withstand it. More recently, we're having a lot of success using high-flow nasal cannula, particularly for those patients who are hypoxic. Obviously it doesn't do a whole lot for CO2 retention, but again, with asthma, CO2 retention tends not to be the major issue.
If we can get those patients through with high-flow nasal cannula, we can avoid having to put them on positive pressure.
Kosowsky: Very rarely. Like I mentioned upfront, if a patient's coming in with anaphylaxis, for sure we would go to parental epinephrine as a first-line therapy. But most of the data say that as long as the patient is breathing, the best way to administer a beta-agonist is inhalational, whether via a metered-dose inhaler or a nebulizer.
Wechsler: Okay. We've seen a lot of patients end up coming to the emergency room — as I mentioned, over one and a half million emergency room visits. But did you know that there are over 400,000 hospitalizations for patients with severe asthma? And that's despite the fact that we have so many new therapies, novel biologic therapies, that have emerged that prevent asthma exacerbations — therapies like anti–IL-5, anti–IL-4, anti-TSLP. They all reduce exacerbations. Have you seen, in the past 5-7 years, as these therapies have emerged, a reduction in emergency room presentations?
Kosowsky: In fact, we have, Mike. I'm not sure how much of that is related to the new biologics, how much of it may be better patient education in terms of patients who are following their asthma management plan to avoid having to come to the emergency department, or maybe there are some changes in the environmental factors.
The National Hospital Ambulatory Medical Care Survey from 2010 showed that there were about 1.8 million emergency department visits for asthma. That was, what, 13 years ago. And the most recent study, which is from 2020, showed that the number of ED visits for asthma is down to about 1.2 million.
That's a significant reduction. As the population has continued to grow and there are arguably more people with asthma, the number of ED visits for asthma has gone down by about a third. So we're definitely seeing the impact of something. I suspect that the biologics have a role.
There are other factors as well. One of the things that we have certainly emphasized within our specialty is that when a patient presents with an asthma exacerbation, even if it's a mild exacerbation that doesn't require hospitalization, one of our goals is patient education. Does this patient have an asthma management plan?
Do they have an inhaled corticosteroid to go home with? Do they have a doctor to follow up with? All these things, in addition to the things we've talked about, have been helpful in reducing the need for ED visits and for hospital admissions.
Wechsler: I think it's one thing to manage the patients in the emergency room, but our real goal should be to prevent these emergency room visits from happening. We are doing that with more education, as you mentioned; with better use of inhaled corticosteroids, increased use of combination inhalers, inhaled steroids, and long-acting beta-agonists.
There was just recently approval of a short acting beta-agonist inhaled corticosteroid combination that patients should theoretically use when they have asthma symptoms. And that will, in theory, reduce airway inflammation while they get bronchodilated when they have symptoms, and that should prevent further exacerbations from happening.
What else can we do to prevent these patients from coming back to the emergency room? You mentioned an asthma management plan. Is there any kind of asthma management plan that you recommend specifically, or do you just tell them to go to the internet and look up "asthma management plan"?
Kosowsky: There's a discharge packet that we send our patients home with. It's been vetted by emergency department physicians as well as by pulmonologists and primary care providers. Some of these plans can get very complicated; I think the idea of simplifying things for patients is important.
You mentioned the idea of having a single inhaler that combines corticosteroid and short-acting beta-agonist. That's a great idea. I can't tell you how many patients just simply get confused by carrying around different inhalers — "Which one do I use when? How do I use it? When do I get a refill?" Anything that we can do to simplify those plans is a step in a positive direction.
Wechsler: I've mentioned the biologics that we've been studying for asthma, that have been approved for asthma in the past 7 or 8 years. There have also been some studies looking at administration of biologics in the emergency room. I know that isn't a standard of care and there haven't really been any substantial studies over the past 7 years.
What are your thoughts about that? Maybe giving a shot in the ER to prevent further exacerbations? Especially as we're developing therapies that have longer half-lives. Did you know that we're currently working on some biologic therapies that are administered every 6 months? That could be a huge benefit for some patients in the ER and that could be part of your emergency room asthma package in the future. You could give them their bronchodilators, give them their steroids, and give them a shot that will hopefully prevent them from coming back in the next couple of weeks.
Kosowsky: I think that makes a tremendous amount of sense, Mike. It's not that different from lots of other areas of emergency medicine where we certainly aim to treat the acute exacerbation, but we also do something that's going to have a long-term effect. You can think about patients who come in with migraine; we can treat the migraine, but if we can give them something to prophylax them from their next migraine, all the better. It's a bit of a culture change for some of us in emergency medicine who may view our roles very narrowly. I think as emergency medicine has grown as a specialty, we're seeing that we have a role beyond the four walls of our emergency departments.
If we can prevent that next ED visit and give the patient a better quality of life, that's great. We know that access to care is sometimes challenging. The fact that we have that patient in our sights and have access to a medication that would help them, we should take that opportunity and potentially use it.
Wechsler: That's a great way to conclude this discussion. We've had a terrific talk today about emergency management of asthma with national expert Dr Josh Kosowsky. We've touched base on a lot of different factors, including how frequently emergency room visits happen and how to work these patients up.
It's important to take a good history. It's important to do a good physical exam. It's important to administer bronchodilators and steroids early on, but I think that we need to have a plan for these patients in the future so that patients will have an asthma action plan and be administered biologics. Perhaps that will prevent asthma exacerbations from occurring.
One of our major goals is to prevent these more severe exacerbations from happening — prevention of intubation, prevention of noninvasive ventilation, and all the complications thereof. Thank you so much for joining us today. Josh, thanks for taking the time to speak to us about emergency management of asthma.
It's been a great discussion. This is Dr Mike Wechsler for InDiscussion. We'll see you next time.