Your EMS unit is dispatched to the home of a woman complaining of difficulty breathing. You arrive on scene within 5 minutes of dispatch. As you arrive at the residence, you see one car in the driveway and note no apparent dangers. The house appears well maintained, and you have always regarded this neighborhood as safe. Observing BSI precautions, you put on your gloves before getting out of the ambulance. You knock on the door and hear someone say faintly, "Come in." You enter with caution, keeping your safety and that of your partner in mind. You hear a woman's voice coming from the living room. The patient is there, sitting bolt upright on the edge of the couch. She appears to be in moderate respiratory distress, as evidenced by accessory muscle use and increased work of breathing. You acquire her informed consent to treat her as you continue your assessment. You notice the patient is holding a medication inhaler, which is blue in color. The medication name on the inhaler is Ventolin; which you recognize as a drug often prescribed for asthma and other respiratory diseases.

The patient gives her name as Charlene Green. The 31-year-old woman states she is having problems breathing because her asthma is more severe than usual. She has difficulty completing her sentences as she gives you this information. You recognize in her presentation a breathing pattern common with asthma cases. She inhales quickly and follows this with slow and more pronounced exhalations. Even without a stethoscope, you can hear her wheeze.

You begin your focused history and physical exam, knowing that when caring for medical patients you usually gain more information from the history than from the physical exam. Ms. Green's airway is open and patent with the moderate distress already noted. Her respiratory rate is 28. You observe that her skin color is normal, but the skin is a little clammy to the touch. You detect a rapid radial pulse at 130 beats per minute. The patient denies any complaints other than her breathing, but you notice that she appears to be apprehensive. Your auscultation of her breath sounds reveals bilateral wheezes on expiration in the upper and lower lobes. You place the patient on a pulse oximeter as your partner prepares to deliver oxygen at 12 lpm via a nonrebreather mask. The room air pulse oximeter reading is 94%. This doesn't surprise you, as you are aware that asthma is not usually a disease that interferes with oxygenation but rather one that interferes with exhalation of trapped air and waste products like carbon dioxide.

You begin to obtain a SAMPLE history while your partner records vital signs. Ms. Green's chief complaint (C/C) is, "It's hard for me to catch my breath." She states that she woke up this morning and did not go to work because she was wheezing so badly. She denies any allergies. The only medication she routinely takes is the Ventolin inhaler (2 puffs every 4 hours as needed for wheezing) and Sudafed (an over-the-counter medication) for nasal congestion. When you inquire of her past medical history, she tells you that, other than asthma, the only problem she has had was eye surgery for a detached retina. She has not had anything to eat or drink this morning. Since getting out of bed she has taken 4 inhaled puffs of Ventolin with virtually no response. Your partner, meanwhile, has recorded these vital signs: pupils, equal and reactive; BP 142/80; pulse, 130; respirations, 28, SaO2 of 94% on room air and an SaO2 of 99% on oxygen.

You assist Ms. Green to the ambulance cot, move her to the ambulance, and begin the 15-minute trip to the hospital. Your protocol directs you to contact medical direction because the patient has already used Ventolin before your arrival. As you are giving your report to Dr. Pauly, the medical director, you note that Ms. Green's Ventolin had expired in 2000 and you relay this information as well. The physician orders you to administer two puffs of an albuterol inhaler that has not expired if possible. You ask Ms. Green if she has another inhaler in her purse. Happily she does, and it has not expired. You prepare the set-up, which requires attachment of a spacer on the device. Spacers are often used to enhance the delivery of medications throughout the respiratory system. You know from your previous teachings that albuterol is the generic name of a medication that is prescribed to consumers under the trade name of Ventolin. You realize that you are basically giving the patient the same medication that she took before your arrival. With your assistance, Ms. Green uses the inhaler. Within moments, she states she that it is working and that she is beginning to feel better. The remainder of the transport is uneventful. The ongoing assessment reveals that her vital signs are BP 128/70, pulse 108, respirations 22, and SaO2 of 100%. The trip to the emergency department is uneventful and you turn her over to the staff there. You complete your run report and deliver a copy to the emergency department staff.

Background

Asthma is a condition that may affect pediatric patients as well as adults. The effects of asthma are often triggered by an immune response of the body. Control of these triggers is key to the long-term management of asthma. Some triggers include stress, infection, dehydration, and allergens such as mold, mildew, pollens, and such. Patients should be assessed for and keep journals to identify such triggers. Avoiding the triggers in their daily routine is often an important element in asthma patients' ability to cope with their condition.

Many asthma patients manage their disease with medications such as Ventolin or Proventil, two trade names for albuterol. Albuterol is a beta2 agonist, a bronchodilator, which simply means that it initiates dilation of the bronchioles. This is beneficial because patients having an asthma attack are suffering from constriction of their bronchial or distal airways. This constriction causes the characteristic wheezing asthma patients often exhibit. However, some asthma attacks are so severe that patients present with no wheezing, simply because they aren't moving enough air to generate the sound. One other effect of a beta2 agonist like albuterol is some mild stimulation of the cardiovascular system, with the medication predominantly affecting the heart rate. Often, during the administration of bronchodilators, you will see an increase in the patient's heart rate. This may cause tachycardia (HR>100 in adults).

As with most chronic diseases, patients try to make use of their medication conform to their daily activities rather than make their daily activities conform to their medication regimen. Thus, many asthma patients own multiple inhalers of the same medications. They may have one for the office, one for the car, one for the bedroom, etc. Therefore, it is easy for them to neglect or miss things like the expiration dates on the various inhalers. Inhalers are not inexpensive, either. Some patients may continue to use expired medications simply because of the expense of buying new ones. If you encounter an inhaler past its expiration date, remember that there are many reasons for expiration dates. The chief reason for an expiration date is the decrease in potency or effectiveness of the medication over time. Additionally, some medications will break down into harmful byproducts with the passage of time.

Physicians may request that you administer a prescribed inhaler to an asthma patient even though the patient has used the same or similar medications prior to your arrival. The physician may also desire that you use a spacer in conjunction with the inhaler. During an acute asthma attack, patients may not be able to inhale deeply enough to get the medications where it needs to be with the inhaler alone. Updraft nebulizers or inhalers with spacers allow the medication to be distributed more deeply into the respiratory system. Physician-prescribed repeat doses may also allow for a quicker or more long lasting effect of the medication.

As with all patients, it is important to be calm and reassuring. Asthma is a complicated disease, which is made worse by the patient's apprehension. You can understand a patient's apprehension. During an acute attack, asthma prevents the patient from being able to completely exhale. Waste products continue to accumulate within the body. The patient feels as if he or she has been holding his or her breath and can't take the next breath. In the words of one 5- year-old asthma patient, "It's like being a fish out of water!" Let the patient rely on your professional approach for a sense of calm and comfort.