Status asthmaticus is a severe attack of bronchial asthma, which proceeds much more intensively and for a longer time than usual, and is not stopped by increased dosages of bronchodilators that the patient takes. It is manifested by prolonged suffocation, cyanosis of the skin and mucous membranes, tachycardia, increased respiratory rate. During decompensation, an acidotic coma may develop. It is diagnosed on the basis of clinical data, blood gas studies. The basis for the relief of status asthmaticus is bronchodilating therapy, hormone therapy. Additionally, oxygenobarotherapy is carried out, according to indications – a ventilator.
J46 Status asthmaticus
Status asthmaticus is a life-threatening condition in clinical pulmonology. It is a complication of bronchial asthma, the mortality rate of which among the young and able-bodied population reaches 17%, while none of the patients with bronchial asthma is immune from status asthmaticus – according to various sources, complications occur in 17-79% of cases. Being both a medical and social problem, status asthmaticus requires rational methods of prevention, which should be aimed at the treatment and prevention of asthmatic, bronchopulmonary and allergic diseases.
Status asthmaticus causes
The risk group includes patients with bronchial asthma who constantly interact with allergens at home, at home or at work. Often, the status asthmaticus develops against the background of acute respiratory infections, acute bronchitis, stress. The trigger for the occurrence of a prolonged attack may be improper therapy of bronchial asthma: abrupt withdrawal of glucocorticoids, inadequate selection of the dosage of bronchodilators, taking aspirin and beta-blockers with concomitant pathology. Physical exertion and strong emotional experiences also often provoke an status asthmaticus. But sometimes asthma debuts with an status asthmaticus, then in addition to the severity of symptoms, panic and fear of death join.
During an asthmatic attack, there is a pronounced violation of bronchial patency due to mucosal edema, bronchial muscle spasms and mucus obstruction. This leads to difficulty in inhaling and to an active elongated exhalation. During a short and short inhalation, more air enters the lungs than comes out during exhalation due to blockage and a decrease in the lumen of the airways, this leads to hyper-airiness and to inflating of the lungs. Due to forced exhalation and tension, the small bronchi become even more spasmodic. As a result of all these processes, the air in the lungs stagnates, and the amount of carbon dioxide in the arterial blood increases and the amount of oxygen decreases. As with the usual severity of seizures, and with status asthmaticus, the syndrome of fatigue of the respiratory muscles develops. Constant and ineffective loads of the respiratory muscles lead to hypertrophy and to the formation of the chest shape characteristic of asthmatics. The enlarged lungs and hypertrophied muscles give it a resemblance to a barrel.
Status asthmaticus differs in the mechanism of occurrence, severity and other parameters. According to the pathogenesis , three forms are differentiated:
- metabolic – slowly developing status asthmaticus, may increase over several days and weeks.
- anaphylactic – immediately developing status asthmaticus.
- anaphylactoid is an status asthmaticus that develops within 1-2 hours, not associated with immunological mechanisms (caused by inhalation of irritating substances, cold air, etc.).
In its development, the status asthmaticus goes through the following stages:
- The stage of relative compensation is characterized by moderately pronounced bronchoobturation and respiratory syndromes.
- Decompensation stage – it corresponds to the initial signs of asphyxia, hemodynamic disorders are associated with bronchopturation and respiratory syndrome.
- Coma is a stage of deep asphyxia and hypoxia.
Status asthmaticus symptoms
The symptoms directly depend on the stage of the status asthmaticus and, if it cannot be stopped, the first stage can gradually go into a state of shock, and then into a coma.
- Stage I – relative compensation. The patient is conscious, available for communication, behaves adequately and tries to take a position in which it is easiest for him to breathe. Usually sitting, less often standing, slightly tilting the body forward and looking for a foothold for the hands. The attack of suffocation is more intense than usual, the usual drugs are not stopped. Shortness of breath and pronounced cyanosis of the nasolabial triangle, sometimes sweating is noted. The absence of sputum is an alarming symptom and indicates that the patient’s condition may worsen even more.
- Stage II – decompensation, or the stage of the silent lung. If the attack cannot be stopped in time, then the amount of unproductive air in the lungs increases, and the bronchi become even more spasmodic, as a result of which there is almost no air movement in the lungs. Hypoxemia and hypercapnia in the blood are increasing, metabolic processes are changing, due to lack of oxygen, metabolism goes with the formation of underexposure products, which ends with acidosis (acidification) of blood. The patient is conscious, but his reactions are inhibited, there is a sharp cyanosis of the fingers, sinking of the supra- and subclavian cavities, the chest is swollen, and its excursion is practically not noticeable. There are also violations from the cardiovascular system – the pressure is reduced, the pulse is frequent, weak, arrhythmic, sometimes turns into a threadlike.
- Stage III is the stage of hypoxemic, hypercapnic coma. The patient’s condition is extremely severe, consciousness is confused, there is no adequate reaction to what is happening. Breathing is shallow, rare, the symptoms of cerebral and neurological disorders are increasing, the pulse is thready, there is a drop in blood pressure, turning into a collapse.
Death as a result of status asthmaticus occurs due to persistent violation of air permeability in the respiratory tract, due to the addition of acute cardiovascular insufficiency or due to cardiac arrest. Cases are described when the status asthmaticus ended with a pneumothorax due to a rupture of the chest.
The diagnosis is made on the basis of clinical symptoms and anamnestic data. Most often, diagnostic measures are carried out by emergency doctors or therapists in a hospital (if the attack occurred while undergoing treatment in a hospital). After first aid, the patient is subject to emergency hospitalization in the intensive care unit or in the intensive care unit, where therapy is carried out simultaneously and the patient is examined as soon as possible. The general analysis of blood, urine, biochemical analysis of blood, the state of the blood gas composition and the acid-base balance coefficient are changed, as well as during an attack of bronchial asthma, only the degree of changes is more pronounced. The ECG in 12 leads shows signs of overload of the right chambers of the heart, the deviation of the EOS to the right. Status asthmaticus is differentiated with PE, bronchial foreign body, hysterical disorder.
Status asthmaticus treatment
At the stage of relative compensation, the patient is supplied with moistened oxygen through a mask. Since conventional pharmacotherapy does not have the desired effect, it is necessary to immediately start intravenous administration of glucocorticosteroids. Drip infusions are carried out, intravenous and inhalation administration of bronchodilators is carried out. One of the methods of treatment is oxygenobarotherapy – a high concentration of oxygen allows you to quickly eliminate the symptoms of increasing acidosis.
Drug therapy in most cases has a positive effect. If the patient is taken to the hospital on time, it is possible to stop the attack, but the severity and rapidity of the manifestations does not always allow it. The ventilator is performed according to indications when drug therapy is ineffective, the patient loses consciousness, the activity of the cardiovascular system is seriously impaired, as well as with the inadequacy of patients and fatigue of the respiratory muscles. At the same time, artificial ventilation of the lungs allows you to adjust and choose the most effective method of arresting an attack.
Prognosis and prevention
Even if the status asthmaticus can be successfully stopped, the prognosis is extremely unfavorable, as this serves as a basis for confirming the deterioration of the course of bronchial asthma. Prevention of status asthmaticus consists in constant and regular examinations of patients with bronchial asthma. Such patients should avoid nervous and physical overstrain, strive to reduce the minimum effective dose of bronchodilator. A healthy lifestyle, desensitization to allergens also helps to avoid complications.
- Papiris S, Kotanidou A, Malagari K, Roussos C. Clinical review: severe asthma. Crit Care. 2002 Feb;6(1):30-44. link
- Lamblin C, Gosset P, Tillie-Leblond I, Saulnier F, Marquette CH, Wallaert B, Tonnel AB. Bronchial neutrophilia in patients with noninfectious status asthmaticus. Am J Respir Crit Care Med. 1998 Feb;157(2):394-402. – link
- Afessa B, Morales I, Cury JD. Clinical course and outcome of patients admitted to an ICU for status asthmaticus. Chest. 2001 Nov;120(5):1616-21. – link
- Peters JI, Stupka JE, Singh H, Rossrucker J, Angel LF, Melo J, Levine SM. Status asthmaticus in the medical intensive care unit: a 30-year experience. Respir Med. 2012 Mar;106(3):344-8. – link
- Braman SS, Kaemmerlen JT. Intensive care of status asthmaticus. A 10-year experience. JAMA. 1990 Jul 18;264(3):366-8. – link