The other night we were dispatched to a call for an Asthmatic with trouble breathing. A woman in her early 40s with a long history of Asthma. As my partner drove to the call I looked at the comments on the mobile computer. History of Asthma? Check. No relief from multiple nebulizer treatments? Check. Previous intubations? Check.
That last one is the most concerning. Although our BLS crews carry Albuterol and have a set of criteria by which they can cancel ALS and transport, any history of intubation tosses that out the window. Of course, if the person in in their 40s and was intubated at age 8, a little discretion (oh no, not that!) comes into play.
We arrived before the fire or the BLS crew, grabbed our life saving gear and went up to the patient’s apartment.
We found a slight (98 pounds) women sucking on the mouth piece of her nebulizer inhaling as much Albuterol as she could. While my partner got vital signs, I listened to her lungs and heard a nice “musical” wheeze on inspiration and expiration. Her blood pressure was 132/76, heart rate was 130, respiratory rate was 12 with prolonged expirations. None of which was a surprise. I put the cardiac monitor on and saw a room air Oxygen Saturation of 88%. Not good. Her ETCO2 was in the low 40s, which is normal, but her wave form was sloped, which is typical for Asthmatics.
While I was setting up a Combivent Nebulizer treatment for her I asked a few questions. One of which was about her intubations. Yes, intubations. As in four in the last two years. Not. Good.
The most recent intubation was in July of this year, and yet she looked pretty good all things considered. Her “numbers” weren’t that bad at all. If not for her history of multiple intubations and the low O2 saturation, she would have been a candidate for BLS transport. Did I mention her history of multiple steroid tapers? Well, I have now.
As we got her ready to move down to the ambulance I noticed (finally) that she was sitting as still as possible. I asked her about this and she told me that ANY exertion made her Asthma attacks much worse. So, we did everything we could to minimize her effort.
Down in the ambulance, we continued to monitor her. Her saturation was up to 97%, which was just OK. Most people with a saturation in that range are fine, but not this lady. It was just very odd, or so it seemed to me.
Of we went to the hospital with no real change in her condition. We went through triage and got the patient settled in her room. Still, she was sitting as absolutely still as possible, as if even moving a bit would tip her over the edge.
I had never seen a patient present quite like this, so I started thinking about it. The strangest thing was her fear of exerting herself at all, as if her Asthma was barely under control and just waiting for a chance to kill her.
Then, for no reason at all, the term “Brittle Asthmatic” came into my mind. A Brittle Diabetic is a person with Type I Diabetes who has a hard time regulating the balance between their Insulin dose and Hypoglycemia. They are “brittle” in the sense that they are always on the edge of falling out of control. So, clever guy that I am, I thought that “Brittle Asthmatic” would be a good term to use for someone who has a hard time controlling their Asthma Exacerbations. Great idea for a blog post, don’t you think?
So, I decided to search out the term on Al Gore’s Internet (I know, but I never get tired of that joke) and was surprised to find that the term not only isn’t original to me, but isn’t even that new. It was first described in 1977. It appears that it’s more commonly used in Great Britain than in the US, but it’s not unknown in the US apparently.
The 2005 Oxford Textbook of Medicine distinguishes type 1 brittle asthma by “persistent daily chaotic variability in peak flow (usually greater than 40 per cent diurnal variation in PEFR more than 50 per cent of the time)”, while type 2 is identified by “sporadic sudden falls in PEFR against a background of usually well-controlled asthma with normal or near normal lung function”. In both types, patients are subject to recurrent, severe attacks. The cardinal symptoms of an asthma attack are shortness of breath (dyspnea), wheezing, and chest tightness. Individuals with type 1 suffer chronic attacks in spite of ongoing medical therapy, while those with type 2 experience sudden, acute and even potentially life-threatening attacks even though otherwise their asthma seems well managed.
I don’t know this patient well enough to know which category she falls into, but if I had to guess, I’d say Type 2. Either way, I’ve learned something that I didn’t know and now have something else to watch out for when evaluating patients.
Knowledge is good.