Do you know when it’s time to go in?

The idea for this post came to me during the middle a recent severe exacerbation. Actually, it was the same exacerbation that put me in the hospital for 12 days, for which I am still recovering.

Foremost on my mind during an asthma excerbation is the question….how bad will it get? Is this flare going to escalate to the point where I need hospital care? If I don’t go in, will I end up on a ventilator, will this be the one that kills me? After all, 4,000 people in this country alone still die of this stupid disease every year, most of them before they make it to a hospital.

Like most chronic asthmatics, I tend to downplay or ignore the severity of my symptoms for as long as possible, because I know the unpleasantries in store for me if I end up in the slammer(ie blood gas sticks, IV insertions, bipap masks, etc.) But in procrastinating, am I playing asthma Russian roulette? Should I go in at the first sign of trouble, or should I try to tough it out and hope it gets better on it’s own? Should I call my doctor or an advise Nurse? Should I check the web to see what other people do?

Other than pre-agreed upon instructions in your asthma action plan ( hopefully you have one), there are really no hard fast rules or standardized guidelines in determining when a flaring asthmatic should seek emergency medical care. It’s totally a judgement call on your part.
Obviously, if your symptoms come on suddenly and they’re severe and you’re gasping for air you should probably call 911 or have someone drive you to the hospital right away. If you’ve been dealing with an exacerbation that’s lasted more than a week ,but doesn’t seem to be getting any better despite taking medication, you should seek help as well. But what if you’re not quite to that stage, what should you do? This can be a tough decision to make, especially at a time when you’re struggling to breath and basically feeling like crap.

Everyone’s asthma is different, but in my case, assuming that my flare didn’t come on suddenly or I was recently discharged from a hospital, I try to use objective criteria, such as my peak flows trends, my FEV1s and my sats readings, as well subjective observations, like how short of breath I feel, to try and assess whether I need a higher level of treatment or monitoring. I say monitoring, because that’s essentially what happens when you go to hospital to be treated for asthma. Most of the drugs they give you in the hospital are the same ones you take at home, only in much higher concentrations. Of course they also have oxygen and assistive breathing devices, such as bipap or a ventilator available if needed.
Probably the most important reason for going to the ER for a bad asthma flare, is that asthma can be extremely unpredictable. It doesn’t matter how severe one’s asthma is. Mild asthma can kill just easy as severe asthma.

At the hospital you’ll have Doctors, Nurses and Respiratory Therapists (in the US and Canada) in close proximity should things worsen or get out of control. Once you’re stable, the ER doctors will determine if you should be admitted to hospital for further treatment or monitoring. If you’re exacerbation is really severe and you’re not improving or you have a history of intubations (having a breathing tube inserted in your airway), they’ll most likely put you in the intensive care unit where they can keep a really close eye on you.

Again, the hospitals primary function in treating asthmatics is to monitor you until you’re over the “hump” and considered clinically stable (which btw,is totally different than “feeling” better). Your asthma flare is going to break when its darn good and ready, and nothing the Doctors, Nurses or “Hospital” can do, is really going to speed that process up. Many times your asthma flare won’t burn itself out completely until you’ve already been discharged from the hospital.

The bottom line here, is that you need to apply common sense and go with your gut feeling in determining whether you should seek medical care for an asthma attack. If your exacerbation is not getting better despite doing everything you’re supposed to, and/or it’s been brewing for more than a few days, or if you have a history of severe asthma and have been intubated and spent time in the ICU, or things just don’t feel right to you, then you should get yourself to the hospital pronto. Don’t try to second guess yourself….err on the side of caution and just go! You might also want to discuss with your family and friends in advance, about what to do in the event of an asthma emergency.

As far as children go, they can’t speak for themselves. Learn to recognize the danger signs, which are often much different in children than adults. And by all means take them in right away if their symptoms don’t improve or if you’re not sure.

Now, on a semi related topic, how many of you frequent flyers have experienced the following scenario?……

You’ve had an exacerbation brewing for a couple days and you’re getting progressively tighter and tighter. You decide it’s finally time to head to the ER. They triage you to a room and suddenly, and almost miraculously, you don’t feel quite as tight as you did 15 minutes early. Then you start 2nd guessing yourself, thinking that perhaps you’re not as sick as you originally thought? Or maybe it’s anxiety that’s making you feel worse than you actually are? You feel a little embarrassed and are actually considering leaving, but it turns out that you are indeed sick and you made the right choice by going in?

To demonstrate just how distorted ones perception of ones own breathing can become during a bad flare, here’s an example of what happened to me a couple years back….

I had been feeling sick as a dog, tight as can be. I reluctantly headed to the ER as above, but the moment they wheeled me back to one of the treatment rooms I started to feel better. I was even telling the doctor that this was a relatively minor flare up that I probably should have waited a little longer to come in. Well, 2 hours later I went into full blown respiratory failure, had a respiratory arrest that required CPR and woke up on a ventilator 2 days later!

Again I can’t stress just how important it is to go with your gut instinct. If you’re an asthmatic and you feel like crap, blame your breathlessness on the asthma first, and then consider the possibility of anxiety, but always in that order. No doubt that anxiety can add fuel to the fire, but asthma can actually kill you all by itself, so don’t mess around.

So, what criteria do YOU use to determine if, or when, you should go to the hospital ? And how high do you set the proverbial ER bar? Do you wait until you’re at the brink of respiratory failure, or do you go in at the first sign of trouble? Studies have shown that the sooner you come in for treatment, the better chance you have of slowing or reversing an attack and preventing a possible hospitalization. Not to mention, possibly saving your life.

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33 Comments

  1. Morgan says:

    Plus I forgot to mention that my asthma usually presents itself as bad coughing, but tonight there’s little to no coughing, just the pain. That’s another thing that makes me feel out of my element.

    • Sorry to hear that you’re having breathing problems. I have to say that while asthma obviously causes chest tightness and shortness of breath, it rarely causes pain. Could it be that you have bronchitis instead of asthma? Both can make it hard to breath, but bronchitis can also cause a painful cough. In any case, if you’re having difficulty breathing , even if you dont perceive it as being that bad, I would see a doctor. An Urgent care center or pvt practice should be fine. Both can prescribe an inhaler if you need one.

      Good luck!

      • Hayley says:

        It causes pain for me when it’s really really bad. You’ve got to remember that the bronchioles are muscles and asthma is spasm and inflammation of these muscles. When it’s particularly bad, surrounding muscles can also spasm up and cause pain. Also spasms can be caused by lack of oxygen to a muscle that is working hard. With asthma, muscles in our backs, chest and belly work really hard especially during severe attacks. But we aren’t taking in the oxygen levels required to feed those working muscles so spasm can result from that too.

        I’m sitting here trying to put off going into the ER. Prednisolone was already started 3 days ago, my nebs are only giving me relief for an hour, then it gets bad enough to have another one, but I don’t, I hold off for 2 more hours because I know if I start regular 2 hourly nebs I need to be on hospital so I’m kind of in denial I guess. Just don’t want to go through this again. I lost count of how many times I’ve been in, by the time I was 7. I’m now 32. It would have to be in the thousands. It’s literally my second home, practically half of my life has been lived there.

  2. Crystal says:

    I struggle with this a whole lot. I have asthma and Vocal Cord Dysfunction. I usually sat okay, but when they both flare up it’s really noisy and very uncomfortable. To make matters worse, the VCD makes it VERY hard to distinguish if my lungs or having trouble or if it’s just my throat closing up. The medicines usually lower my potassium critically, and I spend a lot of time in the Emergency Room. I started taking Singulair, and it’s helping a ton! Still…I always struggle with knowing when to go. Mostly because my dog ate my Peak Flow Meter (twice), and I haven’t gotten another one. I’m a teacher and am always really paranoid about being present at work. I left my full-time job at the public school and am teaching part-time now at a learning center. My biggest hindrance with going to the ER is, “Am I going to have to miss work?” I know that sounds superficial, but my job is very important to me. Even now, I’m currently having a flare and sound like an seal when I cough and wheeze both in and out, but I don’t want to miss work. (I just got this job a month ago). I’m sure that when I go in, they’ll hear how loud my wheezing is and send me home anyway. It’s not really fair. I think I’ll probably always have an internal war with myself on when to go to the E.R. It stinks. :S

    • Hi Crystal,

      You bring up some very good points. To an untrained or inexperienced healthcare provider , VCD and various other respiratory and cardiac conditions can mimic asthma. Medications used to treat asthma can be very potent and carry side effects. That’s why it’s so important that people be diagnosed accurately.

      Take care!

    • Hayley says:

      Yeah and different doctors have very different approaches and opinions. I have been sent home when I was rushed in by ambulance and no improvement in ER, ticking all the usual boxes for a high dependency admission, and other times been admitted in situations like going to the ER because I was on vacation and didn’t have my nebuliser and puffer wasn’t working so just wanted a neb and be sent on my way – but they admit me even though feeling 100% better, no wheeze after neb etc. it’s weird. They also judge me at triage because I’m a very calm asthmatic. They basically don’t believe me and triage me as a non priority a lot of the time and that is scary because I have to sit there for hours in the waiting room getting worse and worse because my neb is at home and if I stayed home I would be able to get relief, but it gets worse than it ever was at home and even if I go to the desk they still just tell me to take a seat. They literally are unaware that I’m so close to lung failure until they get me on the bed and hook me up to the monitors. If only they could do that stuff at triage!

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