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 one of these really bad flares is the question….how bad will it get? Is this exacerbation going to escalate to the point where I need hospital care? If I don’t go in, will this be the one that kills me? After all, 4,000 people in this country alone still die every year from asthma. Many of them before they get to a hospital.

Like most severe 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 doing so, 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?

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. This can be a tough decision for one to make, especially at a time when you’re struggling to breath or even think clearly.

For me, assuming that my flare isn’t too severe or sudden, I’ll try to use objective criteria, such as my peak flows, FEV1s and sats, as well subjective observations, such as my dyspnea level, to try and assess whether I need a higher level of treatment and 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 exact ones you take at home, only in much higher concentrations. Of course they also have oxygen and assistive breathing devices available if needed.

The main benefit, and probably the most important reason of being in the hospital during an acute flare, is that you have Doctors, Nurses and RTs in close proximity if things get out of control.. which they can easily do with asthma. If the doctors determine that you’re sick enough where you actually need to be admitted, and/or are at risk for death and/or need to be intubated (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. More times than not though, if you’re stable but just not turning around fast enough, they’ll usually put you in a regular hospital room and check up on you every few hours.

The other benefit of being in the hospital during a bad flare is that they can perform diagnostic tests, give you IV medications, etc. But again, the hospital’s primary role 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. Most of the time your asthma exacerbation 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. If your exacerbation is not getting better despite doing everything you’re supposed to, and/or your exacerbation has 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…. just go!

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, have many of you frequently 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 complicated ones perception of ones own breathing can be, a couple years back this very same thing happened to me . I felt sick as a dog, tight as can be. I reluctantly headed to the ER as above, and miraculous started feeling better the moment I entered the building. I was even telling the doc 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, it could save your life.

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20 Comments

  1. sarahsasthmablog says:

    You know, I was going to reply to this, then realized I'm getting more than enough for my own blog post (around when I started the third paragraph) and decided to make it a blog entry. XD Hopefully, I'll have it up and coherent tonight (spelling is no guarantee because my dominant eye's a bit messed up from the cellulitis and I can't see too well out of it at the moment – good news is I shouldn't lose sight permanently from this).

  2. rayzwocker says:

    This line says it all: "After all, 5,000 people in this country die every year from asthma. Many of them die before they get to a hospital." If in doubt, get the the F***ing hospital!

  3. mommato2beauties says:

    For me, with my daughter, I have a pretty high "ER" tolerance level, for exactly the reasons you state…they give the same medications…just at higher concentrations…and I've worked it out with her pulmo…how many treatments piggy backed I can do before he wants me to bring her in. Sometimes, I bring her in before…if she looks really bad, if her O2 is particularly low, if SHE asks to go…it's definitely a "gut" sort of thing. I'm definitely of the believe…"when in doubt, check it out" better to go to the ER and not really need to go, than not go, and have a tragedy happen.

  4. Lisa says:

    your comment: "Your asthma flare is going to break when its darn good and ready, and nothing the Doctors, Nurses or “Hospital” can do is going to make that happen any faster" – never thought of it this way, but completely true!, and would add that it is true even if you are fortunate to be able to monitor symptoms at home

    • It\’s true, a severe asthma exacerbation can last several weeks. Most asthmatics are in the hospital for 4-5 days.

      • Lisa says:

        this last exacerbation of mine ran a 5 -6 week stubborn course of being in the 60-70% with a few dips into the 50%. Then -bam!- I'm feeling great, in the high 70%s, hitting a few 82%. I know I still have to watch myself, but feeling like my f/u appt will be a good one for a change :)

  5. mymusicallungs says:

    Speaking personally, it's when I know I need iVs that I throw in the towel. Thankfully I haven't been in since July last year, and I have had a couple of biggie exacerbations with chest infection issues added in. I just seem to be playing Houdini for the time being and escaping ER by the skin of my teeth.

    The second I arrive at ER I get IV steroids and IV mag sulf and those are the differences between staying home and going in, plus higher flow O2 and BiPap being on hand.

    I've driven myself to the ER a couple of times and have gone in via ambulance 4 times in the last 5 years I think but usually J will take me as he has had enough!

    I don't understand though when this was such a biggie for you that you a) contemplated driving yourself and b) ended up taking public transport? Baffles me. You were in such a bad way-surely somebody could have driven you or if not an ambulance?

    I think a high proportion of the mortalities stem from people being caught out by their asthma en route to hospitals. Not to mention the danger to others when we drive ourselves, and the insecurity of leaving our car in the car park for days on end.

    I'm just glad you went, you stubborn old thing you, and that you're feeling a little bit better each day now. xx

    • I know it\’s crazy to delay going in or to take public transportation to the hospital, but Ive been hospitalized so many times over the years, that it\’s just not big deal for me.
      I guess I just don\’t care anymore. I have a huge tolerance for respiratory discomfort anyway, so unless I\’ was turning blue or stopped breathing all together, I would take my sweat time getting to the hospital.

  6. POP says:

    I've actively been pushed out the hospital or only kept overnight despite now carrying the label of 'severe persistent' so it's kind of eye opening that other people get admitted!

    I hate being in the hospital. The treatments jack you up and you can't sleep. It's exhausting. Like you said, you do all the recovering after you're discharged anyway. My last episode, they broke up the acute phase, but I still was nebulizing 24/7 for 2 weeks after going home. It took about 9 months for my lungs to recover completely.

    I have begged for a better nebulizer treatment plan so I can stay out of the ER, but the docs won't give it me.

    I tend to go to the ER when I feel that what I'm doing isn't working. So I may not be super sick yet, but the interventions I have at home aren't doing their job either. My philosophy has been that I would rather get help before it gets bad. It's not a philosophy that all ERs seem to enjoy.

    This last episode, I waited too long and was stupid about it. Failed to realize that if 5 days of 60mg prednisone did nothing that I probably needed help. By that time I was too impaired to think clearly.

    Making good choices about the ER is difficult!

    M

    • What I wouldn\’t give to get kicked out in a day or two…. I hate hospitals! My last one was 12 days. But I understand where you\’re coming from. Most hospitals and doctors don\’t know how to properly treat severe asthmatics. If they\’re kicking you out after just a day, Id find another hospital. That\’s just plain crazy, unless you weren\’t that sick.
      Hope you start to feel better soon:-)

  7. Krystie Gruppuso says:

    Hi Stephen,
    I had a severe asthma attack about 4 weeks ago, my parents didn't bring me to the hospital for it. It started when I was watching my last track meet I was depressed and mad when I was at the track meet my chest was a little tight and I had a cough I took my inhaler and it helped when I took it. Later on when I got home I was really sad that I had to quit track and I started to cry and my asthma kicked in I was breathing really heavy, my chest was extremely tight, wheezing, and it was very hard for me to answer the questions my stepmom was asking me about my asthma because I was very short of breath, I was also very dizzy when I walked. I don't think my parents realize how bad asthma can be. I'm going to a new doctor this month so hopefully he will put me on the right medication to control my asthma. I'm very limited to what I can do now I can't exercise much because it triggers an attack, I can't visit family right now because I can't be around cats for they trigger bad asthma attacks for me, parents still smoke so I try to limit my exposure to smoke.
    Please write back.
    I need your advice

    • If your breathing is as bad as you claim, you really need to be evaluated by a competent pulmonologist. Asthma Kills, don\’t mess around with and certainly don\’t exercise when you\’re in the middle of a flare. If your parents wont listen, seek help somewhere else. Talk to a counselor at School. Good luck!

  8. Faith says:

    I haven’t had a terribly bad asthma attack in two years, but now it’s coming back as bad as it was before, and I’m out of nebulizer medication. I’ve just been using my inhaler fairly often, and I’m coughing and wheezing a lot, and sometimes it gets hard to talk, and its been that way for the past few days. My mom would always know when I needed to go to the ER for stronger medication, butane I don’t know how she knew, but she passed away two years ago, and my dad never dealt with the asthma problem, and I don’t know what to do. Please help

    • Stephen says:

      You shouldn’t need someone else to tell how bad your asthma is getting or whether you should seek medical care. You’re the one with asthma, only you know how you are feeling. If you’re having a hard time breathing and your medications are working, call your doctors or go to the hospital. If someone wont take you, call 911.

  9. Judy says:

    I realize I’m responding to a blog that’s two years old, but I just saw this and have an odd answer. It’s really pretty simple for me: I work in physical medicine and rehabilitation and have treated people in nursing homes who had a severe attack, made it, but were neurologically devastated. I’ve also worked in hospitals and have seen them walk right through DNR/DNI orders, especially with young people. I made up my mind several years ago. I don’t want to risk being neurologically devastated and being in a nursing home for 40 years. Normally, the people I’ve seen are awake, but unable to communicate and it seems like no one’s home, though who really knows for sure. So, I don’t go. When they ask me, “how many times have you been intubated”, the answer is simple, “none, because I don’t go to the hospital as I would rather die at home. I have a medical power of attorney to enforce my wishes and I’m DNR/DNI.” (stands for do not resuscitate, do not intubate). Of course, the allergist still have to make recommendations of when to go to the hospital, and I understand that.

  10. stephanie says:

    Stephen

    First of all — thank you for taking time to create and educate on your site. I have learned a lot — for example, I didn’t know your SAT level could remain normal even in an asthma attack.

    My guess is you know more about asthma that most ER doctors. You know your body and what works and does not work. When you go to the ER and run into ER doctors that (1) don’t take your symptoms seriously or (2) try to palm off treatment that you know will not work, how do you handle this?

    I think I am probably like you a bit. I hold off going to the ER because I am not sure I am “really” sick. Recent example I was sick over XMAS and after two days of home treatment not working I felt I was wearing out and my doctor was out of town on vac. Since I have had previous serious attacks I decided it was finally time to head to emergency room (also hubby was out of town and I was home alone) — got to hospital. Started feeling better — quit wheezing but still pretty tight. Dr finally examined me four hours later and said “you are not wheezing, nothing wrong with you.” gave me a script for prednisone and cough medicine which I already had and sent me on my way.

    Two days later I was ADMITTED to different hospital .

    So — are there any recommendations you have for dealing with these people especially in situations where you know you are getting worse even if they don’t recognize it???

    Thanks

    Stephanie
    (FEV1 60, QVAR, Theophylline, Singulair, Albuterol, Home nebulizer, Zyrtec.) Nothing else we have tried seems to work as I am allergic to HFA227 and Lactose.

  11. Kelly says:

    I find this rather hard to answer … its not that I don’t know when to go and knowing when to held off too see if things are going to get worse or just pass on its own.

    I have spent the last year of my life in and out of ER, I think at the last count I was hitting the 20 mark for ER visits in a 12 month period … most of these by ambulance. And the last admitted twice in December (1st at after 29years). This was just after 70days worth of prednisone. So now I find it very hard to determine how things are going to go.

    The last time, I ended up in urgent care where they did an X-ray and said there is nothing wrong with you but bronchitis here some antibodies … wasn’t impressed!!! 2days later I was to the point of not being able to talk again. Had my vocal cords checked … its not that!!

    So from last experience, I have determined a few things. Meds were “not” working, when I have 6-8puffs of ventolin, 4 puffs of symbicort … can’t stop coughing and so full of mucus, its probably time to go. However, sometimes this theory doesn’t always work … I have gotten in more ventolin and thought things were starting to work and the bottom falls out.

    So basically, you really need to watch & understand what is happening. I have been told that nothings wrong but once the Doc saw me, had me on nebs within 5mins.

    Sorry, I babbled some on this I am good at that!! :)
    Kelly :)

    • Wow, 20 ER visits in a year? Maybe it’s different where you live, but you would think that someone (ie. a case manager) would notice your high ER utilization rate and try find out what the problem is, especially if you were only admitted one time out of those 20. Except for a couple times when I was a teenager, I can’t remember a time that I went to ER without being admitted to the hospital.

      Some hospitals are better than others, but I totally agree with you that there has to be better education for ER staff in treating asthmatics. Also, I would never waste my time going to an “Urgent Care” center, they’re just not equipped to deal bad asthmatics.

      Obviously your asthma is not controlled. Do you have a Respirologist?

      • Kelly says:

        Hi Stephen;

        Yeah, its not as well controlled as it could be. Just about all of those 20 visits were ugly too. Yeah never go back to Urgent care, nurses were all wonderful, the doc could over taken a flying leap off a short bridge!!!

        This all started in April of last year, within the first 5 visits I had a pulm/respiratologist. What the problem is, i think, they can’t determine exactly what is happening. I do my best to stay away from my triggers, including colds/flus. But when i get sick … I am sick!!

        Yes, I have a pulmonlogist/respiratologist plus 2 asthma nurses that I can contract when ever I need to.

        Referred to an Asthma specialist as well and still waiting.

        Right now things are good, which I am hoping things will stay that way. Education has been one of the best things that I have gotten. And have been told that puffer techniques are all good and I am doing everything that I am suppose too. But when things go south, man there is no going back!!! I have tried to head to the docs before things get bad but doesn’t seem to make any difference.

        Hey, Thanks for listening, I really appreciated :) You have some great stuff and awesome information on your site!!!

        Kelly :)

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Most frequently asked question

"Can you have an asthma attack with a normal sat reading"?
The answer is..YES!
While it's a little unusual to see a person with a perfect O2 sat of a 100% during a severe exacerbation, its pretty typical to see sats in the 94-97% range. The reason for this, is that asthma is a disease of the airways , not the alveoli where gas exchange takes place. Most asthmatics dont desaturate during the early stages of an attack,unless theres a secondary problem such as pneumonia. You have to be extremely ill with asthma if your sats are low.

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