What to do in a Medical Emergency

Asthma and Allergies

Asthma

Dr. Michael Carius, emergency department chairman at Norwalk Hospital in Norwalk, Connecticut

Although asthma and allergies are two separate conditions - asthma is a chronic disease of the bronchial airtubes, whereas allergies involve an overreaction of the body's disease-fighting immune system - the two conditions can be intertwined and often overlap. 

For example, because most people with asthma also have allergies, asthma attacks (sometimes referred to as "exacerbations") can be triggered by exposure to allergens, such as pollen, mold or animal dander. This type of asthma is known as allergic asthma, and it is one of several types of asthma.

In addition, asthma and certain allergic conditions, such as hay fever and peanut allergy, share the potential to be life threatening. Allergies can be life-threatening when they lead to anaphylaxis. Asthma can be fatal when a severe asthma attack does not respond to inhaled bronchodilators and leads to symptoms of respiratory failure, a condition known "status asthmaticus."

Finally, since many of the symptoms of asthma are the same as they are for allergies, physicians may use some of the same medications to treat both.

Here you will find information about asthma, allergies, precautions and preventions, and preventing attacks while traveling.

Asthma

AsthmaAsthma is a chronic lung disease that results in 1.8 million emergency visits and about 4,000 deaths each year. There are several types of asthma, and although the disease can be controlled, there is not yet a cure, which means that asthma patients must manage their condition on a daily basis. Moreover, it is estimated that about half of asthma sufferers do not have their condition under control, making it more likely that these patients will end up in an emergency department as a result of an asthma attack. When poorly controlled, asthma is potentially life-threatening.

The characteristics of asthma include inflammation (swelling and irritation) of the airways and bronchoconstriction (tightening of the muscles surrounding the airways). Often worse at night, these problems shrink the airways, making it more difficult to breathe. The often-missed warning signs of poorly controlled asthma are:

  • Waking at night wheezing and/or coughing
  • Requiring a quick-relief inhaler more than twice a week
  • Missing school or work
  • Being unable to participate in everyday activities
  • Requiring emergency or urgent care in order to breathe properly

Respiratory infections, such as the common cold or flu, are common triggers of asthma exacerbations, (which is why persons with asthma are advised to get a flu shot each fall when the vaccine becomes available). Other triggers include exercise, laughing or crying hard, cold air and irritants, such as poor air quality (e.g., Code Red ozone pollution days in the summer), chemicals, smoke, perfume and air fresheners. Some allergens also can serve as triggers. Common inhaled allergens include dust, pollen, mold or animal dander.

The symptoms of asthma include:

  • Difficulty breathing
  • Tightness in the chest
  • Coughing and wheezing

Asthma attacks that appear to be severe or that do not respond to the patient's normal medication require immediate medical attention. Less serious attacks or an increasing frequency of asthma attacks should be evaluated by a visit to one's doctor. In some cases, the patient may seek the advice of an asthma care specialist - such as an allergist or pulmonologist.

Asthma patients should go to the emergency department if they have severe asthma symptoms, especially if these symptoms are accompanied by severe sweating, faintness, nausea, panting, rapid pulse rate, and pale, cold, moist skin. (These may be signs of shock or a potentially life-threatening drop in blood pressure.) These patients may be experiencing a potentially fatal asthma attack, known as "status asthmaticus."

Seek immediate medical attention for the following symptoms and warning signs associated with this potentially life-threatening condition:

  • Persistent shortness of breath or breathlessness experienced even while lying in bed.
  • An asthma attack that is not relived by a usually effective rescue inhalers.
  • Lips or fingernails are turning blue (or gray in persons with dark complexions).
  • Straining to breathe or the inability to complete a sentence without pausing for breath.
  • A feeling of chest tightness.
  • Feelings of agitation, confusion or an inability to concentrate.
  • Hunching of shoulders, straining of abdominal and neck muscles or sitting or standing to breathe more easily

These are all signs of impending respiratory system failure, a potentially fatal condition. Be aware also that fatal asthma attacks often occur with few warning signals, and that they can come on quickly, leading rapidly to asphyxiation and death. Fatal asthma attacks are more common among persons who have poor control of allergens or asthma triggers in their daily environments and an infrequent history of using peak flow monitors and inhalers as aids in controlling their asthma.

Finally, it is important to note that extremely severe, potentially fatal asthma attacks may not feature more wheezing and coughing - thus making such symptoms unreliable in judging the severity of asthma attacks. In such cases, the breathing airways have become so restricted that there is not enough air going in and out of the lungs to cause wheezing or coughing. (In addition, wheezing also can be a sign of other health conditions, such as respiratory infection and heart failure, so it is important to seek prompt medical attention if these other serious conditions are suspected.)

Emergency department treatment of asthma typically includes oxygen, inhaled bronchodilators (such as albuterol), and systemic corticosteroids (such as prednisone). Long-term asthma treatment includes inflammation "controllers," such as inhaled corticosteroids, and symptom "relievers" such as inhaled bronchodilators.

Since the key to preventing asthma attacks is controlling them, it is important to seek out proper medical care, take medication as directed and become educated as to how best avoid previously described "asthma triggers."

Allergies

Dr. Angela Gardner, Emergency physician at the University of Texas Medical Branch in Galveston, Texas

Allergies involve an overreaction of the body's immune system, which is responsible for fighting infections. There are many types of allergies, including seasonal allergies (which involve allergic reactions to pollens, grasses and weeds), perennial allergies (which last for 9 or more months out of the year), chronic allergies (to allergens such as dust and mold), food allergies, medicine allergies, insect venom allergies, and animal allergies, among others. In addition, some people develop a potentially life-threatening allergy to latex, which is found in rubber gloves, while others can become "sensitized" to substances they have been repeatedly exposed to at work, a condition known as "occupational allergy."

Allergic responses range from mild to life threatening. Common mildly annoying allergy symptoms include sneezing, congestion, runny nose, watery eyes, headache and fatigue. However, exposure to some allergens, such as peanuts, shellfish, insect stings, medications, and latex can quickly progress to severe life-threatening reactions or anaphylaxis. For that reason, seek emergency care right away if you experience a mix of some of the following symptoms:

  • Difficulty breathing
  • Wheezing (along with high-pitched breathing sounds)
  • Confusion
  • Anxiety, fear, apprehension
  • Slurred speech
  • Swelling of the face, eyes, tongue or extremities
  • Trouble swallowing
  • Severe sweating
  • Faintness, lightheadedness, dizziness
  • Heart palpitations (feeling one's heart beat)
  • Nausea and vomiting
  • Diarrhea
  • Abdominal pain, cramping
  • Panting
  • Rapid or weak pulse rate
  • Pale, cold, moist skin or skin redness
  • Blueness of skin, including lips or nail beds (or grayish for darker complexions)
  • Loss of consciousness

To help prevent the need for emergency care for allergy attacks, you can take the following preventive measures:

  • Visit your physician regularly. The continuing advice of a doctor is crucial to the long-term treatment of allergic conditions. Your physician may refer you to a medical specialist, known as an allergist/immunologist, who has received special training in diagnosing and treating allergic diseases. This type of specialist can recommend certain drug therapies or desensitization treatments (also known as "allergy shots").
  • Know your allergies. If you and your physician suspect you have allergies, you may be tested to determine what is triggering your symptoms.
  • Avoid allergens. Once you know what you are allergic to, avoid the allergen. For example:
    • If you are allergic to shellfish, don't eat it; your first reaction may be mild but additional exposures can quickly lead to life-threatening reactions.
    • If cats make you break out in hives, don't pet them or keep them in your home.
    • If you are allergic to insect venom, take precautions when going out of doors, particularly at certain times of year when such insects are more prevalent or aggressive, or when picnicking or in wooded environments. Persons with insect-venom allergies should also carry self-injectable epinephrine (EpiPen or TwinJect), diphenihydramine or a bee-sting kit (per a health provider's instructions); injectable epinephrine should be used only on the person for whom it has been prescribed.
    • If you are allergic to pollen or mold, avoid the outdoors on windy days or when you begin to notice symptoms. The wind often stirs up pollen and mold and carries it through the air. Also, don't hang laundry out to dry. Pollen and molds can collect on sheets and clothing And minimize activity outdoors at dawn (5 a.m. to 10 a.m.) when pollen is usually emitted into the air. -To minimize exposure to outdoor allergens, keep car windows closed when you drive, and consider using air conditioning when your seasonal allergy symptoms are at their worst, both in your car and at home (provided the system is regularly cleaned and maintained and filters are frequently changed).
    • If you are allergic to grass or molds, do not cut your grass and avoid the outdoors when others are mowing their lawns.
    • If you are allergic to mold (or have an allergic asthmatic reaction to it) and experience heightened allergic symptoms in your everyday home or work environment, consider hiring someone to investigate and address the problem. (Do not attempt to remove moldy insulation and other items from your home yourself; doing so can cause an intense allergic reaction.)

Additional Precautions and Prevention

People with allergies and asthma, which are often related, should always carry medications with them and ask their doctors about wearing medical alert bracelets or jewelry. (The MedicAlert® Foundation sells medical identification bracelets on their website at www.medicalert.org.)

More specifically, individuals with asthma should always carry a quick-relief inhaler (bronchodilator), such as albuterol, and avoid known asthma triggers when possible. Individuals at risk of anaphylaxis, for whom a doctor has prescribed self-injectable epinephrine (such as an EpiPen or TwinJect), should carry it at all times and know how to use it in an emergency. Show your family and friends how to use it on you as well.

Persons with allergic asthma and related allergies should avoid exposure to pollution from poor air quality or tobacco smoke. If you live in a city that measures and forecasts air quality, stay indoors as much as possible when the forecast is poor (e.g., "Code Red," Code Orange"). If you are prone to exercise-induced asthma, be aware of your limitations, especially if you do strenuous activity in polluted or high-pollen areas (e.g., places that have a lot of trees, grass, weeds).

Injectable epinephrine should not be used on persons other than the person for whom it has been prescribed (e.g., asthmatics or persons allergic to insect venom). Some people may have underlying health conditions that could be adversely affected by this drug.

Preventing Attacks While Traveling

  • Take all necessary medications with you in their original prescription bottles, in case you need to refill prescriptions while away. Pack extra quantities of medications to make sure you don't run out. Do not pack medications in checked luggage in case your luggage is lost; keep it in a carry-on bag.
  • Carry topical hydrocortisone cream and antihistamine medication with you - if you are using an over-the-counter medication, make sure you have used it before and that it is effective.
  • If using a nebulizer for delivering anti-asthma medication, don't forget to take it on vacation, along with an electrical current converter for it if traveling abroad; portable nebulizers that are plugged into auto cigarette lighter receptacles are also available.
  • If your doctor requests that you use a peak flow meter and record chart, be sure to take these items with you.
  • Bring your allergy-proof pillow or bedding to guard against dust mites.
  • If staying in a hotel or bed and breakfast, check ahead of time to find out whether perfumed air fresheners, deodorizers or other scented products will be used. (Scented carpet cleaning agents also may be a problem.)
  • In hotels, ask for a nonsmoking room, preferably on a nonsmoking floor.
  • If sensitive to mold, call ahead to determine whether this might be a problem, particularly if you are staying in a cabin or a beach bungalow. If driving, check your vehicle for mold and mildew problems, and if camping, check tents and other mold-prone items.
  • If sensitive to sulfites, when eating out check with the restaurant staff to find out whether this additive has been used as a food preservative. If so, ask if your meals can be prepared without it. (Sulfites are commonly used as a preservative in wine, dried fruits and dried potato products. They also occur naturally in wine.)
  • If food allergies are a significant problem, pack snacks at home you can eat while traveling - in case you find yourself without access to "safe" foods.
  • If allergic to pollens (e.g., trees, grass, weeds), check the pollen counts in the area you are traveling to by calling the local Chamber of Commerce or the National Allergy Bureau at 1-800-9-POLLEN. Also, call 1-800-7-ASTHMA for local support group contacts who may be able to offer useful local information.
  • Check with your insurer on coverage limitations and policies regarding out-of-state or out-of-network coverage.

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