Can You Die From an Asthma Attack?

Introduction

Asthma is a chronic illness characterised by inflammation and narrowing of the respiratory system, resulting in difficulty breathing and restricted amounts of oxygen reaching the lungs. 

An asthma attack is a term used to describe the onset of severe asthma symptoms that include severe airflow restriction. Though asthma attacks can be fatal when very severe, in most cases asthma is managed through a personalised asthma management plan to avoid cases of severe, life-threatening, or fatal asthma attacks. 

In the UK alone, an estimated 8 million people live with asthma. However, asthma attacks account for only 60,000 hospital admissions per year with an even lower death rate from asthma attacks. 

Death rates from asthma attacks in the UK stand at about 1200 people per year which translates into 0.015% of the 8 million diagnosed. According to the Asthma Australia council, a person is more likely to die from an asthma attack if they are aged over 75 years.

What are the causes of asthma?

Asthma usually develops or is diagnosed during childhood and has risk factors that include a personal or family history of allergies, male gender, respiration infections in infancy, prenatal exposure to tobacco smoke, low birth weight or prematurity, obesity, and social deprivation. 

Risk factors for late-onset or adult-onset asthma include exposure to tobacco smoke, living in damp housing, fungal spores, air pollution, and workplace exposures to substances such as flour dust and isocyanates from paint. 

The prognosis for asthma is better with childhood onset as adults are five times more likely to die from asthma than children. Male children are also more likely than female children to grow out of asthma as they transition into adulthood.

Though the overall cause of asthma is still complex and still not fully understood, it is thought to be underlined by multiple factors that include genetics and environmental exposure.

Risk Factors for asthma attacks

The triggers for an asthma attack include pollen, dust, cold air, viral respiratory tract infections, sinusitis, intense exercise, tobacco smoke, other forms of smoke, chemical fumes, gastroesophageal reflux disease, stress, other emotional factors, and drugs such as beta-blockers.

Symptoms

The most common symptoms of an asthma attack are:

• shortness of breath 
• bouts of coughing
• increased wheezing
• a tight feeling in the chest
• an increased rate of breathing

In more severe cases, symptoms include: 

• inability to complete sentences in one breath 
• agitation
• increased pulse rate or palpitations
• slowed heart rate
• feeling drowsy
• confusion
• bluish discolouration of the skin
• coma

Prevention

The risk of severe asthma attacks can be lowered or prevented completely by adhering to an asthma management plan. The asthma management plan for each person depends on how often they have symptoms of asthma and how much the symptoms impact their daily lives.

The components of an asthma management plan include:

1. Avoid triggers such as tobacco, pollen, dust, cold air, intense exercise, chemical fumes, stress and other emotional factors, and drugs such as beta-blockers, aspirin, and NSAIDs.
2. Weight loss, adequate rest, and a balanced diet and exercise regimen.

Controller medication: These are medications that are regularly used to prevent the occurrence of attacks. 

There are various medication options available with the choice of medication or combination of medications. These mainly focus on reducing the occurrence of baseline symptoms of asthma (and the need for rescue medication), reducing the number of asthma attacks, and allowing patients to enjoy their day-to-day lives with no limitation of physical activity.

These drugs are prescribed in a step-up manner till satisfactory control is achieved. In patients whose asthma symptoms at baseline are intermittent, control involves the regular use of Ventolin inhalers which contain short-acting Beta-agonists (SABA). 

In patients whose asthma symptoms are persistent, the first step of controlling medication involves the regular use of an inhaled steroid such as Beclomethasone inhalers. The dose of the inhaled steroid can be tapered to the maximum dose possible to control asthma. 

If this fails to achieve adequate control, the combination of an inhaled steroid and long-acting Beta-agonist such as Diskus, Seretide, or Symbicort is prescribed for the patient. The dose of Diskus, Seretide, and Symbicort can be tapered to achieve adequate control. However, if these fail, other long-term controller medication such as oral steroids and leukotriene receptor antagonists may be considered.

Asthma is considered controlled when:

• There are less than 3 days in a week where asthma symptoms are experienced.
• There are less than 3 days in a week where Ventolin inhalers or short-acting Beta-agonists are needed for symptomatic relief.
• The patient does not experience night-time symptoms/ awakening due to asthma.
• There are no more asthma attacks/ exacerbation attacks.

Treatment of asthma attacks

Asthma attacks can be classified as: 

• mild-moderate
• severe 
• life-threatening 
• near-fatal

Asthma attacks are considered severe if the patient is unable to complete a sentence in one breath, has oxygen saturation < 92%, and other features that aren’t considered life-threatening or near-fatal. 

Life-threatening asthma attacks are characterised by cyanosis (bluish discolouration), drowsiness, poor respiratory effort, and a silent chest. A near-fatal asthma attack is an asthma attack that requires mechanical ventilation/intubation in an ICU or is characterised by raised blood levels of carbon dioxide.

The goal of acute asthma attack treatment is to relieve symptoms and get blood oxygen saturation up between 94%-98%. The first-line treatment for asthma attacks consists of a short-acting Beta-agonist (SABA), supplementary oxygen if blood oxygen saturation is <92%, and oral corticosteroid e.g., prednisolone for some days. 

While the asthmatic person is at home or yet to reach the hospital, SABA can be administered using a Ventolin inhaler together with a spacer that increases the dose delivered. This is usually all that is needed to resolve symptoms in mild asthma attacks and a hospital visit may not be warranted.

At the hospital, SABA administration via a Ventolin inhaler together with a spacer may be continued in patients with a mild-moderate asthma attack. In severe and life-threatening asthma, however, SABA will be administered using an oxygen-driven nebulizer. In patients with a poor initial response to SABA, a drug called ipratropium bromide is combined with SABA for nebulization. 

Intravenous SABA such as IV salbutamol is only considered in patients such as very young children in whom inhaled therapy cannot be used reliably. Intravenous or intramuscular steroids are also considered for patients who cannot take oral steroids. In patients who do not have a satisfactory response to the mainstay bronchodilator therapies (SABA and ipratropium bromide), clinicians may consider administering IV magnesium sulphate or IV Aminophylline.

Conclusion

In conclusion, the risks of dying from an asthma attack are relatively slim. Most cases of asthma attacks can be prevented by adhering to asthma management plans and deaths from asthma attacks are rare due to very efficient treatment protocols. The risk of death from asthma is higher in those who do not properly adhere to their asthma management plan, have completely stopped taking their controller medication, have previously had life-threatening or near-fatal asthma attacks, suffer from adult-onset asthma, and people aged over 75 years.