Asthma Part 1: Epidemiology,

Pathophysiology, and
Assessment
Kenny Navarro,
Paramedic
Greg Friese, MS,
NREMT-P, WEMT

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Case: 13 y.o. male

CDC

Asthma Research

This lesson examines current science as

it relates to the prehospital treatment of
asthma emergencies

Objectives: Part 1

Identify the epidemiology, anatomy, and

pathophysiology associated with asthma
Explore assessment findings associated
with asthma attacks

2010 AHA ECC Guidelines

American Heart
Associations 2010 CPR
and ECC Guidelines

Objective 1: Asthma Concepts

Asthma Definition

Chronic airway
disease
characterized by
increased reactivity
of the lower airways
to some stimuli

What is Asthma?
Asthma causes recurrent and distressing:
Wheezing
Breathlessness
Chest tightness
Coughing

Pathology of Asthma
Asthma produces its effects by leading to
airway inflammation and airflow limitation

Normal Lungs

Asthma

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma
Created and funded by NIH/NHLBI

Pathology of Asthma
Muscles around the airways constrict, and
less air passes in and out of the lungs

Normal Lungs

Asthma

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma
Created and funded by NIH/NHLBI

Epidemiology

Study of the distribution and determinants

of diseases and injuries in human
populations
Epidemiologists describe who has a
disease to help identify its causes
Once the cause is understood,
interventions can be developed to
prevent, manage, and control the disease
More information is needed to adequately
define the scope of asthma

Epidemiology

2 million+
emergency
department visits
each year
Many asthma
deaths occur
before patient
reaches
emergency
department

Adult and Child Asthma

Prevalence United States, 1997-2004
Child Lifetime

Prevalence (%)

12

Adult Lifetime

10

Child Current

Adult Current

Child Attack
Adult Attack

4
2
0

Year

2006 EPS LLC

Source: National Health Interview Survey; National Center for Health Statistics

12-Month Asthma Prevalence

by Race United States, 1980-1996

Prevalence (%)

12
10

Black

8
6
4

White

2
0

Year
Year
2006 EPS LLC

Source: National Health Interview Survey; National Center for Health Statistics

Asthma Prevalence by
Race/Ethnicity United States, 1997-2004
Hispanics reported the lowest asthma
prevalence for all three measures
Prevalence (%)

14
12
10
8

Lifetime
Current

6
4
2

Black NH

White NH
Hispanic

Attack

Year
2006 EPS LLC

Source: National Health Interview Survey; National Center for Health Statistics

Current Asthma Prevalence

by MSA Size United States, 2001
MSA Size

10

5M+
2.5 4.99
1.0 2.49
0.50 0.99
0.25 0.49
< 0.25
Non-MSA

Prevalence %

7.5
5

2.5
0
Total

2006 EPS LLC

Child

Adult

Source: National Health Interview Survey; National Center for Health Statistics

Current Asthma Prevalence

by Poverty Status United States, 2004
12

Poverty
0 0.99
1.00 2.49
2.50 4.49
4.50 +

Prevalence %

10
7.5
5
2.5
0
Total

2006 EPS LLC

Child

Adult

Source: National Health Interview Survey; National Center for Health Statistics

Asthma Triggers

If the first asthma

attack occurs during
the adult years, the
trigger seems to be
environmental

Risk Factors
Characteristics of
people that increase
the probability that
they will experience
a specific disease or
a condition
associated with a
disease

Risk Factors: IgE

Atopy is a genetic factor characterized by

production of immunoglobulin E after
exposure to environmental allergens
A person with high levels of IgE is more
likely to have an allergic response
High levels of IgE may predict the future
development of asthma

Risk Factors: Age

Almost half of the 2

million emergency
department visits every
year for asthma involve
children < 18

Risk Factors: Age

Children with one

asthmatic parent
contract asthma at 3-6
times the rate of
children with no family
history
With two asthmatic
parents, the child is 10
times more likely to
develop asthma

Risk Factors: Allergens

Toddlers who live

with at least one
smoker are nearly 3
times as likely to
wheeze as children
in smoke-free homes

Other Asthma Triggers

Other Asthma Triggers

Other Asthma Triggers

Asthma Morbidity and

Mortality

Incidence of asthma deaths has been

steadily rising since 1980
1980 1993 asthma mortality rates
doubled for children between the ages of
5 and 14 years
Black children are 6 times more likely to
die of asthma than white children

Asthma Morbidity and

Mortality

Many patients cannot interpret the

severity of their symptoms and wait until
late in the attack to seek care
Some patients dont take prescribed
medications exactly as they should
Many patients are reluctant to use drugs
that cause side effects
Psychiatric disorders may interfere with
ability to comply with treatment

Asthma Morbidity and

Mortality

Patients and their families might not take

the necessary steps to control allergens in
their homes

Pathophysiology
Spasm
(bronchoconstriction)

10

Pathophysiology
Spasm
(bronchoconstriction)
Swelling
(airway surfaces)

Pathophysiology
Spasm
(bronchoconstriction)
Swelling
(airway surfaces)
Secretions
(plug the bronchial tree)

Over-inflation

As the patient inhales,

lungs inflate
Bronchoconstriction
slows deflation
Very small
bronchioles constrict
More air goes in than
can come out
Results in air trapping
and over-inflation

11

Over-inflation
As the asthma attack
progresses, the body
must increasingly work
harder to produce even
greater negative
pressure for air
movement

Pulsus Paradoxus

Identify pulsus paradoxus

by noting the loss of a
radial pulse when the
patient inhales and the
return of the pulse during
exhalation

Asthma Diagnosis

Asthma can be difficult

to diagnose

12

Asthma Diagnosis
Medical
History

Physical
Exam

Lung
Function

Medical History

Symptoms
Coughing
Wheezing
Shortness of breath
Chest tightness

Patterns to symptoms
Family history
Severity

Medical History Questions

Do you have a troublesome cough, particularly at

night?
Are you awakened by coughing or difficult breathing?
Do you cough or wheeze after physical activity?
Do you have breathing problems during a particular
season?
Do you cough, wheeze, or develop chest tightness
after exposure to allergens?
Do colds go to your chest or last more than 10
days?
Do you use any medications? How often?
Are your symptoms relieved after you take
medication?

13

Physical Examination

A wheezing sound in the lungs

Hyperexpansion of the chest area
Hunched shoulders
Chest deformity
Nasal swelling
Diminished breath sounds
Increased secretions or polyps
Indications of an allergic skin condition

Lung Function

Spirometer measures maximum amount of

air forcibly exhaled from the lungs after a
very deep breath

Costs of Asthma

United States, 19801998

Projection for the Year 2000

15

Estimated
costs in
billions of
dollars

10
5
0

1980* 1985* 1990** 1994** 1998** 2000

Year

2006 EPS LLC

Source:

* Weiss, et al. 1992

** Weiss, et al. 2001

14

Costs of Asthma

Costs of asthma
management programs
Inpatient and outpatient
medical care
Physician services
Emergency visits
Ambulance use
Drugs
Devices
Nursing services
Allergy testing
Research

Short term and long

term treatment
complications
Absence from work and
school
Travel
Time waiting for care
Death
Difficult to measure
costs anxiety, pain,
suffering, and
decreased potential
resulting from school
absenteeism

Objective 2: Assessment

Asthma Assessment

Mild

Moderate Severe
Severe asthma indications

15

Position of Comfort

Tachypneic
Sitting upright
Tripod position
Using accessory
muscles to
breathe

Mental Status
Lethargy,
exhaustion,
agitation,
restlessness,
combativeness,
disorientation, and
confusion are
ominous signs

Breath Sounds

Wheezing is a common
physical finding
Severity does not
correlate with degree of
airway obstruction
There are many causes
of wheezing

16

Breath Sounds
Audible wheezing may
or may not be present;
however, the ability of
EMS personnel to
accurately interpret
breath sounds has been
questioned

Breath Sounds

Noisy environments
Moving ambulances
Poor equipment
Lack of medical
history
Lack of emphasis
Improper technique
Inexperience

Breath Sounds

Assess every
patients lungs
Differentiate normal
from abnormal
Listen to inhalation
and exhalation
Absent breath
sounds are an
ominous sign

17

Respiratory Rate

Respiratory rate > 30

breaths per minute
is an indication of
severe asthma

Pulse Oximetry

Apply as soon as
patient contact is
made
Baseline readings
give you something
to compare
therapy against

Capnography

18

Pulse Oximetry

90% of patients in one

study had
unrecognized hypoxia
by physical exam
85% of those did not
complain of
respiratory distress

Circulation Assessment

Pulse rate > 100 is likely

Pulse > 130 is an
indication of a severe
asthma attack
Check the patients skin
color, temperature, and
condition

Physical Exam

Look for accessory

muscle use,
retractions, and
paradoxical
breathing

19

Asthma SAMPLE History

Higher incidence of fatality:
Hospitalization within past
year for severe asthma
Previous near-fatal attack
Recent withdrawal from
corticosteroids
History of intubation, seizure,
syncope, or respiratory
failure due to asthma
Psychiatric and psychosocial
problems

Asthma History

Patient may only be able to speak 1 or 2

words at a time, so ask yes or no questions

Asthma History
If the patient cannot speak, ask family
members or bystanders for information

20

Severe Asthma Signs

Poor response to
interventions
Diaphoresis and pallor
Retractions and accessory
muscle use
Diminished or absent breath
sounds
Speaking 1 or 2 words
Pulse rate > 130
Respirations > 30
Altered mental status

Status Asthmaticus

Degree of bronchial
obstruction is severe
from onset or worsens
and is not relieved by
usual therapy
True emergency that
requires early
recognition and
immediate transport
Imminent danger of
respiratory arrest

Status Asthmaticus
Greatest risk:
Recurring attacks
Middle age or older
< 10-year history of
asthma
Corticosteroids
Smoker
Comply poorly with
medical instructions

21

Summary

Incidence of asthma has been rising steadily and no

reason to think it has reached its peak
Asthma afflicts patients of all ages, races, ethnicities,
geographic locations, and income levels
Asthma attack triggers include environmental allergies,
stress, cold air, and exercise
Spasm, swelling, and secretions of lower airways are
pathophysiology of asthma
Assessment is aimed at differentiating a mild or
moderate asthma attack from a severe asthma attack
Altered mental status and speaking only one or two
words at a time are leading indicators of a severe
asthma attack

Credits
Course Authors

Kenny Navarro, Paramedic

Greg Friese, MS, NREMT-P

Design and
Production

Images

CDC Public Health Image Library

Emergency Preparedness Systems LLC
Kenny Navarro

Narrator

John A. Chamberlain Jr.

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