Definition

Status asthmaticus is a condition in which asthma does not improve with the usual asthma medications. Asthma is a disease caused by allergic factors that lead to narrowing of the airways, resulting in difficulty breathing. If an asthma attack occurs rapidly and does not respond to usual treatment, it can lead to status asthmaticus. 

Status asthmaticus is also known as severe asthma exacerbation (a severe asthma attack) or acute severe asthma. In status asthmaticus, symptoms of difficulty breathing do not improve with usual asthma treatment, such as bronchodilator inhalers (which widen the airways). This condition can last for several minutes or even persist for hours. Status asthmaticus can lead to respiratory failure, prolonged hospitalization, and even death. Therefore, status asthmaticus is considered a medical emergency that requires immediate and aggressive treatment.

Causes

The exact causes of status asthmaticus in some asthma patients and why asthma treatment does not respond to status asthmaticus symptoms are not yet known. However, status asthmaticus is usually caused by the same triggers that contribute to asthma attacks, including:

• Respiratory tract infections
• Severe stress
• Cold weather
• Severe allergic reactions
• Air pollution
• Exposure to chemicals and other irritants
• Smoking
• The onset of status asthmaticus may also be related to uncontrolled asthma, often due to not following the treatment plan prescribed by the doctor.

Status asthmaticus disrupts the respiratory gas exchange process in the lungs. This leads to lower oxygen levels compared to higher carbon dioxide levels in the blood, which in extreme cases can lead to coma (loss of consciousness) and death. Status asthmaticus can also cause trapped air in the lungs, leading to increased pressure in the chest that can cause lung collapse and even cardiac arrest.

Risk Factors

Several factors can increase the risk of asthma patients developing status asthmaticus, including:

• History of poorly controlled asthma
• Contact or exposure to triggers that cause asthma attacks, such as dust, heat, cold, fatigue, certain foods, and others
• History of irregular use of asthma control medications as prescribed by the doctor
• Being male
• Frequent nighttime awakenings due to asthma
• Breathlessness that does not improve with regular use of asthma medications
• Using one or more short-acting inhalers in the last month
• Having an upper respiratory tract infection

Symptoms

The symptoms of status asthmaticus often start with symptoms similar to an asthma attack, initially including:

• Shortness of breath
• Wheezing
• Coughing

However, in status asthmaticus, the symptoms will progressively worsen and may be accompanied by other symptoms such as:

• Severe difficulty breathing
• Excessive sweating
• Difficulty speaking (unable to speak in complete sentences)
• Fatigue and weakness
• Pain in the abdominal, back, or neck muscles
• Feeling restless, confused, or unable to concentrate
• Blue lips or skin
• Decreased consciousness
• Feeling breathless even when lying down
• Feeling the need to sit or stand to breathe more easily

Diagnosis

In diagnosing status asthmaticus, the doctor will inquire about the symptoms you are experiencing and how well you can breathe. The doctor will also ask if you are experiencing fatigue or if there is wheezing when you inhale and exhale. Additionally, the doctor will ask about previous asthma attacks and asthma medications that have been taken before or routinely. The doctor will then perform a physical examination, such as checking your pulse rate and listening to your breath sounds using a stethoscope. 

Other additional examinations may also be required, such as oxygen saturation examination with a pulse oximeter, spirometry examination (to assess lung capacity), chest X-ray examination to rule out pneumonia or other lung infections, electrocardiogram examination to rule out heart problems, etc. 

• Common diagnostic signs of status asthmaticus include:
• Breathlessness at rest
• Inability to speak in sentences or unable to speak at all
• Increased respiratory rate at rest (more than 30 breaths per minute)
• Increased resting heart rate (more than 120 beats per minute)
• Agitation (restlessness) and quick temper
• Low blood oxygen levels (hypoxemia followed by hypoxia)
• Reduced respiratory capacity (measured with a peak flow meter)

Management

Every asthma attack needs immediate management, even when at home. If you experience an asthma attack, immediately use reliever medication as directed by your doctor. If your symptoms worsen and do not improve after using asthma reliever medication, immediately visit the nearest healthcare facility. 

Status asthmaticus is usually a medical emergency and typically does not improve with usual asthma treatment, making it quite difficult to treat. If your previous asthma medication use has not successfully relieved your symptoms, the doctor may try it again at a higher dose or in combination with other treatments. Management of status asthmaticus usually includes:

• Administration of oxygen
• Medications:
• High-dose inhaled bronchodilators, such as albuterol or levalbuterol, to open your airways
• Corticosteroids: tablets, injections, or inhalation to reduce inflammation
• Ipratropium bromide, a different type of bronchodilator than albuterol
• Epinephrine injections
• Temporary use of a ventilator machine (breathing assistance device)

The doctor may need to try various treatments in combination before finding a way to manage status asthmaticus.

Complications

There are several complications of status asthmaticus that may occur depending on the stage of treatment or other conditions, such as:

• Respiratory failure or cessation due to your airways widening and filling with mucus, making it impossible to breathe.
• Cardiac arrest, due to a lack of oxygen that can disrupt your heart rhythm.
• Hypoxemia is a condition where there is insufficient oxygen in the blood, which, if it persists for too long, can cause brain damage or death.
• Respiratory alkalosis, due to low carbon dioxide levels in your blood.
• Hypercapnia, an excess of carbon dioxide. As the disease progresses, your lungs will also fail to remove carbon dioxide, resulting in excessive levels. This condition is highly likely if you are using a ventilator.
• Pneumothorax, a condition in which your lung collapses and air leaks into the space between your lung and chest wall.
• Pneumomediastinum, a condition where air leaks from the lung and enters the chest cavity.
• Side effects of medications, such as Theophylline, a medication that can help open your airways but may have negative effects on other parts of your body.
• Death

Prevention

There is no known way to fully prevent status asthmaticus if you have asthma. However, there are several things you can do to reduce the risk of having it. The most important step is to follow the advice and treatment recommended by your doctor. Even when your symptoms seem to improve and you have no symptoms, do not stop any medication until your doctor instructs you to do so. Other preventive measures you can take include:

• Monitoring asthma triggers. Try to keep a list of specific items, situations, or activities that often trigger your asthma attacks. This can help you avoid them in the future.
• Carrying an inhaler everywhere. Always carry an emergency inhaler, especially when traveling, and bring some additional medications.
• Seeking help from friends and family. Inform people close to you so they can recognize signs of a severe asthma attack and why they should take you to the hospital if they see you experiencing one. People who do not have asthma may not realize how serious your condition is.

When to See a Doctor?

Immediately visit the emergency room if you experience asthma symptoms (shortness of breath, wheezing, coughing) that cannot be relieved with your usual asthma inhaler medication. Status asthmaticus is a medical emergency, so the sooner you receive treatment, the lower the risk of complications.