Acute asthma and hospital admission

As the temperatures soared last weekend my asthma nosedived, after getting through an entire salbutamol inhaler on Sunday, on Monday I called my specialist asthma nurse for advice regarding increasing my steroid tablets, but because of my rather complex history, she needed to check the best course of action with my consultant in the mean time she advised I switch from my usual dry powder accuhaler device to a metered dose inhaler (spray) via a spacer. By the time she had spoken to my consultant and called me back I had polished of another inhaler, and was told that I needed to be assessed in A&E.

The A&E triage nurse was less than impressed by the amount of salbutamol I had taken; whilst I was aware it was a lot, I’d always worked on the assumption that if I need it I need it and should take it. The only guidance I’ve ever had regarding seeking emergency care is to seek help if salbutamol doesn’t work, but it was working, admittedly not as well as normal and not for very long. In A&E I was very tachycardic, which those assessing me put down solely to overuse of salbutamol and left me in a corridor with a pulse ox, at least it wasn’t in the waiting room with people staring at me I guess. Eventually a doctor spoke to me and asked if I required anymore salbutamol and agreed with me that if I need salbutamol then I need it, and informed me that I would need to be admitted for 24hours for observation. I had to wait around 15-20 minutes before I got my neb though as I had to wait until they had a cubicle free, but things improved very quickly when I was on the O₂ driven neb, but once that was finished I was almost immediately kicked back out of the cubicle to the corridor for someone who turned out to have nothing wrong with them (I know that the staff didn’t know that at the time, but it added insult to injury so to speak). Despite my O₂ sats being normal, the oxygen had made breathing feel easier, so I was doubly unimpressed to be kicked out of the cubicle. Incidentally I have had oxygen during a couple of procedures when my breathing was fine and it doesn’t feel any different to breathing air in those circumstances. Eventually, Mr Worried-Well went home and I got my cubicle back, only to have to move again to a cubicle with a trolley rather than just chairs so they could do an ECG, but before the ECG could be performed I was transferred to the Medical Assessment Unit (MAU1).

The staff nurse and registrar that greeted me were pleasant and seemed helpful, the registrar wrote up my regular medication on my drug chart (almost correctly) and organised the ECG along with a chest X-ray, some blood tests and told me I’d be having a cannula fitting in case I deteriorated during the night although the cannula never actually happened. I was brought a fan to make me more comfortable, though as I expected it was very difficult to get any sleep at all that night. It felt that almost immediately after dozing off I awoke at around 6.00am coughing and feeling very tight chested only to find that I hadn’t been prescribed any “when required” salbutamol in any form. My next scheduled salbutamol and ipratropium nebs weren’t due till 8.00am so couldn’t be given yet. This lead to a very uncomfortable, not to mention potentially dangerous, wait which culminated in a horrendous coughing fit when a patient at the other end of the bay decided to take what I call a “deodorant bath”, by which time the nurses had changed shift and the new nurse took pity on me and gave me the dose early. When the doctor came round on ward rounds I was informed that I would need to be kept under observation for a further 24 hours. Whilst on this ward I did find myself doing what I felt to be the job of the nurses and support staff, I answered questions from both patients and nursing staff regarding medication. Patients were also sharing a zimmer frame and as the only mobile patient I found myself having to get up and pass the frame around when patients needed the toilet, which I found very tiring. Perhaps this was my own fault but I don’t think I could have in good conscience left them to it when the nurse was busy.

Later that afternoon I was moved to a respiratory ward (Brierley 2) and was surprised by how many asthma triggers were present on a respiratory ward. Staff wore perfume, patients were using hairspray and taking deodorant baths, several patients smelled strongly of cigarette smoke and cigarette smoke was regularly drifting in through the windows, even the alcohol hand gel was a trigger. Visiting time was best described as an asthma trigger free for all and I’m pretty sure that at one point a patient had a crafty cigarette out of the window. I still had no “as required” salbutamol and my evening fexofenadine dose had been charted to be given after dinner, when my gaviscon would have reduced its effectiveness, my husband got this changed for me when he visited, although despite being told I would be charted for both nebs and inhalers when required only nebs were added.

The doctor who I spoke to during morning rounds on Wednesday informed me that usually they need patients to off nebs for 24 hours before discharge, but that if I was able to stop them then they might be able to let me out that evening. She then proceeded to cross the 5mg salbutamol and atrovent nebs to be replaced with a single puff of my 200mcg salbutamol accuhaler, to say the inhaler alone was not enough would be an understatement, even when I took extra puffs of it (I was still under the impression that I had both nebs, and inhalers were charted for as required use). In the end I had to ask for the nebs, but I did manage to get by on 2.5mg salbutamol nebs around four times a day. I was still waking up feeling very unwell, as with most asthmatics my lungs are always worst in the early hours, and that combined with the number of other patients taking more deodorant baths and using hairspray made mornings particularly hard. When I’d had my nebs I felt pretty good and like I really shouldn’t have been in hospital, but when I was coming off them I felt awful. I no longer had a fan to keep me cool, and though it’s unlikely that overheating had a direct effect on my lungs it did affect my overall wellbeing as I seem to be very prone to dizziness and generally feeling unwell in hot weather. In the end my husband went out and bought me a fan to help me feel more comfortable.

The doctor I saw on Thursday morning wanted me to be clear of nebs for at least 24 hours before I was allowed home, and when I explained that I didn’t feel safe on the ward with all of the triggers around and would be better off at home he decided said that I shouldn’t be going home as reacting to the triggers meant my lungs were too twitchy to go home and that trigger avoidance has no effect in asthma care! Well that’s news to me, maybe I can go back to wearing my favourite perfume and start drinking wine and pear cider again? There were several points where I thought I wasn’t ever going to be able to leave the hospital due to the near constant triggers. Thursday’s doctor did increase my prednisolone again to 50mg daily and wrote up as required salbutamol via my inhaler.

Fridays ward rounds were late and with lots of triggers and not enough salbutamol I was sure that all the struggling I’d done to avoid and more nebs could have been undone in an instant. In the end I had a lucky escape, despite feeling pretty awful on just my inhaler I managed to convince Friday’s doctor that I would be safer at home. Once I was told I could go home I was a lot less picky about documenting my salbutamol doses on my drugs chart, and probably took a fair bit more than I was supposed to, but I felt that being in hospital was hurting more than helping and I am still convinced of that fact. After 6 hours waiting for my medicines to come back from the pharmacy, a pointless wait when you consider that the ward staff knew I had an adequate supply of all my medicines at home. By the end of the 6 hours I was really struggling again, and if I’d had to wait much longer I probably would have had to ask for another neb and stay another night, I think that’s the first time I’ve ever been grateful that I’m a none wheezer (which normally causes endless problems) and was able to hide it!

Throughout the entire stay I was told that one of the specialist asthma nurses would come to see me, but no-one did; since getting home I have managed to speak to my nurse on the phone, but won’t get to see her for another week. I suppose that the weather has probably had an adverse effect on a lot of us with difficult asthma so they’re probably very busy at the moment.
 

One thing that really annoyed me was the fact that it was costing me £10 a day to watch TV, Freeview TV, plus a few films that were being played on an endless loop. Included in the £10 was a bedside telephone with free calls to landlines, which is pretty pointless since mobiles are no longer banned from wards and I have unlimited free calls to landlines and mobiles, much more useful as I only needed to call mobiles. There was supposed to be internet too, but it was worse than useless if the website wasn’t blocked by the admin, presumably for using too much bandwidth the unit ran out of memory constantly even when loading basic pages with low memory requirements designed for mobile phones. In fact the only page that did load took longer on the hospital internet than it did to load the same thing on my phone. So basically it was £10 a day to watch freeview TV, yes you can get a discount if you buy multiple days at a time, but how many inpatients actually know how long they’ll be in for?

To sum up

The whole ordeal has taught me that I probably should have been hospitalised with my asthma a lot, this was definitely not the most ill I’ve been with my lungs, but it was my first admission. The fact that it took 4 days to escape implies that it is/was a bad attack and that I should probably be seeking emergency evaluation a lot sooner, rather than stubbornly insisting that my reliever inhaler is “kind of working”; if this is the case this admission could mark the beginning of a lot of hospital admissions.

I don’t feel safe in hospital! There’s just too many triggers and variables I cannot control, I feel vulnerable and afraid, something that I’ve never felt when I’ve managed my attacks (many of which have been worse than this one) at home.

This attack has also highlighted a problem that I thought had resolved itself, or that perhaps I’d imagined, the propellants in spray inhalers (MDI’s) cause me to have paradoxical bronchospasm, normally the effect of the salbutamol in the MDI is enough to counteract this, but in the midst of an attack when my airways are especially sensitive it’s more like fighting a losing battle, but I’m also unable to get the most out of my dry powder inhaler either when things are looking very bad as I struggle with the technique. Nebulised salbutamol is awesome, it works really well and I pick up quickly on it, which kind of makes me wish I’d had nebs with many of my previous attacks. Given my MDI problems, and problems on the ward I feel that I’d really benefit from a home nebuliser with strict instructions on when to call it a day and go to A&E. I spoke to one of the Asthma UK nurses recently about the admission and my inhaler issues and she actually suggested asking my consultant about home nebs, however, prescribers are usually very reluctant to prescribe home nebulisers for asthma because some patients will delay emergency treatment with them, so I’ll just have to ask and see what they say.