Severe asthma attack - no wheezing & oxygen levels fine

I was in A&E today with a really bad Asthma attack. No wheezing, clear chest but really struggling for breath, headache, anxiety, fatigue and the confusion that accompanies an attack.

However, my oxygen levels were fine & without the wheezing the doctor refused to accept that I was having an attack. A long discussion followed, and I was fairly blunt about his patronising attitude and refused to leave, he finally relented and gave me the desperately needed steroids.

However, I'm perplexed as to why don't they check the carbon dioxide levels?

From what I understand the oxygen levels would be fine but it's the CO2 levels that build up in the blood leading to respiratory acidosis. I understand that the latter can be treated through ventilation to help lower CO2 levels and with steriods for the inflammation. It's really frustrating that doctors are refusing to accept breathing problems without signs of wheezing, and also refusing to check CO2 levels.

9 Replies

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  • Standard protocol is to check ABGs, which would include CO2 measurements, i'll be honest, its not something i've ever requested but i find it really strange that they'd refuse to check, i'd have thiught they'd err on the side of caution. You're right that for some people blood o2 levels are much less of an issue than co2, my o2 can be fine and co2 starting to really go up. I tend to be more a high co2 type person. It depends how much treatment you'd had, but they'd be unlikely to ventilate you before trying quite a bit unless you were REALLY acidotic (feel free to correct me anyone - i've not been intubated but have had high co2 so assumed my experience was standard in that they try whatever possible before tubing!)

    Have you had issues with co2 levels in the past?

    Did they treat you with IV or oral steroids? Did they give you nebs? Its frustrating when you get ""no wheeze, no asthma"" docs, there are quite a few threads on here about it!

    Have you seen your GP/Cons about it? they might be able to give you some advice as to how to handle the situation, if you have lots of bad attacks without a wheexe they might be able to give you a letter or something to give to A&E staff as 'proof' that you are diagnosed asthmatic and stuff!

    The list you gave at the start is similar to the symptoms of high co2, but i think the list of high co2 symptoms and the list of 'panic attack' symptoms are annoyingly similar, docs will often read anxiety wrongly (although most A&E staff are pretty good)

    Hope you're feeling better! Did they give you a few days of pred? (assuming thats the steroid you reffered to!) Make an appt with your GP asap if you havent already been and then you can discuss your concerns!

    Sophire

  • It depends how much treatment you'd had, but they'd be unlikely to ventilate you before trying quite a bit unless you were REALLY acidotic (feel free to correct me anyone ... Have you had issues with co2 levels in the past?

    Sophire

    I have a long history of Chronic Asthma including lots of hospital admissions. The high CO2 issue is something which I've been researching following issues with intense muscle cramps, tightness, fatigue and confusion. I wanted to to get my arterial blood gasses checked and wondering if I can request this via GP. If it is acidosis that is a problem that would explain the muscle pain, fatigue and confusion.

    I'm also speculating that it could auto-immune in origin, once again because of the muscle cramps/pain issue as well as muscle/connective tissue loss.

    Did they treat you with IV or oral steroids? Did they give you nebs? Its frustrating when you get ""no wheeze, no asthma"" docs, there are quite a few threads on here about it!

    Sophire

    No nebs, just oral preds, 40mg a day/four days.

    Have you seen your GP/Cons about it? they might be able to give you some advice as to how to handle the situation, if you have lots of bad attacks without a wheexe they might be able to give you a letter or something to give to A&E staff as 'proof' that you are diagnosed asthmatic and stuff!

    Hope you're feeling better! Did they give you a few days of pred? (assuming thats the steroid you reffered to!) Make an appt with your GP asap if you havent already been and then you can discuss your concerns!

    Sophire

    I've made an appointment to see the GP, I could ask for a letter, that's a good idea. I just found the attitude really shocking, I was sitting in front of A&E doc struggling to breath and he wouldn't recognise there was a problem even though my peak flow was at 50%. It was only when I refused to leave then he prescribed me preds.

  • I really dont know much about long term blood gas issues - my thinking was that you would be *very* unwell all the time in order for co2 levels to be high on a day-to-day basis. I know mine go up and down fairly quickly (i have a problem where my co2 will get high during the attack, but because ive been working so hard to breathe for a few days/hrs depending on that particular attack that i then hyperventilate slightly when its getting easier to breathe and get low co2, not really an issue, occasionally get a phosphate infusion as i think part of that process uses up phosphate, but it does mean that i think co2 changes quickly) I also know i can be struggling quite a bit and co2 AND o2 be fine. My cons said that as im young and my lungs are physiologically pretty healthy, just their behaviour which is shocking (i think by that he meant im not at all COPD-ish) that he thinks i can hold my sats for quite a bit longer despite really struggling, coz i can just put more effort in until im resally exhausted and then it all goes downhill quickly! Thats his main justification for keeping me in when he does!

    I assume you've had ABGs in the past? or cap gases? do you know if they've come back normal?

    Would discuss the issue with GP, sounds to me (in my completely non-professional and looking at it only from my experiences) like an electrolyte thingy. I think that can be quite common and mess with muscles, its not uncommon for difficult asthmatics to have low potassium if they are using a lot of salb (as that lowers K). I could also imagine some sort of adrenal surpression if you've had a lot of pred in the past? that certainly can cause fatigue and confusion, and sodium imbalances (which in turn can cause muscle cramps). There are LOADS of causes of those kind of fairly non-specific symptoms, your best bet is to discuss it with GP, would imagine (and like i say, i dont know) that there are things that are far more likely than acidosis. Thats one of the dangers of the internet and research - it can give a false impression of how common some things are. Obvs it depends how you use the internet, i know that personally i no longer bother using things like NHS direct, the silly thing ALWAYS tells me to ring 999, even my everyday, perfectly normal self gets sent to A&E by that site! lol!

    Did he say what he thought was going on to cause low PF and breathlessness? it frustrates me when they question the diagnosis without coming up with an alternative suggestion, *something* was going on, if he didnt think it was asthma, it doesnt mean its nothing and therefore shouldn't be ignored! sigh!

    Is the pred helping you much?

    Hopefully you'll be feeling much better soon, and GP will have some good ideas! Are you under a cons as well? are you on a lot of meds for your asthma?

  • I really dont know much about long term blood gas issues - my thinking was that you would be *very* unwell all the time in order for co2 levels to be high on a day-to-day basis. I know mine go up and down fairly quickly ...

    I assume you've had ABGs in the past? or cap gases? do you know if they've come back normal?

    Yup Ive been quite ill and off work with fatigue and brain fog. I've not had ABG's, this is on my list of things to ask doctor.

    Would discuss the issue with GP, sounds to me (in my completely non-professional and looking at it only from my experiences) like an electrolyte thingy. I think that can be quite common and mess with muscles, its not uncommon for difficult asthmatics to have low potassium if they are using a lot of salb (as that lowers K). I could also imagine some sort of adrenal surpression if you've had a lot of pred in the past? that certainly can cause fatigue and confusion, and sodium imbalances (which in turn can cause muscle cramps). There are LOADS of causes

    Yes Ive been trying to eradicate electrolysis levels as the cause of the muscle cramps, been drinking electrolytes which have made a little difference to mental alertness, also ordering potassium to see if supplementing that will help. Regards adrenal suppression that could be a possible cause of fatigue but not the cramps, I periodily supplement with liquorice to support adrenals.

    Interesting now on day two of taking the preds, and I feel so MUCH better, both mentally and physically which leads me to believe it could be a auto-immune issue. The anxiety has calmed right down, and I can focus for extended periods, the muscles and brain on fire symptons have calmed down too.

    Also with my breathing restricted for long (I was too afraid to go to doctors asking for preds because there was no wheezing) there could be high CO2 levels to, which would account for the muscle cramps. I've just not had any success in the past getting a specialist referral, but I'm going to try and push my GP who I'm seeing next week, at the very least to get my arterial blood gasses checked.

  • Yup Ive been quite ill and off work with fatigue and brain fog. I've not had ABG's, this is on my list of things to ask doctor.

    The fatigue and brain-fog are something I can relate to - I really sympathise. Have you had thyroid and so on checked? I've never heard of ABGs being useful other than in the middle of an acute attack (in asthma), so if your doctor looks blankly at you, that will be why!

    Yes Ive been trying to eradicate electrolysis levels as the cause of the muscle cramps, been drinking electrolytes which have made a little difference to mental alertness, also ordering potassium to see if supplementing that will help. Regards adrenal suppression that could be a possible cause of fatigue but not the cramps, I periodily supplement with liquorice to support adrenals.

    You can more cheaply supplement potassium by replacing some of your daily salt intake with lo-salt - that's 2/3 potassium chloride and 1/3 normal salt.

    Personally I get muscle cramps very badly when I'm in or bordering on adrenal crisis. If your electrolytes are out, due to cortisol being out, you'll get muscle cramps - most frequently from low sodium but in my case it's low potassium usually.

    In adrenal suppression you can also get too-high levels of some electrolytes, so you wouldn't be able to adjust that for yourself by supplementing.

    Re ""I supplement with liquorice to support adrenals"" - Liquorice (root only) will support the mineralocortoid side of things - aldosterone (produced in the adrenals) as normally replaced with fludrocortisone, which controls fluid and electrolyte balance. Liquorice won't do anything towards the glucocorticoid (main steroid) side of things, so it won't impact on the main function of your adrenals. Aldosterone controls fluid and salt levels, so if you're over-supplementing with liquorice you'd actually find that your electrolytes might get more out of balance if you're not aldosterone-deficient to start with. Generally aldosterone failure only occurs with full Addison's disease, not adrenal insufficiency.

    Also with my breathing restricted for long (I was too afraid to go to doctors asking for preds because there was no wheezing) there could be high CO2 levels to, which would account for the muscle cramps. I've just not had any success in the past getting a specialist referral, but I'm going to try and push my GP who I'm seeing next week, at the very least to get my arterial blood gasses checked.

    Obviously I'm not a medic, but as I said before, I don't expect that the GP will check your ABGs. To get CO2 build up you'd need to be breathless to the point of not being able to speak more than a few words - normal speech will 'blow off' the CO2, so if you're able to do normal day-to-day stuff, or speak a sentence, there's no need afaik to suspect CO2 levels are raised. As Soph said, high CO2 is an acute and life-threatening situation in asthma. CO2 retention is an indicator of respiratory failure. That's generally only chronic in people with COPD and similar chronic obstructive (rather than restrictive) lung disease.

    Generally at the point where you might retain CO2 as an asthmatic (without underlying additional lung disease), you'd be well beyond the ability to use the internet / eat / drink etc.

    Personally I think you need to back-track a bit on the ABGs thing - apart from anything else having an ABG done is generally extremely painful! General phlebotomists don't always take ABGs so you might have to have the test done by a specialist - even doctors often have difficulty with it (getting a needle in to your wrist artery is rather tricky). You can ask your GP to explain to you more fully why ABGs are an acute test. If you genuinely feel that you're so restricted in exhaling right now that you might be retaining CO2 then you need to be in a hospital. Don't be embarrassed or held back by lack of wheeze if you're that poorly - silent chest is exactly the kind of feature that goes along side CO2 retention in an acute attack.

    If you think you're retaining CO2 routinely then it would definitely be a case for specialist referral, as that would indicate some other disease process than 'asthma'. I'm not sure what age you are - obviously the range of likely causes is highly correlated to your age.

    Good luck with the GP - I'd be inclined to go in and have a genuine conversation (if your GP is up to that) about your concerns, rather than feel you have to have the answers before you even start.

    Ref the referral - do you know what 'stage' of asthma treatment you are on at the moment? Referrals are generally triggered if your asthma isn't controlled by Stage 4 of the treatment protocols - that means reliever + steroid inhaler + long acting reliever inhaler + supplementary treatment. So - for example, if you were on ventolin, seretide and montelukast, and still having regular problems (not just exacerbations due to colds and so on) then you should be referred to the specialist. If you don't know what Stage you are on, ask your GP. If they don't know what you're talking about, see a different GP :)

  • The fatigue and brain-fog are something I can relate to - I really sympathise. Have you had thyroid and so on checked? I've never heard of ABGs being useful other than in the middle of an acute attack (in asthma), so if your doctor looks blankly at you, that will be why!

    Personally I get muscle cramps very badly when I'm in or bordering on adrenal crisis. If your electrolytes are out, due to cortisol being out, you'll get muscle cramps - most frequently from low sodium but in my case it's low potassium usually.

    In adrenal suppression you can also get too-high levels of some electrolytes, so you wouldn't be able to adjust that for yourself by supplementing.

    :)

    That explains why ABG's are not taken, I just assumed it was a very easy test.

    Ive had adrenals checked privately a few years back through a saliva test, and the cortisol levels were within range, but with low dhea levels. I'll ask fo a thyroid check, thanks. Can I get electrolytes checked on the NHS? I've yet to supplement with potassium to see if that has any affect, but I do know that I'd been neglecting hydration for quite a while and not making a connection with electrolytes and muscle cramps.

    Regards the liquorice and adrenals, I cycle with liquorice, haven't supplemented for a while and generally ensure supplementation is at low levels.

    Is there anything else I can use to support glucocorticoids? If my thinking is right, then higher glucocorticoids would have an anti-inflammatory effect? The reason being that when I'm on prednisone my sanity and mental functionality really improves, and the physical pain/cramps ease somewhat. This makes me wonder if it's an auto-immune issue.

    If you genuinely feel that you're so restricted in exhaling right now that you might be retaining CO2 then you need to be in a hospital. Don't be embarrassed or held back by lack of wheeze if you're that poorly - silent chest is exactly the kind of feature that goes along side CO2 retention in an acute attack.

    If you think you're retaining CO2 routinely then it would definitely be a case for specialist referral, as that would indicate some other disease process than 'asthma'. I'm not sure what age you are - obviously the range of likely causes is highly correlated to your age.

    Yes I am restricted with exhaling, I have very rigid & atrophied abdomen, diaphragm and muscles from childhood, I'm v skinny/small with very little chest volume (does that make sense). The other problem is that I'm on the Aspergers autism spectrum so in the past I've had great difficulty articulating the pain and breathing issues, this is something which i've only started tackling in the last couple of years by addressing aspergers related speech issues (methylation, enzymes, detox .... ).

    Additionally with aspergers we come across 'flat' ie no body language or tone to offer an indication of what's actually going on. This leads doctors not making the link between what's being said and what's actually going on inside. I had this problem again when I walked into A&E last week. Often I'm in so much pain, and coupled with the inability to express it, makes me (internally) rage and feel extremely destructive. However, externally this is all very well hidden.

    Other factors in my case are age (40's) and cultural factors which further hinder communication; again issues I'm only now starting to address.

    My health issues have been severe enough to mean that I've not worked most of my life even though I have a good science degree (as a mature student), and my general quality of life is very low because of the isolation thats compounded by illness and not working. Until now I've not known how to approach the health issues within the NHS and have mostly been doing hit and miss experimenting (eg methylation, sulphation) which has helped enormously with the Aspergers side of things,

    Previously I had assumed that the restricted breathing was a sympton of a hypersensitive neurology (aspergers) & the impact of (past/present) stress on it, so I've been ignoring the asthma and exploring muscle and neurology issues related to autism. But considering that I spend the majority of time alone, very rarely socialise or talk, have speech issues which are related to breathing (slow quite voice, running out of breath whilst speaking which I'd previously assumed were due to the autism) I'm now thinking the asthma is possibly contributing to my problems in its own right, and that I need to address it through specialist referral, rather then continue suffering in silence thinking there's no cure or treatment possibility.

    I guess the other problem is that in childhood I was given a huge amount of drugs, including antibiotics and steroids, to stabilise the asthma, and ever since I'd become very ware of doctors and hospitals :(.

    Ref the referral - do you know what 'stage' of asthma treatment you are on at the moment? Referrals are generally triggered if your asthma isn't controlled by Stage 4 of the treatment protocols - that means reliever + steroid inhaler + long acting reliever inhaler + supplementary treatment. So - for example, if you were on ventolin, seretide and montelukast, and still having regular problems (not just exacerbations due to colds and so on) then you should be referred to the specialist. If you don't know what Stage you are on, ask your GP. If they don't know what you're talking about, see a different GP :)

    I don't know what stage, and this is odd as I've spent the years between age 9 and age 20 in hospitals at least twice a year for very severe asthma attacks, for a minimum of two weeks each admission. The attacks were so bad that I could barely walk a few steps without having to stop for breath, and the admissions included intensive care. Again, the problem was that I could never aticulate the need for help until my symptoms deteriorated very severely.

    However, in relative terms, post age 20 my breathing improved enough for the hospital admission to be every few years, and I just accepted that this was as good as it was going to get. Recently I wondered if I should perhaps try and get advocacy help in relation to my asthma and my GP so I can pursue specialist referrals and stay focussed on the asthma issue.

    Anyway, I've just realised that this is the first time I've really fully expressed what's going on in relation to the asthma, maybe i should just take a copy of this post to my GP :)

  • Curioser thanks so much for taking the time to do such a detailed post, you've opened up a whole range of options for me to explore via my GP. I'll respond fully to what you've later (when mentally alert). Just a quick thanks for now :)

  • I just wanted to add in that if youve been in the ICU for asthma you WILL have had ABGs done, they always will have done them! They arent a particularily hard test (although they are painful) but i think you need a specialist machine to do them, and they need to be done straight after theyve been taken so GPs can't do them!

    To be restricted enough to be retaining CO2 it would almost certainly be more than you would experience with day-to-day difficulties (unless there is something non-asthma going on, i think a few asthmatics who have had enough permenant damage to have very low lung function might retain, but its pretty rare and im sure you'd know about it!)

    Have you ever done Peak flows? what sort of values can you get?

    Deffo try to get somewhere with your GP, would taking someone else with you help? or writing it down before? to help you get your point across!!

  • cI just wanted to add in that if youve been in the ICU for asthma you WILL have had ABGs done, they always will have done them! They arent a particularily hard test (although they are painful) but i think you need a specialist machine to do them, and they need to be done straight after theyve been taken so GPs can't do them!

    To be restricted enough to be retaining CO2 it would almost certainly be more than you would experience with day-to-day difficulties (unless there is something non-asthma going on, i think a few asthmatics who have had enough permenant damage to have very low lung function might retain, but its pretty rare and im sure you'd know about it!)

    Have you ever done Peak flows? what sort of values can you get?

    Deffo try to get somewhere with your GP, would taking someone else with you help? or writing it down before? to help you get your point across!!

    Hi Soph, the last ICU admission was 20 years ago, but yes I imagine ABG's would have been taken then. Regards peak flow if I'm having a wheezy attack then it's around 300, a non-wheeze attack then I can still puff out a good 500 if I push hard enough, but that still means I'm struggling to breath normally without straining, and thus the breathing becoming very shallow and upper chest.

    When I get a wheezy attack with audible chest infection & low peak flow it's all really straight forward. It's when it's non-wheezy and peak flow is normal, but very struggling to breath that it becomes very confusing to understand whats going on. However, on both occasions preds help enormously.

    I do know that engaging the muscles in the out breath for me is very complex and difficult. I'm fighting muscle resistance and contraction in the opposite directions. By the end of that out breath my abs are completely contracted and tense and my chest is slumped. Fully exhaling is a battle, and as much as I've tried to practice fully exhaling it just doesn't get easier, quite the opposite - the muscles get tenser.

    In the past I've tried yoga classes (for three years) to try and strengthen and also relax the torso muscles so I can breath deeply and normally with ease, but its always been counter-productive. Eventually I gave up yoga because the more I tried to stretch the more the muscles tightened.

    I have invested a significant amount of time and energy exploring alternative breathing approaches to see if that resolves the issue. But it looks like I'm (reluctantly) back to looking at medical/drug based approaches including taking prednisone more often, or even regularly, something which I've been very wary of doing in the past.

    I'm afraid I don't have anyone I can take with me to the GP, but I probably will take a printout of this thread.

    It takes a hundred 'edits' before what I'm finally saying reflects what I mean or am feeling, and at the GP you only get one shot. One of the skills I'm self-teaching is to reflect on what I've said and if it truly conveys what I mean, and try and see how the listener might interpret it. For Asperger sufferers each one of these steps is logistical mountain.

    Whilst understanding is increasing of these issues ,there's very little support available to teach us how to surmount them. There's a common saying that aspies never learn from their mistakes, and this is precisely because they lack the internal framework to process what's going on and grow from it.

    Given that the NHS is notoriously dismissive when it comes to investigating chronic complex conditions, and regards those less articulate (and demanding) as hypochondriacs, then accessing services becomes impossible. The anxiety, rage and stress which develops from being dismissed is far too much a burden on top of the issues you're already dealing with.

    Life ends up feeling like you're standing in front of a brick wall constantly banging your head on it, there is such a disconnect with the external world.

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