How to Treat an Asthma Attack in Africa

We have had a tough and busy last few days working in the Pediatric Ward.  We are full beyond capacity and have admitted lots of sick children who we don’t know the diagnosis.  I woke up this morning and secretly prayed that we would have smooth rounds, that children would be improved and things would go well.

We had rounded on the first 5 beds when they wheeled in a little 2 yo girl on a stretcher.  She was laying very still under the covers and my first thought was that she was dead.  I came over and pulled back the covers and found a lethargic, unresponsive child who was working very hard to breathe, harder than I had seen before.  She had pulses, but would not respond.  When I listened to her lungs, she was not moving much air in and out and had a very prolonged expiration.   Her mother told us she had been healthy and started to work hard to breathe over last night.  I thought she was in respiratory distress due to an asthma attack.  

We put oxygen on her, and started breathing treatments with salbuterol and gave IM steroids.  After the second treatment, she started to wake up and push us away.  She was still working very hard to breathe but was moving more air and her oxygen saturation had improved.  I smiled both inside and outside in relief.  Finally something I knew how to treat and could help the child. 

After the second treatment, the nurses placed her in the bed and walked away.  She needed to continue salbuterol to keep improving, so I asked over and over for another treatment.  Finally one of the nurses said, “we have used all the salbuterol, there is none in this town or in Bamenda (the larger neighboring city)”.  I was shocked.  This previously healthy girl may die because we didn’t have any more of the medicine we needed.  It was the most frustrated I’ve felt in my time here.  I kept myself calm and started thinking through all of the other things we could do to treat her asthma.  We gave intramuscular epinephrine that didn’t have the concentration on the bottle or box anymore so I was very unsure if it was the right dose.  We started aminophylline – a drug that can easily become toxic and we don’t use in the US anymore.  All the things I normally use – albuterol, atrovent, methylprednisone, magnesium – weren’t available.  I didn’t have ICU nurses or respiratory therapists to watch her closely.  I didn’t have labs to check the drug levels of the aminophylline.  But we had to do something to keep her alive as she was deteriorating again in front of our eyes, so we did everything we could think of to do. 

Mary and Brian are two family medicine/psychiatry residents that are in Mbingo with our group.  They happened to see me and I filled them in on our situation.  They had a very hard time believing there was no salbuterol and went to the pharmacy to see what other options there were.  They found out we had lots of salbuterol inhalers, just not the nebules.  We use the nebulized form in young children because they cannot inhale on demand to take the inhaler.  But when you attach a long tube called a spacer to the inhaler, you can activate the inhaler into the spacer and then have the child breathe the air with the medicine out of the spacer.  We raced home to make a spacer out of a water bottle and duct tape.   I was very grateful to have creative friends here who were willing to help me find a way to take care of my sick patient.  We brought the homemade spacer back up to the ward and showed the nurse.  She looked confused for a moment and then reached far back into the supply cabinet and pulled out a single spacer, like the ones we use in the US.  We had had one the whole time, but either no one mentioned it or knew what it was for.  It will still be a long night for the child and her family, but I am much more hopeful that now she will survive.  Even though today wasn't as smooth and easy as I hoped it would be, I learned how to quickly work with the resources I had to give care in Africa.