panic attack or asthma attack?

Jolie, BSN · Sep 12, 2015

The first thing I would not do is beat myself up over providing care to the best of my ability and knowledge. But that comes with time:) You had no knowledge of her past history of asthma, which may or may not have been accurate anyway? How long ago did she "have asthma?" Was it diagnosed by a doctor, coach or grandmother? Did she ever take medication to control it? If so, what and how long ago? How did this diagnosis come to be "resolved?" Again, by a health professional or by someone else's determination?

Did you have any description of what led up to her episode? Might it have been triggered by food, choking, physical exertion or emotional upset?

Asthma does not always present with wheezing, so absence of that would not necessarily rule out an asthma attack. But there is usually some indication of increased work of breathing. Did this young lady exhibit any visible retractions, use of accessory muscles, make any audible grunting, or attempt to position herself in a manner to expand her chest?

It sounds like you followed a standing order or protocol for an individual experiencing difficulty breathing, which is exactly what you should have done. Nurses are not diagnosticians. We follow evidence based protocols based upon our best judgment of uncertain situations. The oxygen and nebulizer treatment you provided were the best options available while awaiting a definitive diagnosis. Even in the absence of asthma, they were highly unlikely to harm her, and had the best chance of helping while her provider determined her actual problem and ordered definitive treatment.

You did fine. And shame on her parents for not clarifying the issue with the school following her 911 intervention the previous day.

maryel · Sep 12, 2015

"Even in the absence of asthma, they were highly unlikely to harm her, and had the best chance of helping while her provider determined her actual problem and ordered definitive treatment."

thank you thank you thank you!!!!!! my supervisor told me the same thing...that neither would've harmed her. my principal also told me thank you and that i did a good job. i just can't stop thinking about it. new job, new school, new people.....its hard not to want people to think I'm a good nurse! i came from the hospital where there are other medical people all around you and to be first on the seen now with no previous ER experience is hard!!

Jolie, BSN · Sep 12, 2015

I meant to add that it might be helpful for you to familiarize yourself with information on vocal cord dysfunction. Again, we don't diagnose, but this sometimes seems to "fit" with young people's episodes of respiratory distress, and it is a condition you can impact by "coaching" the student to regain control.

SnowyJ, RN · Sep 12, 2015

It sounds to me like you did all you could and should do. We don't have any respiratory standing orders at my school and it worries me.

I know for sure I would not have that student come back to school without a clear note to do so from her physician, a definitive diagnosis and medication/orders.

JenTheSchoolRN, BSN, RN · Sep 14, 2015

OP, I agree you did the right thing based on your assessment at the time. It is frustrating when families do not provide needed medical information to us. But even with that information, it can be a tough call.

I had a very similar thing happen to an asthma kiddo last year. Student has hx of asthma and had been on predisone 3 times already during the brutal MA winter. She also had a hx of anxiety. She was having what I suspected might be an anxiety attack in my office, but her anxiety attacks have triggered real asthma issues, so after a neb, calming strategies, the student continued to hyperventilate and had wheezing that would come and go. O2 sat remained above 97% the entire time, but student continued to complain of worsening SOB. I could not reach Mom, don't have access to O2, so I called EMS. The student wasn't transported as Mom arrived on scene while they were here and took student to the ED herself, where she received an additional neb. Mom sighed at the hassle, but was glad I called when I couldn't reach her.

My office is not an ED. I am not a doctor. If I feel I need immediate help beyond my walls - especially if I can't reach a parent, I will call EMS.

100kids, BSN, RN · Sep 14, 2015

It sounds to me like you did all you could and should do. We don't have any respiratory standing orders at my school and it worries me.

Same here!

Flare, ASN, BSN · Sep 17, 2015

i had a student last year that presented very similarly. Walked out of the classroom because he said he couldn't breathe, tripod stance, c/o tingling in hands, his o2 sat was low, but his lungs didn't sound too bad. Well, my thoughts went to either unknown asthmatic or possible use of a substance. This is a student i almost never see by the way. ems, police (police thought same as me with use of substance). Kid was dx in ER with anxiety and returned next day. The same type of event happened with this child 3 more times. Didn't go as far as EMS but did contact guidance and his parent. Never did find out what exactly was triggering the panic attacks... maybe it was just being in middle school.

quiltynurse56, LPN, LVN · Sep 17, 2015

Probably both. I am not a school nurse, but have plenty of experience with asthma (2 kids, myself, husband and others). One of my daughter's friends would have panic attacks which let to a full blown asthma attack.

With hyperventilating, try the slow deep breath method of breathing and see if it slows things down - would most likely indicate panic. As has been said, giving the neb did not harm the student.

FlyingScot, RN · Sep 17, 2015

I have severe asthma and there are times when I have an attack I panic which exponentially increases the severity of the attack. The thing is I'm not a wheezer so my asthma does not have the textbook presentation but my panic does. That's what people see first. I have a handle on it but I have been known to pull over on the side of the road to get control of my anxiety which is very hard to do when you're sucking air.