How do you differentiate and manage a panic attack versus an asthma attack?

Differentiating and Managing Panic Attacks versus Asthma Attacks

The key to differentiating between panic attacks and asthma attacks lies in identifying specific symptoms: wheezing, mucous congestion, and coughing are present in asthma attacks with sensitivity >90% and specificity >70%, while panic attacks typically present with hyperventilation-hypocapnia symptoms without these respiratory signs. 1

Clinical Differentiation

Asthma Attack Features

• Objective respiratory signs:
  • Wheezing (hallmark feature)
  • Mucous congestion
  • Coughing
  • Reduced peak expiratory flow (PEF <50% of predicted or best) 2, 3
  • Respiratory rate >25 breaths/min (adults) or >50 breaths/min (children) 2
  • Response to bronchodilators

Panic Attack Features

• Predominant anxiety symptoms:
  • Sense of impending doom
  • Fear of dying
  • Chest tightness without wheezing
  • Hyperventilation pattern
  • Normal peak flow measurements
  • No response to bronchodilators
  • Symptoms of choking sensation and shortness of breath without objective signs of respiratory distress 4

Overlapping Features

• Shortness of breath
• Chest tightness
• Increased heart rate
• Anxiety

Assessment Approach

1. Objective Measurements (Critical):

   • Measure peak expiratory flow (PEF) - reduced in asthma, normal in panic
   • Check oxygen saturation - may be reduced in severe asthma, normal in panic
   • Auscultate for wheezing - present in asthma, absent in panic
   • Observe for accessory muscle use - present in asthma

2. Response to Treatment:

   • Trial of bronchodilator - improvement suggests asthma
   • Controlled breathing techniques - improvement suggests panic

3. Important Considerations:

   • Panic disorder is common among asthma patients (33.3%) 5
   • Patients with both conditions tend to overreport symptoms 6
   • Asthma patients with panic disorder show no difference in airway responsiveness but report higher levels of subjective distress 6

Management Algorithm

For Confirmed Asthma Attack:

1. Immediate Treatment:

   • High-flow oxygen via face mask
   • Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 2, 3
   • Prednisolone 30-60 mg orally (adults) or 1-2 mg/kg (children, max 40 mg) 2, 3
   • If life-threatening features present:
     • Add ipratropium 0.5 mg to nebulizer 2
     • Consider IV aminophylline or salbutamol/terbutaline 2

2. Monitoring:

   • Repeat PEF measurements 15-30 minutes after starting treatment
   • Maintain oxygen saturation >92% 3
   • Monitor heart rate, respiratory rate

3. If Not Improving:

   • Increase frequency of nebulized β-agonist (every 15-30 minutes)
   • Add ipratropium if not already given 2, 3
   • Consider ICU transfer if deteriorating

For Confirmed Panic Attack:

1. Immediate Approach:

   • Reassurance in calm environment
   • Controlled breathing techniques (slow, diaphragmatic breathing)
   • Remove from triggers if possible

2. Pharmacological Options (if needed):

   • Consider benzodiazepines for acute management only (with caution)
   • Avoid sedatives in patients with asthma 2

3. Follow-up:

   • Referral for cognitive-behavioral therapy
   • Consider SSRI treatment for recurrent panic attacks

For Patients with Both Conditions:

1. Acute Management:

   • Treat as asthma first (safer approach) with objective measurements
   • Add panic management techniques once asthma stabilized

2. Long-term Management:

   • Education on distinguishing symptoms 6
   • Optimize asthma control with appropriate controller medications
   • Address panic disorder with psychological interventions

Pitfalls and Caveats

1. Misdiagnosis Risks:

   • Treating panic as asthma can lead to unnecessary medication exposure
   • Treating asthma as panic can delay life-saving treatment
   • Patients with both conditions may have exaggerated perception of symptoms 6

2. Special Considerations:

   • Severity of asthma is often underestimated by patients and clinicians 2
   • Patients with repressive coping styles may have impaired ability to perceive asthma symptoms 7
   • Patients with panic disorder report more subjective distress despite similar or lower physiological arousal during asthma symptoms 6

3. When to Refer to Specialist:

   • Uncertainty about diagnosis
   • Poor response to standard treatment
   • Frequent emergency department visits
   • Comorbid conditions affecting management 2

By systematically assessing objective respiratory signs and utilizing appropriate diagnostic tools, clinicians can effectively differentiate between these conditions and implement appropriate management strategies.