The storm

Image by LUEK.

How could anyone have predicted that amazing night? asks Angelo Pricolo

On 21 November 2016 Melbourne experienced the world’s largest epidemic thunderstorm asthma event, which was unparalleled in size, severity and impact.

Calls to 000, Ambulance Victoria, and our hospitals were pushed to the limit with huge spikes in callouts, and people presenting to hospital emergency departments (ED) and pharmacies. In fact ED units were so overwhelmed and unable to handle the demand for puffers they were diverting patients to the closest open pharmacy.

That was us. Nurses-on-call were also directing patients to us.

At the height of the crisis we had over 50 wheezing, often first-time sufferers crowding the isles of our small 90 square metre pharmacy. Most had no idea what was happening or why, hence confusion prevailed.

Since 1980 there have been five reports of epidemic thunderstorm asthma events in Melbourne identified in the academic literature. They have all been in the month of November.

Anecdotally we were aware that the city ED units expected more asthma admissions after heavy rains or thunderstorms. We warned some people some of the time but never expected an event of these proportions.

Research suggests that an uncommon type of thunderstorm occurring during the grass pollen season triggers epidemic thunderstorm asthma in Victoria. These thunderstorms cause grass pollen grains and fungal spores to be swept up into the clouds as the storm matures.

The pollen grains absorb moisture and may rupture due to osmotic shock, releasing a large amount of smaller allergenic particles. One pollen grain can release up to 700 starch granules.

These allergenic particles are small enough to get past the nose and throat and reach deep into the lungs. They can induce an allergic response, triggering bronchoconstriction.

Certain types of thunderstorms in the right conditions are thereby able to expose large numbers of people to these potential asthma triggers and rapidly cause an epidemic of asthma. Only a small minority of thunderstorms in pollen season result in epidemic thunderstorm asthma.

Therefore, while both thunderstorms and high grass pollen levels appear to be necessary factors in the development of this phenomenon, alone these factors are not sufficient to result in an event. It’s not a simple association.

I vividly remember leaving the pharmacy at about 4pm, getting a taxi to the airport for a flight to Canberra. There was a Pharmacy Guild National Council meeting the next day. Other than the perfect storm brewing all seemed to be running smoothly…

Entering the meeting next morning I started to hear some chatter of a health event in Melbourne the previous night. But it wasn’t until I received a text message from the pharmacy technician that it started to become clear the city was in a state of panic.

Pharmacy assistant Tania Doric told her employer, pharmacist Angelo Pricolo, that the night had been “the most challenging, confronting and scariest shift I have ever worked!”

“People were being turned away from hospital and being sent to us. We sold easily 200 Ventolins. Customers were dropping in the shop… it was absolute mayhem.”

“Oh my God, Angelo, last night was crazy. I don’t know where to start… it was the most challenging, confronting and scariest night I have ever worked. There were people everywhere, in the aisles, lying down, even crying.

“At one stage we had more than 50 people. People were being turned away from hospital and being sent to us. Ambulances whirled past but did not stop. The doctor next door went home.

“The security guard was helping handing out Ventolin and spacers. We were trying to show people what to do. Customers were dropping in the shop. One guy was on the floor for half an hour. He would have died for sure. We stayed till 1:00am. It was absolute mayhem. I’m still shaking.”

So as things unraveled over the next few days we began to piece together the events and their significance. Some parts alarmed us, some made us proud and hopefully all informed us for future events. All things considered the pharmacist, technician and the unlikely hero, a security guard, probably saved lives.

The doctor going home at 10pm was outrageous. That time was probably the apex and yet somehow through lack of communication or understanding of the need, we lost access to another pair of skilled hands.

Interestingly, people converged in the pharmacy even while the medical centre was open. Even though we had an adjoining door, pharmacy has direct access, not a waiting room and thankfully on this night lots of Ventolin.

The ambulance hotline was inundated. They were responding to more calls than they could handle and attending a pharmacy was not part of their mission. They attended to specific patient callouts, usually at their homes. On reflection this seemed a policy that needed review. Making pharmacy an impromptu hub seems logical.

It would have been the perfect use of resources had ambulance officers attended the pharmacy, as they could have assisted multiple patients without wasting travel time. It was a disappointing outcome that we could not prioritise one ambulance to the pharmacy. I know this point was clearly made to regulators and the Health Department.

Shifting to the clinical aspects of the night; how amazing is the humble Spacer? A hollow vessel with a valve is more effective at delivering a smooth muscle relaxant (salbutamol aka ventolin®) than any other method. Including nebulizers, turbuhalers and uber drivers.

Yet still today we see people spray multiple puffs from an aerosol directly into their mouth in the misguided belief that the majority of this dose will reach their lungs. It doesn’t, it’s absorbed in the mouth and joins the general circulation visiting the rest of the body and often causing disturbing heart palpitations. 

Luck played its part in saving lives on that night, as we had just received an order for 144 Spacers. Many went out that night along with, our records show, just under 250 inhalers. So many of these went to first time users who were struggling to breathe and not really sure why.

Tracy was the pharmacist on duty and she recalls some particulars.

“There were a lot of people that had never used an inhaler so we did our best in an inadequately short time to educate them on inhaler technique and encouraged the use of a Spacer. After we realised the mass scale of it I started just doing a demonstration for the whole shop and asking everyone to watch just to save us time.

“It was bizarre working in a situation where you knew something big was happening – inundation of people unable to breathe and a constant din of ambulances up and down Sydney Road but no idea what the cause was.

“We had several calls from on-call hospital pharmacists requesting ‘all our Ventolin’ which we refused.

“I was incredibly grateful for my immensely capable technician working that night, Tania – I don’t think I would have been as calm without her by my side. We did have a couple of regulars coming in with a stack of repeats but when they saw what was happening they were fine when we asked them to come back another night!”

Epidemic thunderstorm asthma is now recognised as a broad and significant risk for the Victorian community, during the grass pollen season. It will require a similarly broad response with planning and preparations across all relevant sectors, particularly emergency and health services.

Tragically as a direct result of this thunderstorm, a total of 19 deaths were recorded in Melbourne with asthma as a contributing or primary cause of death. Added to this, many more families got the shock of their lives.

Angelo Pricolo is an addiction medicine pharmacist and former National Councillor of the Pharmacy Guild of Australia.

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1 Comment

  1. Debbie Rigby

    “how amazing is the humble Spacer”

    Great reflection Angelo of a terrifying event for many people and health providers. Many lessons have been learned from this catastrophic event, and like all “unprecedented” events, that’s the key to preventing or better managing the next one. And pharmacists really made a difference then; but the challenge is to continue to provide education and awareness to consumers.

    I just read this publication on an in-vitro comparison between different types of spacers, including home-made ones – which may often be required in events such as the Melbourne thunderstorm asthma.

    The study suggests that antistatic spacers deliver much more aerosol to the lungs than non-antistatic spacers. The total emitted dose (TED) from non-antistatic spacers (including home-made water bottle spacers) was significantly lower than antistatic spacers – 30-35% vs 50-70%.

    We have all seen patients (and movie stars) doing a quick puff-puff without a spacer – actual deposition in the lungs with this technique is close to zero. So our challenge is to help patients understand how to use their pMDIs, ideally with a spacer.

    I have been advocating for some time for cautionary ancillary labels for inhalers – inhale slow and steady for pMDIs and SMIs, and inhale quick and deep for DPIs. For pMDIs most people inhale far too fast and for too short duration – even if they get the inhalation-actuation timing right! Optimal inspiratory flow rate is 20-30 L/min over 4-5 seconds for adults and adolescents.

    I explain to patients that a spacer gives more time for drug inhalation as it gives more volume and space for the propellant to evaporate. Spacers make large particles from the puffer deposit within it rather than being deposited in the mouth and throat – really important for ICS, Also, the extra distance traveled by the aerosol in the spacer increases the dose of fine particles that can reach the deep smaller airways. I find that patients really like getting an explanation of why, rather than being lectured that they ‘must’. And finally that the antistatic spacers are the best choice.

    Washing non-antistatic spacers and drink bottle and letting them dry in the air had a significant impact on the delivered dose, but time for drying may be a problem in emergencies like the thunderstorm asthma event.

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