Severe Acute Asthma Exacerbation Research Articles

Management of life-threatening asthma in adults

Asthma is a disease of predominantly reversible airway obstruction characterized by a triad of bronchial smooth muscle contraction, airway inflammation, and increased secretions; it is a major health problem for all age groups. For the majority, control of asthma symptoms is readily achieved; however, in a small minority, asthma may cause death. Although the mortality rate for asthma in those aged less than 65 yrs is now falling, there remain around 1400 asthma deaths in the UK each year (http:// www.laia.ac.uk/kf_asthma_03.htm). Most of these occur in the pre-hospital setting and, in retrospect, the majority is considered potentially preventable. Factors associated with asthma death include disease severity, inadequate treatment, inadequate monitoring, the under use of written asthma management plans and adverse psychosocial and behavioural factors (www.sign.ac.uk/guidelines/fulltext/63/ index.html). Levels of severity of acute asthma exacerbations have been defined. The features of acute severe, life–threatening, and near fatal asthma are listed in Table 1. Of note, patients with life-threatening asthma may not appear distressed and might only display one of the features listed. Life-threatening asthma tends to occur as two sub-types. Most commonly, there is a history of progressive worsening of symptoms over several days; the majority of patients in this group report nocturnal dyspnoea in the previous three nights. As a result of greater bronchial inflammation and mucous secretion, this group (occurring more frequently in females) tends to respond more slowly to treatment. In contrast, a smaller sub-group, more frequently male, presents with a rapidly progressive condition with highly reactive airways. These patients have intense bronchospasm that often responds more rapidly to bronchodilator therapy. In February 2003, The British Thoracic Society together with the Scottish Intercollegiate Guidelines Network published guidelines on the management of asthma (http://www.britthoracic.org.uk/asthma-guideline-download.html). They were updated in November 2007. In common with other recommendations, these give guidance only up to the commencement of intensive care. Evidence for therapies in intensive care from randomized controlled trials remains sparse. Ongoing management of lifethreatening episodes (Fig. 1) is often difficult with rapid and dynamic changes in physiology. Complications of treatment are frequent.

INTRAVENOUS MAGNESIUM FOR TREATING ACUTE EXACERBATIONS OF ASTHMA IN CHILDREN: A SYSTEMATIC REVIEW

INTRODUCTION: Inhaled bronchodilators and systemic corticosteroids are the mainstay of treatment for acute exacerbations of asthma. A systematic review of the use of magnesium has been published, but the results are incomplete and the recommendation is “weak.” OBJECTIVE: The objective of this study was to determine the effect of intravenous magnesium in children with acute asthma. METHODS: Randomized, controlled trials were identified by searching the Cochrane, Medline, Embase, CINAHL, and ProQuest databases. Other sources were used to identify “gray literature.” Randomized, controlled trials in which children with an acute exacerbation of asthma were treated with intravenous magnesium versus placebo were included. Data were extracted from the full papers, and methodologic quality was assessed using a scale from 0 to 5. RESULTS: Six studies involving 215 patients were included. Hospital stay was reduced in the magnesium-treated group. The percentage improvement in the percentage predicted peak expiratory flow rate was 43.5% greater in the treatment group. Significant differences were also seen in the forced expiratory volume in 1 second (weighted mean difference: 74.5%) and the forced vital capacity (weighted mean difference: 64.5%). There was improvement in asthma scores in 3 of the 4 studies that reported this outcome. There were no clinically significant differences in vital signs. No major adverse events were reported. CONCLUSIONS: Intravenous magnesium is safe and beneficial as adjuvant therapy in the treatment of children with moderate to severe acute asthma. Magnesium should be for children who have moderate to severe acute exacerbations of asthma that do not respond to nebulized β-2 agonist.

A severe acute asthma exacerbation complicated by pneumomediastinum and atelectasis of the lungs

A severe acute asthma exacerbation complicated by pneumomediastinum and atelectasis of the lungs

The Synergistic Interactions of Allergic Lung Inflammation and Intratracheal Cationic Protein

Airways hyperresponsiveness (AHR) is a hallmark feature of asthma, and can be caused by various disparate mechanisms. Mouse models of AHR have been useful for studying these mechanisms in isolation, but such models still typically do not exhibit the same degree of AHR as seen in severe human asthma. We hypothesized that more severe AHR in mice could be achieved by imbuing them with more than one mechanism of AHR. We sought to determine if the airway wall thickening accompanying allergic inflammation and the exaggerated smooth muscle shortening induced by intratracheal cationic protein could act together to produce a severe form of AHR. We used the forced oscillation technique to measure methacholine responsiveness in BALB/c mice that had been sensitized and challenged with ovalbumin followed by an intratracheal instillation of poly-l-lysine. We found that both ovalbumin and poly-l-lysine treatment alone caused moderate levels of AHR. When the two treatments were combined, however, they synergized in terms of their effect on lung stiffness to an extent that could even be fatal, reflecting a significantly enhanced level of airway closure. Our results suggest that mechanistic synergy between airway wall thickening and exaggerated smooth muscle shortening produces a more germane mouse model of asthma that may have particular relevance to the pathophysiology of the acute severe asthma exacerbation.

The use of magnesium in bronchial asthma: a new approach to an old problem

Magnesium deficiency is a common electrolyte disorder in patients with acute severe asthma, but intracellular magnesium content better reflects its homeostasis than does its serum concentration. Magnesium takes part in many metabolic processes in the organism, including energy metabolism, protein and nucleic acid synthesis, cell cycle, the binding of substances to the plasma membrane, and maintenance of cytoskeletal and mitochondrial integrity. It also modulates ion transport and influences intracellular calcium concentration. Maintenance of the cells' transmembrane gradient depends on the presence of magnesium, and hypomagnesemia may result in an increase in neuromuscular cell excitability. Magnesium is a cation modulating the smooth muscle contractility of different tissues: hypomagnesemia causes their contraction and hypermagnesemia their relaxation. Suggestions of a positive influence of magnesium in the treatment of asthma exacerbation have been known for a long time, but research results differ. A single dose of intravenous magnesium sulfate given to patients with acute asthma exacerbation has been shown to be safe, but its efficiency is still under discussion. According to the Global Initiative for Asthma GINA-2005, magnesium sulfate administration is not recommended for routine treatment, but it is permitted in patients with severe asthma exacerbation not responding to treatment (evidence category A). Recommendations of the British Thoracic Society allow one dose of magnesium sulfate to patients with acute severe asthma exacerbation and inadequate initial response to broncho-dilating inhalation treatment (evidence category A). Future investigations should help to establish the indications for magnesium use in the treatment of acute asthma exacerbations as well as the magnesium dose and the scheme of its administration.

A comparison of levalbuterol with racemic albuterol in the treatment of acute severe asthma exacerbations in adults

This multicenter, randomized, double-blind trial compared nebulized levalbuterol (Lev) and racemic albuterol (Rac) in the treatment of acute asthma. Methods Adults with acute asthma exacerbations (FEV 1 20%-55% predicted) received prednisone and either Lev (1.25 mg, n = 315) or Rac (2.5 mg, n = 312). Nebulized treatments were administered every 20 minutes in the first hour, then every 40 minutes for 3 additional doses, then as necessary for up to 24 hours. The primary end point was time to meet discharge criteria. Secondary end points included changes in lung function and hospitalization rates. A subset of 160 patients had plasma ( S)-albuterol concentrations determined at study entry. Results Time to meet discharge criteria did not differ between the 2 treatments. FEV 1 improvement was greater following Lev compared with Rac, both after dose 1 and cumulatively over the entire treatment period (dose 1 in intent to treat [ITT] group: Lev 0.50 ± 0.43 L, Rac 0.43 ± 0.37 L; P = .02), particularly among the 60% of patients not on recent steroid therapy (dose 1: Lev 0.58 ± 0.47 L, Rac 0.44 ± 0.37 L; P < .01), and patients whose entry ( S)-albuterol concentrations were in the highest quartile of those measured. A small and similar proportion of Lev-treated (7.0%) and Rac-treated (9.3%) patients required hospitalization ( P = .28). Among patients not on steroids, fewer Lev- than Rac-treated patients required admission (3.8% vs 9.3%, P = .03), as was also the case for patients with high plasma ( S)-albuterol concentrations. Asthma relapses (5% in 30 days) were lower than in previous reports and did not differ between groups. Conclusions This study suggests that early, regular nebulized β 2-agonist and systemic corticosteroid therapy may reduce hospitalization and relapse rates in patients with acute severe asthma. Lev was well tolerated and compared favorably with Rac in improving airway function, particularly in those who were not on inhaled or oral corticosteroids and in those who had high plasma ( S)-albuterol concentrations at presentation.

Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators

Background Since the advent of inhaled ß2-agonists, anticholinergic agents and glucocorticoids, the role of aminophylline in paediatric acute asthma has become less clear. There remains some consensus that it is beneficial in children with acute severe asthma, receiving maximised therapy (oxygen, inhaled bronchodilators, and glucocorticoids). Objectives To determine if the addition of intravenous aminophylline produces a beneficial effect in children with acute severe asthma receiving conventional therapy. Search strategy The Cochrane Airways Group register of trials was used to identify relevant studies. The latest search was carried out in December 2004 Selection criteria Randomised-controlled trials comparing intravenous aminophylline with placebo in addition to usual care in children met the inclusion criteria. Data collection and analysis Two reviewers independently assessed studies and extracted data. Disagreement in the selection of trials was resolved by consensus. Attempts were made to contact authors to verify accuracy of data. Main results Seven trials met the inclusion criteria (380 participants). Methodological quality was high. All studies recruited children with acute severe asthma and requiring hospital admission. Six studies sought participants who were unresponsive to nebulised short-acting beta-agonist and administered systemic steroids to study participants. In two studies where some children were able to perform spirometry, baseline FEV1 was between 35 and 45% predicted. The addition of aminophylline to steroids and ß2-agonist significantly improved FEV1% predicted over placebo at 6-8 hours, 12-18 hours and 24 hours. Aminophylline led to a greater improvement in PEF% predicted over placebo at 12-18 hours. There was no significant difference in length of hospital stay, symptoms, frequency of nebulsations and mechanical ventilation rates. There were insufficient data to permit aggregation for oxygenation and duration of supplemental oxygen therapy. Aminophylline led to a three-fold increase in the risk of vomiting. There was no significant difference between treatment groups with regard to hypokalaemia, headaches, tremour, seizures, arrhythmias and deaths. Authors' conclusions In children with a severe asthma exacerbation, the addition of intravenous aminophylline to ß2-agonists and glucocorticoids (with or without anticholinergics) improves lung function within 6 hours of treatment. However there is no apparent reduction in symptoms, number of nebulised treatment and length of hospital stay. There is insufficient evidence to assess the impact on oxygenation, PICU admission and mechanical ventilation. Aminophylline is associated with a significant increased risk of vomiting. PLAIN LANGUAGE SUMMARY Acute asthma is a common paediatric emergency prevalent in many countries. Treatment aims to reverse asthma by opening up the airways and targeting the underlying inflammation of the airways. Beta-agonists, anticholinergic agents and glucocorticoids are currently the most commonly used strategies. In the past, aminophylline has been extensively used for the management of acute asthma, despite side effects. However, its use has declined with the availability of effective inhaled bronchodilators and glucocorticoids. The purpose of this review was to assess whether the use of intravenous aminophylline in children receiving maximised inhaled bronchodilators and glucocorticoids produced additional beneficial effects. We identified a small number of good quality trials which compared aminophylline with placebo in children given inhaled bronchodilators and glucocorticoid therapy. This review found evidence that children treated with aminophylline had a greater improvement in lung function than children treated with placebo, when both groups received inhaled bronchodilators and steroids and they responded incompletely to these initial therapies. However, aminophylline use also resulted in greater risk of vomiting. Aminophylline use in children may be appropriate if children have a role in severe acute exacerbations of asthma where response to maximised therapy (inhaled bronchodilators and glucocorticoids) is poor. These results are based on small numbers and further work in this area is required. Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Chronic inhaled corticosteroids do not affect the course of acute severe asthma exacerbations in children

Chronic therapy with inhaled corticosteroids (ICS) suppresses airway inflammation and increases airway responsiveness to beta(2)-adrenergic receptor agonists. We hypothesized that the chronic use of ICS would be associated with shorter duration of hospitalization in severely ill children with status asthmaticus. An 8-year retrospective chart review was conducted of all children admitted to the ICU with status asthmaticus. During the study period, 241 children were admitted, and 44% reported the use of chronic ICS. ICS use was associated with increased baseline asthma severity, previous hospitalization for asthma, and public insurance status. However, ICS use had no effect on hospital or ICU length of stay, type, and duration of treatments received, or the rate of recovery determined by a standard severity of illness scoring system. In the subsets of patients including children with persistent asthma and those who received intravenous terbutaline, there was also no improvement in outcomes with the use of chronic ICS showing that the chronic use of ICS did not improve response to beta(2)-adrenergic receptor agonists in severely ill children with status asthmaticus. Although useful as a preventive therapy, the chronic use of ICS does not appear to affect the course of severe acute asthma exacerbations in pediatric patients once hospitalized.

Adverse drug reactions to nonsteroidal anti‐inflammatory drugs, COX‐2 inhibitors and paracetamol in a paediatric hospital

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in children has rapidly escalated over the last 5 years in Australia. This is primarily as a result of the availability of ibuprofen as an over-the-counter preparation. Several recent, significant adverse drug reactions (ADRs) to NSAIDs, at the Royal Children's Hospital (RCH) in Melbourne, Australia prompted review of all of the RCH reactions reported to these agents over 5 years. The ADR programme documents both spontaneously reported ADRs and ADRs identified by discharge coding. For this study, reported reactions to aspirin, celecoxib, ibuprofen, indomethacin, naproxen, paracetamol and rofecoxib, for the previous 5-year period, were retrieved from the hospital ADR database. Nineteen reports of ADRs to NSAIDs and six to paracetamol, in patients aged from 4 months to 22 years (median 10 years) were identified. Reactions were predominantly rash (n = 10), gastrointestinal (n = 5) and respiratory (n = 4) side-effects. These included reports of haematemesis with both celecoxib and ibuprofen. One patient died of severe acute exacerbation of asthma following initiation of rofecoxib. NSAID exposures are a significant cause of morbidity in children. Both nonselective NSAIDs and the newer COX-2 inhibitors were associated with significant drug reactions. The overall severity of these ADRs highlights the need for vigilant surveillance of ADRs in paediatrics, including both established and newer agents.

Clinical Efficacy of Racemic Albuterol Versus Levalbuterol for the Treatment of Acute Pediatric Asthma

An efficacy treatment study is conducted comparing levalbuterol to racemic albuterol for acute pediatric asthma in the emergency department (ED). This was a prospective, double-blind, randomized, controlled study involving 129 children (2 to 14 years), presenting to a pediatric ED with an acute moderate or severe asthma exacerbation. Children were treated using a standard ED asthma pathway. Primary outcomes were changes from baseline in clinical asthma score and the percentage of predicted forced expiratory volume in 1 second after the first, third, and fifth treatment. Secondary outcomes included number of treatments, length of ED care, rate of hospitalization, and changes in pulse rate, respiratory rate, and oxygen saturation. Occurrence of adverse events was recorded. Sixty-four children in the racemic albuterol and 65 children in the levalbuterol group completed the study. There were no differences between groups in primary outcomes, secondary outcomes, or adverse events. There was no difference in clinical improvement in children with acute moderate to severe asthma exacerbations treated with either racemic albuterol or levalbuterol.

The Efficacy of Ketamine in Pediatric Emergency Department Patients Who Present With Acute Severe Asthma

We determine whether a continuous infusion of ketamine can decrease the severity of a moderately severe acute asthma exacerbation by a clinically significant 2 points using a 15-point Pulmonary Index scoring scale. A double-blinded, randomized, placebo-controlled trial was performed to evaluate patients aged 2 to 18 years who presented to a pediatric emergency department with an acute asthma exacerbation. Exclusion criteria included temperature greater than 39 degrees C (102 degrees F), focal infiltrate on radiograph, or any glucocorticoid use in the last 72 hours. Eligible patients received 3 treatments with albuterol, ipratropium bromide, and a dose of oral or parenteral glucocorticoids. If the Pulmonary Index score remained 8 to 14, enrollment proceeded. All enrolled patients received continuous nebulized albuterol at 10 mg/hour and were randomized to receive an intravenous bolus of 0.2 mg/kg of ketamine, followed by a 2-hour ketamine infusion at 0.5 mg/kg per hour or an equal-volume regimen with normal-saline placebo. A Pulmonary Index score was performed on patients at 0, 30, 60, 90, and 120 minutes. Sixty-eight patients were enrolled, with 33 randomized to the ketamine infusion and 35 randomized to placebo. Mean ages of patients enrolled, chronic severity of asthma, and duration of symptoms before presentation were similar between groups. At enrollment, the mean Pulmonary Index score in the placebo group was 10.3+/-1.1 versus 10.5+/-1.5 for the ketamine group (difference of means 0.2; 95% confidence interval [CI] -0.5 to 0.8). Sixty-two patients completed the entire 2-hour infusion protocol. No significant difference between groups was seen in rate of improvement in the Pulmonary Index score at completion. The mean decrease in the Pulmonary Index scores at the end of the infusion was 3.6+/-1.3 in the placebo group versus 3.2+/-2.0 in the ketamine group (difference of means 0.4; 95% CI -0.4 to 1.3). No short-term adverse effects necessitating discontinuation of the infusion or adverse behavioral impacts at 48 hours after discharge were noted. We conclude that ketamine given at 0.2 mg/kg followed by an infusion of 0.5 mg/kg per hour for 2 hours provided no incremental benefit to standard therapy in this cohort of children with a moderately severe asthma exacerbation.

A comparative efficacy of Russian bronchodilating drugs in therapy of asthma with regards to pathological agents

We examined 364 asthma patients while treated in the Saratov pulmonary centre from 1989 to 2002. The aim of the work was to improve medication course programs including Russian oral bronchodilating drugs. The coefficient of harmony of changes which indicates a rate and synchrony of dynamics of clinical and laboratory parameters under a therapy was calculated using the method of regressive and graphic ratio. Severity of acute asthma exacerbation and, at less extent, severity of asthma course were proven to exert decisive influence upon results of the therapy

Effects of Two Nebulization Regimens on Heart Rate Variability During Acute Asthma Exacerbations in Children

Analysis of heart rate variability (HRV) has been used to evaluate changes in sympathovagal balance. The present study was designed to investigate the influence of two therapeutic regimens on autonomic cardiovascular regulation during acute asthma exacerbations (AAE). Twenty children, 7–13 years of age, with moderate or severe AAE were randomized in two equal groups to receive either 0.15 mg/kg/dose salbutamol (group 1) or a combination of lower-dose salbutamol (0.10 mg/kg/dose) and ipratropium bromide (5 mcg/kg/dose) (group 2). Exacerbations were treated with three nebulizations (Tx) of either regimen given 20 minutes apart. HRV indices [total power, high-frequency component (HF), low-frequency component (LF), and LF:HF ratio] were analyzed at specific time intervals during the management of AAE. Therapy had a significant time-dependent main effect on total power (p = 0.001), LF (p < 0.0001), and HF (p = 0.005) but reached only borderline significance for LF:HF ratio (p = 0.053). The decrease in LF was more pronounced in group 2 vs. group 1 at 10 minutes post-Tx1 (p = 0.034) and at 10 minutes post-Tx2 (p = 0.05), but there was no significant difference between groups at 10 and 20 minutes post-Tx3. There were no significant differences between groups in any of the other HRV indices. Both regimens improved FEV1 (p = 0.0001) to the same magnitude. During AAE, three consecutive inhalation treatments with either high-dose salbutamol-only or lower-dose salbutamol plus ipratropium bromide combination, resulting in similar FEV1 improvement, cause domination of sympathetic over parasympathetic nervous system of similar overall magnitude but distinct patterns of HRV indices.

Association of Tumor Necrosis Factor-α and Neutrophilic Inflammation in Severe Asthma

There is evidence that neutrophils are increased in the airway of severe disease or acute exacerbations of asthma. The mechanisms by which neutrophils are recruited to the airways and contribute to the pathophysiology of asthma remain to be elucidated. Tumor necrosis factor (TNF-α), which can induce both tissue accumulation and activation of neutrophils and eosinophils, has been shown to be increased in the airways of severe asthma. The objective of this study is to evaluate whether TNF-α is associated with neutrophilic inflammation in asthma. Following an inhalation of hypertonic saline, induced sputum was obtained from 9 healthy controls, 9 mild persistent asthma patients who were treated with low-dose inhaled corticosteroids; and 7 severe persistent asthma patients who were treated with combinations of drugs including high-dose inhaled corticosteroids, oral prednisolone, bronchodilators, and leukotriene receptor antagonist. After 0.1% dithiothreitol (DTT) homog- enization, they were examined for total cell count, cellular differentiation, and the concentrations of TNF-α and myeloperoxidase (MPO). The concentration of TNF-α was not correlated with neutrophils in healthy controls or mild asthma patients. In sputum from severe asthma patients, however, the concentration of TNF-α is significantly correlated with both the percentage of neutrophils and the concentration of MPO. The concentration of TNF-α is not correlated with the percentage of eosinophils in healthy controls, mild asthma patients, or severe asthma patients. TNF-α may be a contributing molecule for both accumulation and activation of neutrophils in the airways of severe asthma.

Common respiratory manifestations of food allergy: a critical focus on otitis media.

Previous investigations have established the pathogenic role of food allergy in respiratory tract symptoms, which rarely occur in isolation. Specific foods have been implicated in these reactions. The role of food allergy in otitis media is controversial, probably uncommon, and further studies are needed. Food-induced asthma is more common in young pediatric patients, especially those with atopic dermatitis. Asthma induced by food allergy is considered a risk factor for fatal and near-fatal anaphylactic reactions. Moreover, food allergy can elicit airway hyperreactivity and asthmatic responses. Therefore, evaluation for food allergy should be considered among patients with recalcitrant or otherwise unexplained acute severe asthma exacerbations; asthma triggered by ingestion of particular foods; and asthma and other manifestations of food allergy (eg, anaphylaxis, moderate to severe atopic dermatitis).

HUBUNGAN ANTARA DERAJAT OBSTRUKSI SERANGAN AKUT ASMA DENGAN KADAR IgE, IFN- DAN IL-4 TOTAL SERUM

ABSTRACT Acute bronchial asthma is a common medical emergency the world over. There now exists compelling evidence of a role for Th2-Th1 paradigm in the pathogenesis of asthma in children. We hypothesized that childhood asthma is associated with the activation of  Th2-Th1 lymphocytes whose products regulate at least in part, the expression of IgE, IFN-γ and IL-4 and thereby disease severity. Our aims, therefore were to compare the level of total IgE, total IL-4 and total IFN-γ in serum from asthmatic and non asthmatic control children matched for age and sex, and to attempt to correlate the IgE, IL-4, and IFN-γ total level of serum in the asthmatics children with disease severity. Fifty one children with acute asthma exacerbation were compare with thirty one no asthmatics normal children matched for age and sex. The level of IgE, IL-4, and IFN-γ were measured using Elisa. Asthma severity was assessed by a symptom score and spirometri. The level of IgE and Il-4 in the serum of the asthma were elevated as compared to the non asthmatic normal controls, whereas the IFN-γ was decreased. There was a significant correlation between elevated levels of IgE and IL-4 with the acute asthma exacerbation severity, whereas the decreased level of IFN-γ was not. Conclusions. The increased levels of IgE , IL-4 and the ratio of  IL-4/IFN-γ play a crucial role in the acute asthma exacerbation severity.

(R,S)-salbutamol plasma concentrations in severe asthma.

Salbutamol is commonly delivered as a racemic mixture of pharmacologically active (R)-salbutamol and inactive (S)-salbutamol. This study investigated inactive (S)- and active (R)-salbutamol plasma levels and their relationship to dose in patients with severe asthma. Basic demographics, racemic-salbutamol dose in the preceding 24 h, lung function tests at baseline and 1 h, and a 10 mL plasma sample were obtained from subjects presenting to the Department of Emergency Medicine with acute asthma. Plasma determinations were carried out using an LC-MS assay with solid phase extraction. All patients (n = 5) had detectable levels of drug in plasma with range of 0.9-7.7 and 4.7-27.4 ng/mL for (R)-salbutamol and (S)-salbutamol respectively. These were correlated to total racemic salbutamol dose. The range of the (S) : (R) ratio was 2.0-5.2, with (R)-salbutamol representing 16-33% of the total plasma concentration, which did not correlate with total salbutamol dose. Only a small fraction of total plasma salbutamol concentration was found to consist of active enantiomer in patients with an acute severe exacerbation of asthma actively undergoing treatment with racemic-salbutamol. As a result of the possible contribution of (S)-salbutamol to poor asthma control further enantioselective investigations are warranted in severe asthma.

The Management of Acute Severe Asthma

Acute severe asthma exacerbations resulting in emergency department visits and hospitalization usually constitute a failure of long-term control therapy. However, even patients with relatively mild asthma can have severe life-threatening episodes. In both children and adults, viral respiratory infections are the major triggering event, although outbreaks of severe asthma have been associated with high concentrations of aeroallergens. Patients should be provided with written action plans on what to do for acute deterioration, and more severe patients may keep prednisone at home to begin after consultation with their physician. The primary therapy of acute asthma exacerbations remains frequent administration of aerosol β2-agonists and systemic corticosteroids for those patients not fully responding to the β2-agonists. Mild exacerbations may be treated with an increased dosage of inhaled corticosteroids. Patients at risk for acute exacerbations may benefit from peak flow measurement, particularly those who have difficulty perceiving airway obstruction. It is recommended that patients remain on full dose of prednisone until they achieve 70-80 percent of predicted normal or personal best peak flow. In the emergency department, the use of β2-agonists by metered-dose inhaler and holding chamber is as effective as nebulizer if given in a sufficient dose 6-10 puffs equivalent to 5 mg via nebulizer. In those patients not responding completely, the addition of ipratropium bromide has shown to produce additive bronchodilation and reduce hospitalizations. Other therapies such as magnesium sulfate, intravenous β2-agonists, heliox and ketamine have been used, but data demonstrating efficacy are insufficient to warrant recommending their general use.

Magnesium Therapy May Improve Pulmonary Function in Severe Acute Asthma

Allergy/Immunology| January 01 2001 Magnesium Therapy May Improve Pulmonary Function in Severe Acute Asthma AAP Grand Rounds (2001) 5 (1): 4–5. https://doi.org/10.1542/gr.5-1-4 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Magnesium Therapy May Improve Pulmonary Function in Severe Acute Asthma. AAP Grand Rounds January 2001; 5 (1): 4–5. https://doi.org/10.1542/gr.5-1-4 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: magnesium, pulmonary function, status asthmaticus Source: Ciarallo L, Brousseau D, Reinert S. Higher-dose intravenous magnesium therapy for children with moderate to severe acute asthma. Arch Pediatr Adolesc Med. 2000;154:979–983. In a double-blind study, 30 children at Rhode Island Hospital with moderate to severe acute asthma exacerbations and peak expiratory flow rates (PEFR) < 70% predicted after 3 treatments with nebulized albuterol or ipratropium bromide (or both) were randomized to receive either 40 mg/kg (maximum dose 2 gm) of magnesium sulfate intravenously over 20 minutes (16 patients, 11 male, mean age 10.9 years) or normal saline (14 patients, 7 male, mean age 12 years). The children were given intravenous steroids if they had not already received steroids when the IV catheter was placed. Additional nebulized treatments were given at the discretion of the provider. Peak expiratory flow rate (PEFR), forced expiratory volume in 1 sec (FEV1), forced vital capacity... You do not currently have access to this content.

Induced sputum eicosanoid concentrations in asthma.

Further definition of the role of leukotrienes (LT) and prostaglandins (PG) in asthma would be helped by a noninvasive method for assessing airway production. The supernatant from sputum induced with hypertonic saline and dispersed using dithiotrietol has been successfully used to measure other molecular markers of airway inflammation and might be a useful method. We have measured induced sputum supernatant LTC(4)/D(4)/E(4) concentrations using enzyme immunoassay and PGE(2), PGD(2), TXB(2), and PGF(2alpha) using gas chromatography-negative ion chemical ionization-mass spectroscopy in 10 normal subjects and in 26 subjects with asthma of variable severity. Sputum cysteinyl-leukotrienes concentrations were significantly greater in subjects with asthma (median, 9.5 ng/ml) than in normal control subjects (6.4 ng/ml; p < 0.02) and greater in subjects with persistent asthma requiring inhaled corticosteroids (median, 11.4 ng/ml) or studied within 48 h of an acute severe exacerbation of asthma (13 ng/ml) than in subjects with episodic asthma treated with inhaled beta(2)-agonists only (7.2 ng/ml). There were no significant differences in the concentrations of other eicosanoids between groups, although there was a negative correlation between the percentage sputum eosinophil count and sputum PGE(2) concentration (r = -0.48; p < 0.01) in subjects with asthma. We conclude that induced sputum contains high concentrations of eicosanoids and that sputum LTC(4)/D(4)/E(4) concentrations are significantly greater in subjects with asthma than in normal subjects. The inverse relationship between eosinophilic airway inflammation and sputum PGE(2) concentration would be consistent, with the latter having an anti-inflammatory role.