Asthma Exacerbations In Adults Research Articles

The pH of exhaled breath condensate (EBC): A non invasive tool for evaluation of asthma in childhood

Rationale Recent studies show that the pH of EBC could be predictive of asthma exacerbation in adults. However no data are available in children. The aim of our study was to establish if EBC pH could be used as a non-invasive mean of monitoring asthma in childhood. Methods Between April and July 2002, a total of 104 consecutive patients with mild persistent asthma (72 M, median age 9.9 years) were enrolled. Thirty healthy children were used as controls (11 M, median age 7 years). All children performed skin prick tests, lung function tests and EBC pH measurements, using a hand-made device. Patients with asthma exacerbation received steroid and β2-agonist treatment for one week, and then the EBC pH determination was repeated. Results Out of 104 patients, 34 (32.7%) showed evidences of acute exacerbation of asthma (AA) and 70 (67.3%) had stable asthma (SA). We found that the pH of EBC in patients with AA was significantly lower than that of patients with SA (7.25 vs 7.32; p<0.05) and that the latter was significantly lower than that of controls (7.32 vs 7.78; p<0.0001). After treatment, the EBC pH of patients with AA was significantly higher than before therapy (7.75 vs 7.25; p<0.0001). Finally, among patients with AA we found a positive correlation between pH and FEV 1, FEF 25, FEF 50 and FEF 75 (p=0.02, p=0.01, p=0.01, p=0.02; respectively). Conclusions Our study shows for the first time in children that the pH of EBC is a reliable non invasive marker for assessing ongoing airway inflammation and response to treatment.

Montelukast and fluticasone compared with salmeterol and fluticasone in protecting against asthma exacerbation in adults: one year, double blind, randomised, comparative trial

Objectives To assess the effect of montelukast versus salmeterol added to inhaled fluticasone propionate on asthma exacerbation in patients whose symptoms are inadequately controlled with fluticasone alone.Design and setting A...

Acute exacerbation of asthma in adults

Acute asthma remains an important cause of morbidity adults. The recognition, assessment and appropriate management of acute asthma are essential to avoid unnecessary morbidity and also mortality, which unfortunately still occurs. This article will present an overview of the hospital management of acute asthma exacerbations in adults. The British Thoracic Society(BTS) conjunction with the Scottish Intercollegiate Guidelines Network(SIGN) published the latest British Guidelines on all aspects of asthma management in February of this year .1 This article is a précis of these latest British guidelines as they relate to acute asthma in adults.

A randomized clinical trial of nebulized magnesium sulfate in addition to albuterol in the treatment of acute mild-to-moderate asthma exacerbations in adults

Study Objective: We sought to compare the efficacy and safety of nebulized magnesium sulfate (MgSO4) plus albuterol with that of albuterol alone in adult patients with mild-to-moderate acute asthma exacerbations. Methods: Patients were randomized to receive nebulized MgSO4 (384 mg in 6 mL of sterile water) or an equal volume of placebo (normal saline solution) in a double-blind fashion after each dose of nebulized albuterol administered (2.5 mg/3 mL) every 20 minutes for the first hour of the study. Spirometry was performed at baseline and every 20 minutes for 2 hours. Monitoring for safety included vital signs, pulse oximetry, and serum magnesium levels. Improvement in percent predicted forced expiratory volume in 1 second was chosen as a primary efficacy end point. Results: Among 74 patients enrolled, 37 were randomized to each of 2 study groups. There were no statistically or clinically significant differences between the 2 study groups in percent predicted forced expiratory volume in 1 second at any point during the trial or overall. There were no significant differences in vital signs, pulse oximetry, or serum magnesium levels at any point during the study. Conclusion: The combination of nebulized MgSO4 and albuterol provides no benefit in addition to that provided by therapy with albuterol in adult patients with mild-to-moderate asthma exacerbations. The efficacy of nebulized MgSO4 in patients with severe asthma exacerbations remains unknown. [Bessmertny O, DiGregorio RV, Cohen H, Becker E, Looney D, Golden J, Kohl L, Johnson T. A randomized clinical trial of nebulized magnesium sulfate in addition to albuterol in the treatment of acute mild-to-moderate asthma exacerbations in adults. Ann Emerg Med. June 2002;39:585-591.]

Synergism between allergens and viruses and risk of hospital admission with asthma: case-control study

Objective: To investigate the importance of sensitisation and exposure to allergens and viral infection in precipitating acute asthma in adults resulting in admission to hospital.Design: Case-control study.Setting: Large district general...

Infections and Asthma

Infections have a variety of influences in the asthmatic patient. Respiratory syncytial virus (RSV) is the most common cause of wheezing illnesses in children under the age of 2 years and may be a risk factor for the inception of asthma in the first decade of life. Once asthma has become recognized clinically, rhinovirus is the leading cause of acute asthma exacerbations in adults and older children. Certain respiratory infections may induce chronic lower airway inflammation that may contribute to disease progression or severity in asthma. Paradoxically, some infections may even protect against the development of asthma. This article reviews the evidence for these associations and the mechanisms proposed to explain these various outcomes.

Does ketamine have a role in managing severe exacerbation of asthma in adults?

To evaluate the role of ketamine in management of severe exacerbation of asthma in adults. Qualitative systematic search using MEDLINE (January 1966-September 2000), EMBASE (January 1988-September 2000), and the Cochrane Database of Systematic Reviews (Issue 2, 2000). One prospective, randomized, double-blind, placebo-controlled trial and five case reports were retrieved. In the clinical trial, low-dosage ketamine as an adjunct to standard therapy offered no benefit in improving outcomes in nonventilated patients. In the case reports, all patients with refractory severe exacerbation of asthma requiring mechanical ventilation appeared to receive some benefit from ketamine, with alleviation of bronchospasm and improved oxygenation. Adverse effects included dysphoria, hallucinations, and increased pulmonary secretions. Limited evidence is available in the literature to support administration of ketamine in severe exacerbation of asthma. Although a few cases suggest possible benefit from ketamine, it should not be considered until controlled clinical trials demonstrate that benefits outweigh risks for patients for whom other standard therapies failed.

Psychosocial factors, respiratory viruses and exacerbation of asthma.

The aim of this research was study the role of psychosocial factors in exacerbations of asthma in adults induced by upper respiratory tract infections (URTIs). It involved a longitudinal study (one year) of 92 adults with asthma. The volunteers were 27 men and 65 women 19–46 years of age with a mean duration of wheeze of 19 years. The main outcome measure was symptomatic colds producing asthma exacerbations (infections confirmed by laboratory assays and exacerbation of asthma confirmed by objective changes in peak expiratory flow rate). The results showed that about 20% of the sample did not report an episode. This sub-group had a high proportion of males, low negative affectivity scores and consumed more alcohol. When volunteers with at least one episode were considered it was found that those who reported more negative life events and had low levels of social support had more episodes. Smokers were more likely to have to visit their doctor when they developed a cold-induced exacerbation of asthma. Overall, these results show that health-related behaviours, demographic and psychosocial factors influence susceptibility to and severity of exacerbations of asthma by URTIs.

The Use of Ipratropium Bromide for the Management of Acute Asthma Exacerbation in Adults and Children: A Systematic Review

Ipratropium bromide is a quaternary anticholinergic bronchodilator that is commonly used to treat obstructive lung disease. Although ipratropium is not usually employed as a first-line bronchodilator to treat chronic asthma, it has been used extensively in hospital emergency departments as adjunctive therapy for the emergency treatment of acute asthma exacerbation. This review will summarize the physiological actions of ipratropium and the rationale for its use as an anticholinergic bronchodilator. Evidence available from randomized trials and from two meta-analyses is summarized to determine whether the addition of inhaled ipratropium to inhaled beta2-agonist therapy is effective in the treatment of acute asthma exacerbation in children and adults. Published reports of randomized, controlled trials assessing the use of ipratropium and concurrent beta2-agonists in adult acute asthma exacerbation were identified by a search of electronic databases, as well as by hand searching. Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted-average method. Use of nebulized ipratropium/beta2-agonist combination therapy was associated with a pooled 7.3% improvement in forced expiratory volume in 1 sec [95% confidence interval (CI), 3.8–10.9%] and a 22.1% improvement in peak expiratory flow (95% CI, 11.0–33.2%) compared with patients who received beta2-agonist without ipratropium. For the three trials in adults reporting hospital admission data (n = 1064), adult patients receiving ipratropium had a relative risk of hospitalization of 0.80 (95% CI, 0.61–1.06). Similarly, randomized controlled studies of pediatric asthma exacerbation and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta2-agonists improves lung function and also decreases hospitalization rates, especially among children with severe exacerbations of asthma. The adult and pediatric studies did not report any severe adverse effects attributable to ipratropium when it was used in conjunction with beta2-agonists. In conclusion, there is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive to beta2-agonists for the treatment of acute asthma exacerbation. In pediatric asthma exacerbation, use of ipratropium also appears to improve clinical outcomes; however, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta2-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects.

Comparison of Nebulised Budesonide and Prednisolone in Severe Asthma Exacerbation in Adults

Background: Short courses of oral prednisolone are used as rescue therapy for severe asthma exacerbations. This study compares nebulised budesonide or oral prednisolone, both followed by budesonide Turbohaler®, as a treatment for severe asthma exacerbations, in the absence of life-threatening features.

Environmental tobacco smoke exposure and asthma in adults.

Environmental tobacco smoke (ETS) contaminates indoor air in homes and workplaces. Although the adverse effects of active cigarette smoking on the respiratory tract have been extensively characterized, the effects of ETS exposure on adult asthma have not yet been investigated extensively and the available data are limited. This article examines the evidence for ETS exposure as a cause of asthma and asthma exacerbation in adults, and for ETS exposure in the workplace specifically as contributing to these health effects. It addresses methodological barriers that limit the available data and evaluates the adequacy of the data for risk assessment.

ROLE OF SYSTEMIC AND INHALED GLUCOCORTICOIDS IN ASTHMA

The National Institutes of Health Expert Panel Report 2, Guidelines for the Diagnosis and Management of Asthma (EPR2), categorizes asthma medications into those that provide quick relief and those that are used for long-term control of the disease.27 In EPR2, asthma is considered as mild and intermittent if symptoms occur twice weekly or less frequently and pulmonary function is normal between episodes. These patients are appropriately treated with as-needed inhaled beta-agonists to relieve symptoms. If asthma symptoms occur more often than twice weekly, if there is nocturnal awakening as often as twice a month, or if pulmonary function testing between episodes of asthma shows evidence of airflow obstruction, the patient is considered to have persistent asthma and to be a candidate for treatment with a long-term control medication that should have anti-inflammatory properties.27 In the latter category EPR2 recognizes corticosteroids as the “most potent and effective anti-inflammatory medication currently available.”27 The inhaled forms are used in the long-term control of asthma, and systemic corticosteroids are often used to gain prompt control of the disease when initiating long-term therapy. The primacy of inhaled corticosteroids is emphasized in EPR2 at each level in the stepwise approach recommended for managing asthma. Thus for mild persistent asthma, either low-dose inhaled corticosteroids or, in children, cromolyn or nedocromil are preferred; for moderate and severe persistent asthma, medium to high doses of inhaled corticosteroids, with the possible addition of long-acting bronchodilators, are recommended.27 EPR2 also presents two approaches for gaining control of asthma. One approach is to begin treatment at the step appropriate to the severity of the patient's disease and to step up treatment if control is not achieved. The preferred approach, however, is to gain rapid control by administering anti-inflammatory therapy at a level higher than that suggested by the severity of the patient's symptoms. This can be accomplished either by initiating a short course of systemic corticosteroids along with inhaled corticosteroids or by initiating a medium-to-high dose of inhaled corticosteroids. Once control is gained, rapid step-down to the treatment appropriate for the patient's level of severity should be instituted. This article reviews the data to support this preeminent role of corticosteroids in the treatment of chronic persistent asthma and exacerbations of asthma in adults.

Chlamydia pneumoniae and exacerbations of asthma in adults.

BackgroundChlamydia pneumoniae is a frequent causative agent of acute respiratory disease and has been recently reported as a possible case of asthma.ObjectiveWe assessed the prevalence of C. pneumoniae infections in adult patients with acute exacerbations of asthma.MethodsOne hundred sixty-eight adult patients with acute exacerbations of asthma and 108 control subjects matched for age, sex, and smoking status were studied. Nasopharyngeal swab specimens were obtained from all subjects and analyzed by isolation in cell culture and polymerase chain reaction (PCR) test for C. pneumoniae. Serum samples were also obtained and tested for C. pneumoniae-specific antibodies by the microimmunofluorescence test.ResultsC. pneumoniae was isolated from two (1.2%) asthma patients and none from controls and detected by PCR from nine (5.4%) cases and one (0.9%) control. Both culture positive specimens were also positive in PCR. Further, serologic evidence of acute C. pneumoniae infection was present in 15 (8.9%) of asthma patients and in three (2.8%) of controls (P = .048). The prevalence of C. pneumoniae-specific IgG and IgA was significantly higher in asthma cases than in controls (IgG >/= 1:16; 85.1% versus 67.6%, P = .001; IgA ≥ 1:16: 47.6% versus 16.7%, P < .001). Mean titer of IgG and IgA was also significantly greater in asthma cases than in controls (IgG: 38.8 versus 18.1, P = .0001; IgA: 17.2 versus 6.1, P = .0001).ConclusionOur data suggest that C. pneumoniae infection may trigger acute exacerbations of adult asthma.

Prediction of Relapse within Eight Weeks after an Acute Asthma Exacerbation in Adults

Associations between historical, presenting, and treatment-related characteristics and relapse within 8 weeks after a moderate to severe asthma exacerbation were studied in a cohort of 284 adult asthmatics. Data were collected prospectively, and a multivariate model was developed and internally validated. Within 10 days, only 8% had relapsed, increasing to 45% by 8 weeks. Three variables that could be identified at the time of discharge were independently associated with relapse. These included: having made three or more visits to an emergency department in the prior 6 months (hazard ratio (HR) = 2.3, 95% CI = 1.6–3.4); difficulty performing work or activities as a result of physical health in the 4 weeks prior (HR = 2.7, 95% CI = 1.6–4.3); discontinuing hospital-based treatment for the exacerbation within 24 hours without having achieved a peak expiratory flow rate of at least 50% of predicted (HR = 2.6, 95% CI = 1.6–4.1). These risk factors may help to identify patients with poorly controlled asthma in need of more intensive and comprehensive management.

Viruses in asthma

J Allergy Clin Immunol 1997;100:147-50.

Continuously Nebulized Albuterol in Severe Exacerbations of Asthma in Adults: A Case-Controlled Study

A retrospective, case-controlled analysis comparing patients admitted to a medical intensive care unit with severe exacerbations of asthma who received continuously nebulized albuterol (CNA) versus intermittent albuterol (INA) treatments is reported. Forty matched pairs of patients with asthma are compared. CNA was administered for a mean of 11 ± 10 hr. The incidence of cardiac dysrhthmias was similar between groups. Symptomatic hypokalemia did not occur. CNA patients had higher heart rates during treatment, which may reflect severity of illness. The incidence of intubation was similar. We conclude that CNA and INA demonstrated similar profiles with regard to safety, morbidity, and mortality.

Corticosteroids - clinical applications: exacerbations of asthma in adults

Corticosteroids - clinical applications: exacerbations of asthma in adults

Short-term association between air pollution and emergency room visits for asthma in Barcelona.

Several studies have assessed the association between urban air pollutants and hospital admissions or emergency room visits for asthma with inconsistent results. The objective of this study was to assess the relation between levels of black smoke, sulphur dioxide, nitrogen dioxide, and ozone and adult emergency room visits for asthma in Barcelona, Spain during the five year period 1985-9. The daily number of emergency room visits for asthma was obtained from a register of respiratory emergencies designed to study the asthma outbreaks occurring in Barcelona. The association between asthma visits and levels of pollutants was assessed separately for summers and winters with Poisson regression models controlling for meteorological and time related variables. Black smoke was associated with asthma visits in summer but not in winter. The relative risk (RR) of asthma visits for a 25 micrograms/m3 increase of current day concentrations of black smoke was 1.082 (95% CI 1.011 to 1.157). The mean current and previous three day levels of black smoke led to a stronger association (RR = 1.114 (95% CI 1.010 to 1.160). In addition, nitrogen dioxide was associated with asthma visits in both summer (RR = 1.045, 95% CI 1.009 to 1.081) and winter (RR = 1.056, 95% CI 1.011 to 1.104). These associations were slightly higher for the previous day's level of nitrogen dioxide. No associations were found for sulphur dioxide or for ozone. This study provides further evidence of the effect of particulate pollution on asthma, and it suggests that nitrogen dioxide may have a role in the exacerbation of bronchial asthma in adults.

The Contribution of Respiratory Viruses to Severe Exacerbations of Asthma in Adults

Viral infections are known to be associated with severe exacerbations of asthma in children. In contrast, there is limited data that viral infections evoke acute episodes of asthma that require emergency care in adults. To determine the role of viral infections in exacerbations of asthma in adults, we examined 33 patients who presented to the emergency room with 35 exacerbations of asthma between September 1990 and March 1991 for the presence of a viral infection. A nasal swab was obtained for virus isolation by culture and rapid antigen detection by fluorescent staining. In 16 patients, serum was collected at initial presentation and 3 to 4 weeks later for acute and convalescent viral antibody titers. All patients had acute episodes of asthma ascertained by medical history and physical examination. About 56% of the patients with asthma exacerbations had symptoms suggestive of viral illness. Rapid antigen detection and viral cultures for influenza A and B, parainfluenza-1, 2, 3, respiratory syncytial virus, adenovirus, and rhinovirus were negative on all patients. Likewise, in all 16 patients tested, acute and convalescent serologic studies did not show a significant rise in titer by complement fixation test. Thus, despite symptoms consistent with viral infection, viral pathogens could not be shown by current virologic techniques. This study suggests that viral infection may not be as prevalent a precipitate of asthma in adults requiring emergency room treatment as is generally thought.

Acute exacerbations of asthma in adults: role of Chlamydia pneumoniae infection

Respiratory infections precipitate wheezing in many asthmatic patients and may be involved in the aetiopathogenesis of asthma. Several studies have demonstrated that viral infections may provoke asthma. Bacterial infections seem to play a minor role. However, Chlamydia pneumoniae has been recently reported as a possible cause of asthma. The aim of the present study was to evaluate the role of C. pneumoniae infection in acute exacerbations of asthma in adults. Seventy four adult out-patients with a diagnosis of acute exacerbation of asthma were studied. Acute and convalescent (> or = 3 weeks) serological determination of antibodies to cytomegalovirus, respiratory syncytial virus, adenovirus, influenza A and B, parainfluenza 1 and 3, Mycoplasma pneumoniae and Legionella pneumophila were performed by means of immunofluorescence tests. C. pneumoniae specific antibodies were detected by two microimmunofluorescence tests using a specific antigen (TW-183) and a kit with three chlamydial antigens. Pharyngeal swab specimens were also obtained for C. pneumoniae identification. Samples for bacterial culture were obtained in patients with productive cough (15 out of 74 patients). Fifteen patients (20%) presented seroconversion to at least one of the studied pathogens. Seven were found to be infected by virus, six by C. pneumoniae alone, and one by M. pneumoniae. One more patient showed seroconversion to C. pneumoniae and cytomegalovirus.(ABSTRACT TRUNCATED AT 250 WORDS)