Bronchodilator Administration Research Articles

Respiratory emergencies in adult horses

SummaryAlthough respiratory distress is encountered infrequently in equine practice, it can be serious and potentially fatal, requiring immediate and decisive intervention. History and physical examination can often give sufficient clues to identify the cause of respiratory distress and initiate emergency treatment. Ultrasonography can also be invaluable when assessing distress caused by lower respiratory tract issues. Upper respiratory tract obstruction, tension pneumothorax and occasionally pulmonary oedema can be rapidly fatal and require immediate intervention by emergency tracheotomy, thoracocentesis and evacuation of pleural air or administration of furosemide and oxygen, if available. Acute severe asthma and substantial pleural effusion are often not an immediate threat to life but nonetheless require fast intervention including administration of bronchodilators and corticosteroids or pleurocentesis, respectively.

Why is my anaesthesia machine detecting halothane after bronchodilator administration? A curious fact

Why is my anaesthesia machine detecting halothane after bronchodilator administration? A curious fact

Examination of disparities in prehospital encounters for pediatric asthma exacerbations.

There are disparities in multiple aspects of pediatric asthma care; however, prehospital care disparities are largely undescribed. This study's objective was to examine racial and geographic disparities in emergency medical services (EMS) medication administration to pediatric patients with asthma. This is a substudy of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial, which includes data from pediatric asthma patients ages 2-18 years. We examined rates of EMS administration of systemic corticosteroids and inhaled bronchodilators by patient race. We geocoded EMS scene addresses, characterized the locations' neighborhood-based conditions and resources relevant to children using the Child Opportunity Index (COI) 2.0, and analyzed associations between EMS scene address COI with medications administered by EMS. A total of 765 patients had available racial data and 825 had scene addresses that were geocoded to a COI. EMS administered at least 1 bronchodilator to 84.7% (n=492) of non-White patients and 83.2% of White patients (n=153), P=0.6. EMS administered a systemic corticosteroid to 19.4% (n=113) of non-White patients and 20.1% (n=37) of White patients, P=0.8. There was a significant difference in bronchodilator administration between COI categories of low/very low versus moderate/high/very high (85.0%, n=485vs. 75.9%, n=192, respectively, P=0.003). There were no racial differences in EMS administration of medications to pediatric asthma patients. However, there were significantly higher rates of EMS bronchodilator administration for encounters in low/very low COIs. That latter finding may reflect inequities in asthma exacerbation severity for patients living in disadvantaged areas.

Racial, Ethnic, and Socioeconomic Disparities in Prehospital Encounters for Children with Asthma

Objective Asthma represents one of the most common medical conditions among children encountered by emergency medical services (EMS). While care disparities for children with asthma have been observed in other healthcare settings, limited data exist characterizing disparities in prehospital care. We sought to characterize differences in prehospital treatment and transport of children with suspected asthma exacerbations by race and ethnicity, within the context of community socioeconomic status. Methods We conducted a multi-agency retrospective study of EMS encounters in 2019 for children (2–17 years) with asthma and wheezing using a national prehospital database. Our primary outcomes included EMS transport and prehospital bronchodilator or systemic corticosteroid administration. Scene socioeconomic status was evaluated using the social vulnerability index. We used generalized estimating equations to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for prehospital bronchodilator use or steroid use by race and ethnicity, adjusting for age, presence of abnormal vital signs, community size, bronchodilator use prior to EMS arrival, and transport disposition. Results We analyzed 5,266 EMS encounters (median age 8 years). Approximately half (53%) were Black non-Hispanic and 34% were White non-Hispanic. Overall, 77% were transported by EMS. In an adjusted model, Black non-Hispanic children were 25% less likely to be transported compared to White non-Hispanic children (aOR: 0.75, 95%CI: 0.58–0.96). EMS administered at least one bronchodilator to 81% of Black non-Hispanic patients, 73% of Hispanic patients, and 68% of White, non-Hispanic patients. Relative to White non-Hispanic children, EMS bronchodilator administration was greater for Black non-Hispanic children, (aOR: 1.55, 95%CI: 1.25–1.93), after controlling for scene socioeconomic status and potential confounding variables. Systemic corticosteroids were administered in 3% of all encounters. Odds of prehospital systemic corticosteroid administration did not differ significantly by race and ethnicity. Conclusion Black non-Hispanic children comprised a larger proportion of EMS encounters for asthma and were more likely to receive a bronchodilator in adjusted analyses accounting for community socioeconomic status. However, these children were less likely to be transported by EMS. These findings may reflect disease severity not manifested by abnormal vital signs, management, and other social factors that warrant further investigation.

Adherence to the asthma pathway, including pre-triage bronchodilator history, reduces hospitalizations

Objective: To determine if adherence to an asthma treatment pathway is associated with a decrease in hospitalizations. Methods: A prospective cohort design was conducted of Thai children aged 2–15 years who visited the emergency department with severe asthma exacerbations, defined as a Buddhasothorn Asthma Severity Score ≥ 8. Patients who received systemic corticosteroids and nebulized short-acting beta-2 agonists combined with ipratropium bromides were classified as the adherence group. The timing of steroid and bronchodilator administration, length of hospital stay, and hospitalization rate were examined in relation to adherence to the asthma pathway. Multivariable logistic regression models and adjusted odds ratios were used to assess associations. Results: A total of 118 episodes of asthma exacerbations (EAEs) from 59 participants were included. Patients who adhered to the pathway had a significantly higher rate of systemic corticosteroid administration within 1 h of arrival at triage (88.6% vs. 41.9%, adjusted Odds Ratio: aOR 10.21; 95%CI 3.52–29.62). A higher proportion of the patients who adhered to the pathway also received inhaled ipratropium bromide ≥ 2 doses within 1 h of arrival at triage (72.7% vs. 12.2%, aOR 23.51; 95%CI 7.73–71.54) and it was administered significantly faster by 31 min (5 min vs. 36 min, p < 0.001) compared to non-adherence group. The hospitalization rate was significantly lower by almost half of EAEs for adherence group (36.4% vs. 63.5%, aOR 0.41; 95%CI 0.18–0.93). Conclusions: Accurate assessment of severity and adherence to the clinical pathway can reduce hospitalization in pediatric patients with severe asthma exacerbations.

Peripheral airway dysfunction in prematurity-associated obstructive lung disease identified by oscillometry.

Mechanisms underlying lung dysfunction after preterm birth are poorly understood. Studying phenotypes of prematurity-associated lung disease may aid understanding of underlying mechanisms. Preterm-born children with and without lung dysfunction and term controls were assessed using oscillometry before and after exercise, and after postexercise bronchodilation. Preterm-born children, born at gestation of 34 weeks or less, were classified into those with prematurity-associated obstructive lung disease (POLD; FEV1 < LLN, FEV1 /FVC < LLN), prematurity-associated preserved ratio of impaired spirometry (pPRISm; FEV1 < LLN, FEV1 /FVC ≥ LLN) and compared to preterm (FEV1 ≥ LLN) and term controls (%predicted FEV1 > 90%). All children underwent cardiopulmonary exercise, and oscillometry assessment at baseline, postexercise, and after postexercise bronchodilator administration. From 241 participants aged 7-12 years, complete data were available from 179: 15 children with POLD and 11 with pPRISm were compared with 93 preterm and 60 term controls. POLD group, when compared to both control groups, had impaired impedance, greater resistance, more negative (greater magnitude) reactance at low frequencies, and also had decreased compliance. pPRISm group demonstrated impaired reactance and compliance compared to term controls. No differences were noted between the preterm and term controls. Exercise had little impact on oscillometry values, but children with POLD had greatest improvements after postexercise bronchodilator administration, with decreased resistance and decreased magnitude of reactance, particularly at low frequencies. Preterm-born children with obstructive airway disease had the greatest oscillometry impairments and the largest improvements after postexercise bronchodilator compared to control groups. Oscillometry can potentially be used to identify preterm-born children with lung disease to institute treatment.

Association of World Trade Center (WTC) Occupational Exposure Intensity with Chronic Obstructive Pulmonary Disease (COPD) and Asthma COPD Overlap (ACO).

Reported associations between World Trade Center (WTC) occupational exposure and chronic obstructive pulmonary disease (COPD) or asthma COPD overlap (ACO) have been inconsistent. Using spirometric case definitions, we examined that association in the largest WTC occupational surveillance cohort. We examined the relation between early arrival at the 2001 WTC disaster site (when dust and fumes exposures were most intense) and COPD and ACO in workers with at least one good quality spirometry with bronchodilator response testing between 2002 and 2019, and no physician-diagnosed COPD before 9/11/2001. COPD was defined spirometrically as fixed airflow obstruction and ACO as airflow obstruction plus an increase of ≥ 400ml in FEV1 after bronchodilator administration. We used a nested 1:4 case-control design matching on age, sex and height using incidence density sampling. Of the 17,928 study participants, most were male (85.3%) and overweight or obese (84.9%). Further, 504 (2.8%) and 244 (1.4%) study participants met the COPD and ACO spirometric case definitions, respectively. In multivariable analyses adjusted for smoking, occupation, cohort entry period, high peripheral blood eosinophil count and other covariates, early arrival at the WTC site was associated with both COPD (adjusted odds ratio [ORadj] = 1.34, 95% confidence interval [CI] 1.01-1.78) and ACO (ORadj = 1.55, 95%CI 1.04-2.32). In this cohort of WTC workers, WTC exposure intensity was associated with spirometrically defined COPD and ACO. Our findings suggest that early arrival to the WTC site is a risk factor for the development of COPD or of fixed airway obstruction in workers with pre-existing asthma.

Acute Hypercapnic Respiratory Failure in COPD.

COPD is a progressive inflammatory process affecting both the airways and alveolar structures of the lungs. Exacerbations of COPD are episodes of acute worsening of this inflammatory process, often triggered by infections. The most severe exacerbations are characterized by substantial air trapping and inspiratory muscle overload, which leads to hypercapnic respiratory failure. Pharmacologic therapies focus on intense bronchodilator administration (usually by aerosol), corticosteroids, and antibiotics. Respiratory life support technologies are often needed for severe exacerbations and range from carefully titrated supplemental O2 administration to positive-pressure ventilation (both invasive and noninvasive). Future life support strategies will likely involve extracorporeal life support technologies.

Whole-exome sequencing identified novel DNAH5 homozygous variants in two consanguineous families with primary ciliary dyskinesia.

Whole-exome sequencing identified novel DNAH5 homozygous variants in two consanguineous families with primary ciliary dyskinesia.

Response to Bronchodilators Administered via Different Nebulizers in Patients With COPD Exacerbation.

The recommended treatment of COPD exacerbations includes administration of short-acting bronchodilators that act to reverse bronchoconstriction, restore lung volumes, and relieve breathlessness. In vitro studies demonstrate vibrating mesh nebulizers (VMNs) provide greater drug delivery to the airway compared to standard small-volume nebulizers (SVNs). We examined whether the physiological and symptom response to nebulized bronchodilators during a COPD exacerbation differed between these 2 modes of bronchodilator delivery. Subjects hospitalized with a COPD exacerbation participated in a comparative clinical effectiveness study of 2 methods of nebulization. Using block randomization, 32 participants in this open-label trial were administered salbutamol 2.5 mg/ipratropium bromide 0.5 mg via vibrating mesh (VMN group, n = 16) or small-volume jet nebulizer (SVN group, n = 16) on one occasion. Spirometry, body plethysmography, and impulse oscillometry were performed and Borg breathlessness scores recorded pre bronchodilator and at 1 h post bronchodilator. Baseline demographics were comparable between groups. Mean FEV1 was 48% predicted. Significant changes in lung volumes and airway impedance were seen in both groups. Inspiratory capacity (IC) increased by 0.27 ± 0.20 L and 0.21 ± 0.20 L in the VMN and SVN group, respectively, between group difference P = .40. FVC increased in the VMN group by 0.41 ± 0.40 L compared to 0.19 ± 0.20 L with SVN, between group difference P = .053; and residual volume (RV) decreased by 0.36 ± 0.80 L and 0.16 ± 0.50 L in the VMN and SVN group, respectively, between group difference P = .41. The VMN group had a significant reduction in Borg breathlessness score, P = .034. Greater improvement in symptoms, and larger absolute change in FVC, was observed in response to equivalent doses of standard bronchodilators administered by VMN, compared to SVN, but no substantial difference in change in IC.

Association of Absolute Eosinophil Count and Post-Bronchodilator Reversibility in the Chronic Obstructive Pulmonary Disease Patients

Objective: To look for the relationship between absolute eosinophil count and post-bronchodilator reversibility in chronic obstructive pulmonary disease patients at Pak Emirates Military Hospital, Rawalpindi Pakistan.&#x0D; Study Design: Cross sectional study.&#x0D; Place and During of Study: Pulmonology Department, Pak Emirates Military Hospital Rawalpindi (PEMH) from Jul to Dec 2019.&#x0D; Methodology: The study was conducted on 150 patients suffering from chronic obstructive pulmonary disease admitted in the Medical Ward or reporting in the Outpatient Department. Lung function was assessed using spirometry pre- and postbronchodilation. The presence and severity of chronic obstructive pulmonary disease were assessed using modified Global Obstructive Lung Disease (GOLD) criteria. The presence of significant bronchodilator responsiveness was taken as ≥12% improvement in the forced expiratory volume (FEV) (1) or the forced vital capacity.&#x0D; Results: Of 150 patients in the final analysis, 95 (63.3%) were male, and 55(36.7%) were female. The mean duration of COPD in our target population was 9.13±1.23 years. 68 (45.3%) had &gt;12% improvement after bronchodilator administration, while 82(54.7%) had &lt;12% improvement. The absolute eosinophilic count was &lt;2% in 49(32.7%), while it was raised in 101(67.3%) patients. &#x0D; Conclusion: Raised eosinophilic count emerged as a predictor of good response after administering bronchodilators among patients suffering from chronic obstructive airway disease. Screening patients for this simple blood component may predictresponse to the initial treatment and help in the tailoring of the treatment plan by the treating physician.Keywords: Chronic obstructive pulmonary disease, Eosinophils, Forced expiratory volume.

Pulmonary rehabilitation after severe exacerbation of COPD: a nationwide population study

BackgroundAcute exacerbations of chronic obstructive pulmonary disease (COPD) lead to a significant reduction in quality of life and an increased mortality risk. Current guidelines strongly recommend pulmonary rehabilitation (PR) after a severe exacerbation. Studies reporting referral for PR are scarce, with no report to date in Europe. Therefore, we assessed the proportion of French patients receiving PR after hospitalization for COPD exacerbation and factors associated with referral.MethodsThis was a national retrospective study based on the French health insurance database. Patients hospitalized in 2017 with COPD exacerbation were identified from the exhaustive French medico-administrative database of hospitalizations. In France, referral to PR has required as a stay in a specialized PR center or unit accredited to provide multidisciplinary care (exercise training, education, etc.) and admission within 90 days after discharge was assessed. Multivariate logistic regression was used to assess the association between patients’ characteristics, comorbidities according to the Charlson index, treatment, and PR uptake.ResultsAmong 48,638 patients aged ≥ 40 years admitted for a COPD exacerbation, 4,182 (8.6%) received PR within 90 days after discharge. General practitioner’s (GP) density (number of GPs for the population at regional level) and PR center facilities (number of beds for the population at regional level) were significantly correlated with PR uptake (respectively r = 0.64 and r = 0.71). In multivariate analysis, variables independently associated with PR uptake were female gender (aOR 1.36 [1.28–1.45], p < 0.0001), age (p < 0.0001), comorbidities (p = 0.0013), use of non-invasive ventilation and/or oxygen therapy (aOR 1.52 [1.41–1.64], p < 0.0001) and administration of long-acting bronchodilators (p = 0.0038).ConclusionThis study using the French nationally exhaustive health insurance database shows that PR uptake after a severe COPD exacerbation is dramatically low and must become a high-priority management strategy.

Effects of a QI intervention on pediatric asthma treatment using patient outcomes and workflow in an emergency department

Objective Evaluate a nurse-initiated quality improvement (QI) intervention aimed at enhancing asthma treatment in a pediatric emergency department (ED), utilizing outcomes and workflow. Methods We evaluated the impact of QI interventions for pediatric patients presenting to the ED with asthma with pre-post analysis. A pediatric asthma score (PAS) of >8 indicated moderate to severe asthma. This secondary analysis of the electronic health record (EHR), evaluated on 1) patient outcomes (time to clinical treatment, ED length of stay [EDLOS], admissions and discharges home), 2) clinical workflow. Results We compared 886 visits occurring between 01/01/2015 and 09/27/2015 (pre-implementation period) with 752 visits between 01/01/2016 and 09/27/2016 (post-implementation). Time to first documentation of PAS was decreased post-intervention (p<.001) by >30 min (75 ± 57 to 39 ± 54 min). There were significant decreases in time to treatment with both steroid and bronchodilator administration (both p<.001). EDLOS did not significantly change. Based on acuity level, those discharged home from the ED with high acuity (PAS score ≥8), had a significant decrease in time to initial PAS, steroid and bronchodilator use and EDLOS. Of those with high acuity who were admitted to the hospital, there was a difference pre- to post-implementation, in time to first PAS (p<.05), but not to treatment. Workflow visualization provided additional insights and detailed (task level) comparisons of the timing of ED activities. Conclusions Nurse-initiated ED interventions, can significantly improve the timeliness of pediatric asthma evaluation and treatment. Examining workflow along with the outcomes, can better inform QI evaluations and clinical management.

Bronchodilator Responsiveness in Tobacco-Exposed People With or Without COPD

Bronchodilator responsiveness (BDR) in obstructive lung disease varies over time and may be associated with distinct clinical features. Is consistent BDR over time (always present) differentially associated with obstructive lung disease features relative to inconsistent (sometimes present) or never (never present) BDR in tobacco-exposed people with or without COPD? We retrospectively analyzed data from 2,269 tobacco-exposed participants in the Subpopulations and Intermediate Outcome Measures in COPD Study with or without COPD. We used various BDR definitions: change of≥ 200mL and≥ 12%in FEV1 (FEV1-BDR), change in FVC (FVC-BDR), and change in in FEV1, FVC or both (ATS-BDR). Using generalized linear models adjusted for demographics, smoking history, FEV1 %predicted after bronchodilator administration, and number of visits that the participant completed, we assessed the association of BDR group: (1) consistent BDR, (2) inconsistent BDR, and (3) never BDR with asthma, CT scan features, blood eosinophil levels, and FEV1 decline in participants without COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 0) and the entire cohort (participants with or without COPD). Both consistent and inconsistent ATS-BDR were associated with asthma history and greater small airways disease (%parametric response mapping functional small airways disease) relative to never ATS-BDR in participants with GOLD stage 0 disease and the entire cohort. We observed similar findings using FEV1-BDR and FVC-BDR definitions. Eosinophils did not vary consistently among BDR groups. Consistent BDR was associated with FEV1 decline over time relative to never BDR in the entire cohort. In participants with GOLD stage 0 disease, both the inconsistent ATS-BDR group (OR, 3.20; 95%CI, 2.21-4.66; P< .001) and consistent ATS-BDR group (OR, 9.48; 95%CI, 3.77-29.12; P< .001) were associated with progression to COPD relative to the never ATS-BDR group. Demonstration of BDR, even once, describes an obstructive lung disease phenotype with a history of asthma and greater small airways disease. Consistent demonstration of BDR indicated a high risk of lung function decline over time in the entire cohort and was associated with higher risk of progression to COPD in patients with GOLD stage 0 disease.

Prehospital Pediatric Asthma Care during COVID-19: Changes to EMS Treatment Protocols and Downstream Clinical Effects

Introduction During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay. Methods This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2–18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics. Results A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (N = 287) compared to after (N = 143). There was a significant decrease in EMS bronchodilator administration from 76% to 59.4% of patients after COVID-19 protocol guidelines were implemented (p < 0.0001). Mixed effects models for hospital admission (to both pediatric inpatient units and pediatric intensive care units) as well as ED length-of-stay did not show any significant effect after the COVID-19 protocol change period (p = 0.18 and p = 0.55, respectively). Conclusions Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.

Bronchodilator effect on regional lung function in pediatric viral lower respiratory tract infections

Objective. Viral lower respiratory tract infections (LRTI) are the leading cause for acute admission to the intensive care unit in infants and young children. Nebulized bronchodilators are often used when treating the most severe cases. The aim of this study was to investigate the bronchodilator effect on respiratory mechanics during intensive care with electrical impedance tomography (EIT) and to assess the feasibility of EIT in this context. Approach. We continuously monitored the children with chest EIT for up to 72 h in an observational study design. The treatment decisions were done by clinical assessment, as the clinicians were blinded to the EIT information during data collection. In a retrospective analysis, clinical parameters and regional expiratory time constants determined by EIT were used to assess the effects of bronchodilator administration, especially regarding airway resistance. Main results. We included six children from 11 to 27 months of age requiring intensive care due to viral LRTI and receiving bronchodilator agents. Altogether 131 bronchodilator administrations were identified during EIT monitoring. After validation of the exact timing of events and EIT data quality, 77 administrations were included in the final analysis. Fifty-five bronchodilator events occurred during invasive ventilation and 22 during high-flow nasal cannulae treatment. Only 17% of the bronchodilator administrations resulted in a relevant decrease in calculated expiratory time constants. Significance. Continuous monitoring with EIT might help to optimize the treatment of LRTI in pediatric intensive care units. In particular, EIT-based regional expiratory time constants would allow objective assessment of the effects of bronchodilators and other respiratory therapies.

PARADOXICAL BRONCHOSPASM IN A SARCOIDOSIS COHORT AT A TERTIARY MEDICAL CENTER

PARADOXICAL BRONCHOSPASM IN A SARCOIDOSIS COHORT AT A TERTIARY MEDICAL CENTER

Nebulización con malla vibratoria de Agonistas β 2 y anticolinérgicos a través de cánula nasal de alto-flujo durante la exacerbación de EPOC: Serie de casos

It is estimated that more than 2.3 million Argentineans suffer from Chronic Obstructive Pulmonary Disease (COPD) with a high rate of underdiagnosis and misdiagnosis. Pharmacological treatment with bronchodilators (BD) is the primary treatment and in cases of severe exacerbation the use of non-invasive mechanical ventilation (NIV) is recommended with a high level of evidence in patients with hypercapnia. High-flow nasal cannula (HFNC) has been postulated as an alternative to NIV in case of intolerance to interfaces or as a rest period bridge during times without NIV. HFNC is increasingly being used in patients with exacerbated COPD as an alternative to conventional oxygen therapy ( COT) and even as combined therapy in patients with NIV. Therefore, the administration of BD through HFNC may be relevant for the treatment of patients with exacerbated COPD.

Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study

BackgroundBecause the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS. MethodsWe performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week. ResultsAWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0–9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5–9 (16.8%) than of 0–4 (1.2%; p < 0.0001). ConclusionsAWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.

Emphasizing Pulmonary Function With Respiratory Therapy in an Infant With Congenital Adrenal Hyperplasia, Bronchopneumonia and Leptomeningitis

A set of hereditary diseases affecting the adrenal glands, a couple of walnut-sized structures above the kidneys, is known as congenital adrenal hyperplasia (CAH). The adrenal glands generate essential hormones like cortisol, mineralocorticoids, and androgens. It is usually diagnosed in the early neonatal period. The documentation of this case study is aimed to provide a case of an infant with CAH associated with bronchopneumonia and leptomeningitis. Brought with complaints of poor feeding, moderate fever associated with chills, and loose stools, was an 11-months-old patient with a known diagnosis of CAH. Symptoms have shown that the baby was in a possible adrenal crisis. He was intubated with an endotracheal tube after repeated episodes of seizures. Investigations revealed signs of bronchopneumonia and leptomeningitis. A thorough assessment, once completed, helped in analyzing relevant problems to be treated with respiratory therapy. Respiratory therapy, in this case, was aimed at improving the blood oxygen levels and assisting breathing by clearing out secretions and opening up the airways. Parent education was the foremost part of the treatment regime, followed by bronchodilator administration, conventional chest physiotherapy, postural drainage positions in the mother’s lap, lung squeezing technique, and perioral pressure. A holistic and multidisciplinary approach is beneficial in patients with CAH undergoing an adrenal crisis. It needs to be offered to the patients who would be benefited, considering the effect, which needs to be reassessed on specific outcomes with changes in the management with the improving condition.