Management Of Acute Asthma Exacerbations Research Articles

Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit

Managing acute asthma exacerbations in critical care can be challenging and may lead to adverse outcomes. While standard management of an acute asthma exacerbation is well established in outpatient and emergency department settings, the management pathway for patients with life-threatening and near-fatal asthma still needs to be fully defined. The use of specific interventions such as intravenous ketamine, intravenous salbutamol, and intravenous methylxanthines, which are often used in combination to improve bronchodilation, remains a contentious issue. Additionally, although it is common in the intensive care unit setting, the use of non-invasive ventilation to avoid invasive mechanical ventilation needs further exploration. In this review, we aim to provide a comprehensive overview of the available treatments and the evidence for their use in intensive care. We highlight the ongoing need for multicentre trials to address clinical knowledge gaps and the development of intensive-care-based guidelines to provide an evidence-based approach to patient management.

Role of peak expiratory flow in the assessment and management of asthma in children

Peak expiratory flow (PEF) is a portable, reliable, and inexpensive method for lung function assessment. PEF can reflect expiratory airflow limitation and its variability can document reversibility, which provides an objective basis for the diagnosis of asthma in children. Short-term PEF monitoring can be an important aid in the management of acute asthma exacerbations, identification of possible triggers, and assessment of response to treatment. Long-term PEF monitoring can assist in the assessment of asthma control and warning of acute exacerbations, and this is useful for children with severe asthma. This article reviews the measurements, influencing factors, interpretation, and application of PEF, and its role in the diagnosis and management of asthma in children, to provide references for the clinical application of PEF in children.

A Retrospective Audit of Pharmacologic and Non-Pharmacologic Management of Childhood Acute Asthma Exacerbation at Usmanu Danfodiyo University Teaching Hospital, Sokoto: Adherence to Global Treatment Guidelines.

BackgroundAdequate management of childhood acute asthma exacerbation requires optimal non-pharmacotherapy and pharmacotherapy. Global asthma guidelines provide critical information and serves as a quick reference decision-support material for clinicians.ObjectivesWe aimed at evaluating hospital management of childhood acute asthma exacerbation to ascertain its conformity to the global treatment guidelines, and to identify factors that predict short or prolonged observation in the hospital.MethodThis was a retrospective audit of the management of acute asthma exacerbation in children seen between 01 January 2017 and 31 December 2018 at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Relevant data on demography, asthma triggers and severity, functional and clinical diagnoses, types of controller medications used before and after presentation, non-pharmacotherapy and pharmacotherapy instituted during presentation, duration of observation in the hospital, and treatment outcomes were extracted from the case file of each eligible patient.ResultsA total of 119 children presented with features of suspected acute asthma exacerbations during the study period but only 63 (52.9%) that met the inclusion criteria for the study were included for analysis. The 63 children that were evaluated had mild (47; 74.6%) and moderate (16; 25.4%) acute asthma exacerbations. Their median (interquartile range) age was 8 (5–15) years. More males (36; 57.1%) than females (27; 42.9%) presented with features of the condition. Majority (50; 79.8%) of the patients had at least one trigger factor and of the 73 trigger factors reported, cold weather (19; 26.0%) was the commonest. Nebulized salbutamol (48; 76.5%), in addition to intravenous (23; 57.9%) and oral (17; 42.5%) corticosteroids, was used during hospital treatment. Patients were discharged mostly on short course of oral corticosteroid only (37; 58.8%). Of the 17 major recommendations in the Global Initiative for Asthma (GINA) guidelines, good (5; 29.4%), moderate (7; 41.2%), and poor (5; 29.4%) levels of adherence were observed. Specifically, moderate and poor levels of adherence were observed in the management of 61(96.8%) and 2(3.2%) patients, respectively. The odds of admission for ≤12 h were higher for female children and patients with mild cases.ConclusionGood and moderate adherence levels to 12 of the 17 GINA recommendations were observed in our center. Nonetheless, reinforcement of institutional guidelines for acute asthma management is suggested to further improve the quality of care of childhood acute asthma exacerbations.

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children

Objective Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations. Methods PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence. Results A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone. Conclusion There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.

Role of Inhaled Corticosteroids for Asthma Exacerbation in Children: An Updated Meta-Analysis.

Background:Several studies showed that inhaled corticosteroids (ICS) may be a potential treatment in acute asthma exacerbation in children. This study was an update meta-analysis on the roles of ICS in the management of acute asthma exacerbation in children presenting to the hospital.Materials and Methods:Published articles with key words of ICS for asthma exacerbation, asthma attacks, and acute asthma in children aged under 18 years in the hospital setting with outcome of hospital admission between 2009 and 2018 were enrolled. The databases used in this study were Medline, Scopus, and Web of Science. Odds ratio of comparison between ICS and other treatments on hospital admissions was calculated.Results:There were 311 eligible studies met the searching criteria; seven eligible studies for the analysis; comprised of three meta-analysis and four added studies. The ICS had a significant reduction in hospital admission compared with placebo in overall with odds ratio of 0.63 (95% confidence interval [CI]: 0.41–0.96) and in moderate-to-severe group with odds ratio of 0.17 (95% CI: 0.05–0.51). Comparing with systemic corticosteroid (SC), ICS had significantly lower hospital admissions overall and in mild-to-moderate group with odds ratios of 0.63 and 0.26, respectively. The combination of ICS and SC had odds ratio of 0.75 (95% CI: 0.57–0.99) over SC in moderate-to-severe asthma exacerbation.Conclusions:ICS significantly reduced hospital admission in asthma exacerbation in children. It may be used alone for mild-to-moderate asthma exacerbation and combination with SC for moderate-to-severe asthma exacerbation.

Influence of HIV status on the management of acute asthma exacerbations

BackgroundAn increased incidence of asthma has been suggested in patients with HIV. We aimed to compare the outcomes of HIV-positive and HIV-negative patients following hospital admission for asthma exacerbation.MethodsA retrospective...

Omalizumab as alternative to chronic use of oral corticosteroids in severe asthma.

Systemic/oral corticosteroids (OCS) have been used for decades in the management of acute asthma exacerbations and chronically in patients with uncontrolled severe asthma. However, while OCS are effective at treating acute exacerbations, there is only empirical evidence regarding the efficacy of OCS at reducing the rate of exacerbations. Evidence, although scarce, is suggestive of high exacerbation rates in severe asthma patients even when receiving maintenance treatment with OCS. In addition, use of OCS is associated with undesirable effects. Despite all this, physicians have continued to use OCS for managing severe asthma and acute exacerbation due to the lack of availability of effective alternatives. Fortunately, in the last decade several biologics have been proven safe and effective for patients with uncontrolled severe asthma. This has led to the Global Initiative for Asthma (GINA) recommending the use of biologics, instead of maintenance OCS, in patients with severe asthma (GINA Step 5). These include one biologic targeting immunoglobulin E (IgE) (omalizumab), and different biologics targeting interleukin-5 (IL-5), the IL-5 receptor (IL-5R) or IL-4 receptor α-unit (IL-4R α), including mepolizumab (subcutaneous), reslizumab (intravenous), benralizumab (subcutaneous) and dupilumab (subcutaneous). Omalizumab for the treatment of severe allergic asthma reduces exacerbations, irrespective of blood eosinophil levels. Anti-IL-5/IL-5R biologics are indicated in patients with severe eosinophilic asthma and repetitive exacerbations, irrespective of the presence or absence of allergy. Recently, an anti-IL4Rα biologic has been approved by the FDA for eosinophilic phenotype or oral corticosteroid-dependent asthma. Finally, physicians should consider using biologics as an alternative to chronic OCS therapy.

Ohio Pediatric Asthma Repository: Opportunities to Revise Care Practices to Decrease Time to Physiologic Readiness for Discharge.

Large-scale, multisite studies in which researchers evaluate patient- and systems-level factors associated with pediatric asthma exacerbation outcomes are lacking. We sought to investigate patient-level risks and system-level practices related to physiologic readiness for discharge (PRD) in the prospective Ohio Pediatric Asthma Repository. Participants were children ages 2 to 17 years admitted to an Ohio Pediatric Asthma Repository hospital for asthma exacerbation. Demographics, disease characteristics, and individual hospital practices were collected. The primary outcome was PRD timing (hours from admission or emergency department [ED] presentation until the first 4-hour albuterol spacing). Data for 1005 participants were available (865 ED presentations). Several nonstandard care practices were associated with time to PRD (P < .001). Continuous pulse oximetry was associated with increased time to PRD (P = .004). ED dexamethasone administration was associated with decreased time to PRD (P < .001) and less ICU admittance and intravenous steroid use (P < .0001). Earlier receipt of chest radiograph, antibiotics, and intravenous steroids was associated with shorter time to PRD (P < .05). Care practices associated with shorter time to PRD varied markedly by hospital. Substantial variation in care practices for inpatient asthma treatment exists among children's hospital systems in Ohio. We found several modifiable, system-level factors and therapies that contribute to PRD that warrant further investigation to identify the best and safest care practices. We also found that there was no standardized measure of exacerbation severity used across the hospitals. The development of such a tool is a critical gap in current practice and is needed to enable definitive comparative effectiveness studies of the management of acute asthma exacerbation.

Implementation of a Two-tiered Asthma Protocol Improves Management of Acute Asthma Exacerbations in a Pediatric Urgent Care Center

Implementation of a Two-tiered Asthma Protocol Improves Management of Acute Asthma Exacerbations in a Pediatric Urgent Care Center

Management of acute asthma exacerbations.

Herein, we review the current guidelines for the management of children with an acute asthma exacerbation. We focus on management in the emergency department, inpatient, and ICU settings. The most recent statistics show that the prevalence of asthma during childhood has decreased in certain demographic subgroups and plateaued in other subgroups. However, acute asthma accounts for significant healthcare expenditures. Although there are few, if any, newer therapeutic agents available for management of acute asthma exacerbations, several reports leveraging quality improvement science have shown significant reductions in costs of care as well as improvements in outcome. Asthma is one of the most common chronic conditions in children and the most common reason that children are admitted to the hospital. Nevertheless, the evidence to support specific agents in the management of acute asthma exacerbations is surprisingly limited. The management of acute exacerbations focuses on reversal of bronchospasm, correction of hypoxia, and prevention of relapse and recurrence. Second-tier and third-tier agents are infrequently used outside of the ICU setting. Reducing the variation in treatment is likely to lead to lower costs and better outcomes.

Physician and parent barriers to the use of oral corticosteroids for the prevention of paediatric URTI-induced acute asthma exacerbations at home.

Administration of oral corticosteroids at the onset of an upper respiratory tract infection (URTI) can be effective in the management of acute asthma exacerbations in children. This study was designed to identify barriers to parent-initiated implementation of clinical practice guideline-recommended use of oral corticosteroids for prophylaxis against severe asthma exacerbations in children. Twenty-seven children who presented to BC Children's Hospital with URTI-induced asthma exacerbations were recruited. Parents received a filled prescription for a course of oral corticosteroids to be used at the earliest onset of their child's next URTI. Each family was contacted monthly over a 1-year period to inquire about URTI events, asthma symptoms, medication use and health care utilization. Focus groups were held with family physicians, paediatricians and parents; transcripts were analyzed qualitatively to identify key themes. Incidence of URTI events among participants was high (85%). Uptake of study medication was low; 44% used the medication as directed at their first URTI event. Eleven per cent of the patients who used the study medication also visited the emergency department for an exacerbation. Focus groups identified four main barriers to the effective use of parent-initiated oral corticosteroids: physician resistance and conflicting messages from providers; parent uncertainty about oral corticosteroids; multiple caregivers and relative ease of access to an emergency department. We have identified key barriers to the effective use of parent-administered oral corticosteroids as an asthma management strategy and gained important insights regarding the research that is required to enhance the applicability of the strategy.

Improving childcare staff management of acute asthma exacerbation – An Australian pilot study

ABSTRACTObjective: This study aimed to evaluate the effectiveness of an asthma first-aid training tool for childcare staff in Australia. The effects of training on both asthma knowledge and skills were assessed. Methods: A pre/post-study design was utilised to assess changes in asthma knowledge and asthma first-aid skills in childcare staff before and after an educational intervention. Asthma first-aid skills were assessed from the participant's response to two scenarios in which a child was having a severe exacerbation of asthma. Asthma knowledge and asthma skills scores were collected at base-line and 3 weeks post the education session, which involved feedback on each individual's skills and a brief lecture on asthma delivered via PowerPoint presentation. Results: There was a significant improvement after intervention in asthma knowledge (Z = −3.638, p < 0.001) and asthma first-aid skills for both scenario 1 (Z = −6.012, p < 0.001) and scenario 2 (Z = −6.018, p < 0.001). In scenario 1 and 2, first-aid skills improved by 65% (p < 0.001) and 57% (p < 0.001), respectively. Asthma knowledge was high at baseline (79%) and increased by 7% (p < 0.001) after the educational intervention. These asthma knowledge results were not significant when adjusted for prior knowledge. Results suggest that knowledge assessment alone may not predict the practical skills needed for asthma first-aid. Conclusions: Skills assessment is a useful adjunct to knowledge assessment when gauging the ability of childcare staff to manage acute asthma exacerbation. Skills assessment could be considered for incorporation into future educational interventions to improve management of acute asthma exacerbation.

Factors Affecting Recovery Time of Pulmonary Function in Hospitalized Patients With Acute Asthma Exacerbations.

PurposeProlonged recovery time of pulmonary function after an asthma exacerbation is a significant burden on asthmatics, and management of these patients needs to be improved. The aim of this study was to evaluate factors associated with a longer recovery time of pulmonary function among asthmatic patients hospitalized due to a severe asthma exacerbation.MethodsWe retrospectively reviewed the medical records of 89 patients who were admitted for the management of acute asthma exacerbations. The recovery time of pulmonary function was defined as the time from the date each patient initially received treatment for asthma exacerbations to the date the patient reached his or her previous best FEV1% value. We investigated the influence of various clinical and laboratory factors on the recovery time.ResultsThe median recovery time of the patients was 1.7 weeks. Multiple linear regression analysis revealed that using regular inhaled corticosteroids (ICS) before an acute exacerbation of asthma and concurrent with viral infection at admission were associated with the prolonged recovery time of pulmonary function.ConclusionsThe prolonged recovery time of pulmonary function after a severe asthma exacerbation was not shown to be directly associated with poor adherence to ICS. Therefore the results indicate that an unknown subtype of asthma may be associated with the prolonged recovery of pulmonary function time after an acute exacerbation of asthma despite regular ICS use. Further prospective studies to investigate factors affecting the recovery time of pulmonary function after an asthma exacerbation are warranted.

Management of acute asthma exacerbations.

Acute asthma exacerbations are common events in the lives of asthmatics, and even the best-managed asthma patients will have acute asthma exacerbations. There are different levels of severity of exacerbations with corresponding management strategies the physician can use to treat acute events. These strategies, including some adjunctive therapies, are reviewed in this article. A review of the English-language scientific literature was performed regarding management of acute asthma exacerbations, focusing of published guidelines, meta-analyses, and database reviews. Symptoms of exacerbations are reviewed with attention to determining the severity of the exacerbation and the place of management, either at home or in a more acute care setting. Medical therapies for the treatment of each severity level are reviewed as to their effectiveness. Post-exacerbation care is also discussed. Asthma exacerbations will happen and both the provider and patient need to be educated on how to manage these occurrences. Whether the patient is managed at home or in a hospital setting will be determined by the level of severity. Regardless of the medical therapies employed, continued focus should be on further prevention of additional exacerbations.

Improving asthma care

The RCN Learning Zone is a FREE online service to help RCN members with their continuing professional development and professional portfolio management. The RCN Learning Zone can be found at www.rcn.org.uk/members/learningzone.php This practice profile is based on NS689 Hazeldine V (2013) Pharmacological management of acute asthma exacerbations in adults. Nursing Standard. 27, 33, 43-49. I care for many people with coexisting conditions, including asthma, in a nursing and residential care home. The CPD article helped me to change practice in this setting. Although the prevalence of asthma is slowly declining, it affects an estimated 3.8 million people in the UK. There have been advances in diagnosing and managing asthma, but exacerbations remain a problem, and early recognition of such exacerbations can save lives. Where I work, several service users experience asthma and other respiratory pathologies. All service users are monitored regularly using the National Early Warning Score (NEWS) observation chart, which includes temperature, pulse, blood pressure, respiratory rate, peripheral oxygen level and consciousness measurements. These parameters are measured routinely in the nursing and residential care home and recorded on clinical charts. It was interesting to read that the signs and symptoms of an acute asthma exacerbation can include cough, wheeze, dyspnoea, chest tightness and variable airflow obstruction. Patients with asthma and other respiratory conditions could be monitored more effectively using a peak expiratory flow (PEF) meter. PEF meters are low cost, portable, and easy to use. Using this meter, along with the NEWS observations, allows for greater monitoring of asthma and other respiratory conditions. Individuals with asthma ideally require a recorded PEF from within the last two years for comparison purposes. This would help nurses to determine if a service user was experiencing an acute asthma exacerbation. A series of PEF readings were taken for service users, initially only for those with asthma, to record baseline levels. PEF can be used with a traffic light system, and this is how it is used at the care home: Red (danger) – PEF less than 50% of the individual’s personal best indicates a medical alert. Advice should be obtained as soon as possible. At the care home, the service user’s GP or nurse practitioner responds as appropriate. Yellow (caution) – PEF 50-79% of the individual’s personal best indicates that the asthma is worsening. Medical review of the service user should be obtained. At the care home, the GP or nurse practitioner responds as appropriate. Green (safe) – PEF 80-100% of the individual’s personal best indicates that the asthma is under control and that the person should continue to be monitored. The rapid assessment of a service user during an asthma exacerbation is important. At the care home, individuals with asthma usually only develop exacerbations when they have an acute illness, such as a chest infection or pneumonia. Monitoring PEF and using the NEWS observation chart will help to improve the care I give NS

Pneumatosis intestinalis complicated by pneumoperitoneum in a patient with asthma.

Pneumatosis intestinalis (PI) is a very rare condition that is defined as the presence of gas within the subserosal or submucosal layer of the bowel. PI has been described in association with a variety of conditions including gastrointestinal tract disorders, pulmonary diseases, connective tissue disorders, organ transplantation, leukemia, and various immunodeficiency states. We report a rare case of a 74-year-old woman who complained of dyspnea during the management of acute asthma exacerbation and developed PI; but, it improved without any treatment.

Pharmacological management of acute asthma exacerbations in adults

Acute exacerbations of asthma can be life threatening. This article provides an overview of the pathophysiology, diagnosis and management of acute severe asthma in adults. An understanding of the signs and symptoms of the disorder, and treatment options will ensure rapid decision making when time is crucial during an exacerbation. A proactive approach to managing acute severe asthma may substantially improve patient outcomes and reduce the need for readmission to hospital.

Parental Preference for Short- Versus Long-Course Corticosteroid Therapy in Children With Asthma Presenting to the Pediatric Emergency Department

Asthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (ED). We aimed to determine parental preference between short- and long-term courses of oral corticosteroids for use in children with mild to moderate asthma presenting to our pediatric ED with acute asthma exacerbations. We surveyed parents of asthmatic children who presented to our pediatric ED from August 2011 to April 2012. Questions characterized each patient's asthma severity, assessed parental preference among systemic steroid and inhaled medication delivery options for acute asthma management, and inquired about compliance, medication costs, and intention to follow up. The majority of our parents prefer the use of 1 to 2 days of steroids to 5 days for acute asthma exacerbations in the ED. Thus, dexamethasone is an attractive alternative to prednisone/prednisolone and should be considered in the management of acute asthma exacerbations in the ED.

Continuing Professional Development: Epinephrine and its use in acute life-threatening asthma in adults

Overview This CPD module, will act as revision of existing treatments for acute asthma exacerbations, as well as discussing the indications for use of epinephrine in asthma and the potential problems you may encounter with its use. Although epinephrine has been used for many years in other medical emergencies, such as anaphylaxis, is not widely used for asthma exacerbations. This module will discuss a number of different methods for the delivery of epinephrine; however it should be appreciated that not all of these routes are suitable for use in asthma. You will also have the opportunity to reflect and consolidate your existing clinical knowledge of epinephrine, as well as providing a basis for further learning about the pre-hospital management of acute asthma exacerbations. There are a number of resources available through the ‘Journal of Paramedic Practice’, and other guidelines and information available to supplement your learning; in particular from the British Thoracic Society, Scottish Intercollegiate Guidelines Network and Joint Royal Colleges Ambulance Liaison Committee. Learning Outcomes After completing this module you will: • Describe and use the clinical findings with which to determine the severity of an asthma exacerbation. • Understand that asthma is a condition with a significant mortality rate, and patients can rapidly deteriorate without appropriate resuscitation. • Understand the different pharmacological treatments in acute asthma, and their uses in current guidelines and protocols. • Appreciate the emerging role of epinephrine in pre-hospital practice and the different routes by which it can be given. • Identity and reflect upon personal areas of concerns in the pre-hospital management of acute asthma exacerbations.

Clinical Usefulness of Asthma Clinical Pathway for Management of Acute Asthmatic Children in Pediatric Emergency Department

The use of the asthma clinical pathway (CP) for asthma management may ensure appropriate treatment for patients. We evaluated the impact of the asthma CP on the management of acute asthma exacerbation in the emergency department (ED) of our hospital in Korea. We conducted a retrospective before-after study on the CP. The patients included children aged 3-15 years who presented with acute asthma exacerbation at our ED. The CP based on the 2006 GINA guidelines was implemented in 2008, whereas the strategy used in 2007 was not a standardized one. Of the forty eight patients in 2008, 3 were hospitalized (6.3%; post-implementation); 7 of 53 patients in 2007 were hospitalized (13.2%; pre-implementation; P > 0.05). According to the results of outpatient observation, the continuation of wheezing decreased from 12 of 21 patients in 2007 (57.1%) to 7 of 22 patients in 2008 (31.8%; P < 0.05), and the administration of relievers decreased from 9 of 21 patients in 2007 (42.9%) to 5 of 22 patients in 2008 (22.7%; P < 0.05). The CP was successfully implemented in the ED of a Korean hospital, and reduced wheezing and administration of relievers was noted in outpatient observations.