Managing Asthma Exacerbations Research Articles

THE EFFECT OF MAGNESIUM SULFATE NEBULIZATION IN ACUTE EXACERBATION OF ASTHMA

Acute exacerbations of asthma are a significant public health challenge, particularly in resource-limited settings. Nebulized magnesium sulfate has shown potential as an adjunctive therapy in managing asthma exacerbations, but its effectiveness and safety in the Pakistani population remain underexplored. Objective: To evaluate the effectiveness and safety of nebulized magnesium sulfate in managing acute asthma exacerbations in a tertiary care hospital in Pakistan. Methods: A descriptive cross-sectional study was conducted among 200 participants with acute asthma exacerbations. Nebulized magnesium sulfate was administered as part of standard or adjunctive therapy. Symptom severity, including shortness of breath, wheezing, and chest tightness, was assessed before and after treatment. Data were analyzed using SPSS version 26, with descriptive statistics summarizing findings. Results: Significant symptom improvement was observed following treatment. The proportion of patients reporting mild shortness of breath increased from 0% to 40.5%, and mild wheezing from 0% to 62.0%. No adverse effects were reported, and 58.0% of participants rated the treatment as somewhat effective. Satisfaction levels were also high, with 58.5% somewhat satisfied and 21.0% very satisfied with the treatment. Conclusion: Nebulized magnesium sulfate is an effective and safe adjunctive therapy for acute asthma exacerbations. Its inclusion in treatment protocols can improve patient outcomes, particularly in resource-constrained healthcare settings. Further studies are warranted to develop standardized guidelines for its use.

Observational study of the Amaze™ asthma disease management platform.

Asthma is often inadequately controlled, which can result in exacerbations that lead to unplanned healthcare visits. Mobile application (app) use could help manage asthma exacerbations. We implemented the Amaze™ asthma disease management platform in clinical practice and assessed user satisfaction, usage, and usability. Adults with asthma and healthcare professionals (HCPs) were enrolled from a community allergy practice (ClinicalTrials.gov Identifier: NCT04901260) and a large academic hospital (ClinicalTrials.gov Identifier: NCT04868500). Primary and exploratory outcomes included assessment of platform design, patient app usage, patient-reported daily asthma status, emergency room/urgent care visits, and ease of implementation by HCPs. The system usability scale and a post-clinic visit survey were also administered. HCPs/staff monitored the Amaze dashboard to assess patient needs and completed a post-study survey. Overall, 159 patients and five HCPs participated in the study. Patients' mean (SD) age was 38.7 (16.4) years; most were female (78%) and White (78%). Mean patient app usage began at 3.6 days/week but declined to 1.0 day/week by the end of the study. Throughout the study, most daily entries (>69%) reported patient asthma status as "good." Most patients were satisfied/very satisfied with the app (66%) and reported it helped them during discussions with their HCP (44%). Most patients rated the usability of Amaze as "excellent" (49%) or "good" (30%). Most HCPs (71%) reported that Amaze was "very easy" to implement. Most patients and HCPs were satisfied with Amaze. The Amaze platform may help patients and HCPs monitor asthma status, which could improve asthma control.

A real-life comparative effectiveness study into the addition of antibiotics to the management of asthma exacerbations in primary care.

Asthma exacerbations are major contributors to asthma morbidity and mortality. They are usually managed with bronchodilators and oral corticosteroids (OCS), but clinical trial evidence suggests that antibiotics could be beneficial. We aimed to assess whether treatment of asthma exacerbations with antibiotics in addition to OCS improved outcomes in larger, more representative routine-care populations. A retrospective comparative effectiveness study into managing asthma exacerbations with OCS alone versus OCS plus antibiotics was conducted using the Optimum Patient Care Research Database. The dataset included 28 637 patients; following propensity score matching 20 024 adults and 4184 children were analysed. Antibiotics in addition to OCS were prescribed for the treatment of asthma exacerbations in 45% of adults and 32% of children. Compared to OCS alone, OCS plus antibiotics was associated with reduced risk of having an asthma/wheeze consultation in the following 2 weeks (children hazard ratio (HR) 0.84 (95% CI 0.73-0.96), p=0.012; adults HR 0.86 (95% CI 0.81-0.91), p<0.001), but an increase in risk of a further OCS prescription for a new/ongoing exacerbation within 6 weeks in adults (HR 1.11 (95% CI 1.01-1.21), p=0.030), but not children. Penicillins, but not macrolides, were associated with a reduction in the odds of a subsequent asthma/wheeze consultation compared to OCS alone, in both adults and children. Antibiotics were frequently prescribed in relation to asthma exacerbations, contrary to guideline recommendations. Overall, the routine addition of antibiotics to OCS in the management of asthma exacerbations appeared to confer little clinical benefit, especially when considering the risks of antibiotic overuse.

Oral corticosteroid prescription patterns for asthma in France, Germany, Italy and the UK.

Oral corticosteroids (OCS) are used to manage asthma exacerbations and severe, uncontrolled asthma, but OCS use is associated with adverse effects. We aimed to describe the patterns of OCS use in the real-world management of patients with asthma in western Europe.We used electronic medical records from databases in France, Germany, Italy and the United Kingdom from July 2011 through February 2018. Patients aged ≥12 years with an asthma diagnosis, at least one non-OCS asthma medication within ±6 months of diagnosis, and available data ≥6 months prior to and ≥90 days after cohort entry were included. High OCS use was defined as OCS ≥450 mg prescribed in a 90-day window during follow-up. Baseline characteristics and OCS use during follow-up were described overall and by OCS use status.Of 702 685 patients with asthma, 14–44% were OCS users and 6–9% were high OCS users at some point during follow-up. Annual prevalence of high OCS use across all countries was ∼3%. High OCS users had a mean of between one and three annual OCS prescriptions, with an average daily OCS dosage of 1.3–2.2 mg. For patients who continued to meet the high-use definition, daily OCS exposure was generally stable at 5.5–7.5 mg for ≥2 years, increasing the risk of adverse effects.Our study demonstrates that OCS use is relatively common across the four studied European countries. Data from this study may provide decisive clinical insights to inform primary care physicians and specialists involved in the management of severe, uncontrolled asthma.

ASSESSING THE BENEFITS OF HAVING A SPECIALIST PAEDIATRIC PHARMACIST AND PHYSIOTHERAPIST IN THE COMMUNITY TO IMPROVE CHILDHOOD ASTHMA OUTCOMES

IntroductionThe local Clinical Commissioning Group has funded an innovative one-year pilot project to assess the value of providing specialist paediatric pharmacist and physiotherapist support direct to families and health care...

Evaluating Caregiver Management of Asthma Exacerbations at Home

Abstract BACKGROUND: Effective management of asthma in the home setting requires asthma education from a health professional along with written plans for asthma exacerbations. These approaches can result in fewer acute asthma visits, fewer missed school days and better asthma control. Nevertheless, a large number of asthma exacerbations result in emergency department visits or hospital admission. Several studies suggest that care-givers may lack the knowledge, the skills, or the confidence to provide care for their child during an asthma exacerbation. OBJECTIVES: The objective of this study was to determine the proportion of caregivers who appropriately manage their child’s acute asthma at home (as per the 2014 Global Initiative for Asthma guidelines) and to identify factors that may be associated with deviations from these guidelines. DESIGN/METHODS: We studied caregivers of children who are known to suffer from asthma using a paper based questionnaire in a single-center outpatient asthma clinic. Caregivers of children aged 3 to 17 years with a physician made diagnosis of asthma greater than 6 months in duration were included. To avoid a diagnosis of bronchiolitis from our study group, new consultations for wheezing or cough without a prior diagnosis of asthma, and less than 3 years of age were excluded. For statistical analysis, we used Excel and STATA 11 for the z test of proportions and comparison of means with a one way ANOVA (a = 0.05). RESULTS: Among the 45 caregivers surveyed, most had children with well controlled asthma based on low scores from a standard asthma control test and a limited number of emergency room visits (1.5±0.1 per year). Sixty-four percent of caregivers were able to correctly identify the initial treatment with 2 puffs of Ventolin; however, 54% did not choose repeating Ventolin treatment within 20 minutes for ongoing symptoms. Moreover, only 58% of caregivers had ever been given a written asthma action plan. Caregivers had a higher degree of confidence (reported on a scale of 1-10) in initiating management (8.9±1.5) compared with stopping treatment (7.3±2.5). CONCLUSION: Despite a high degree of confidence in starting treatment for asthma attacks, half of the caregivers surveyed identified inappropriate steps to manage asthma exacerbations at home. Providing a written asthma action plan may improve caregiver confidence and knowledge in asthma exacerbation management. However, routine assessment and review by a healthcare professional is essential in reinforcing recommended behaviours for home asthma management.

Utility of FeNO Measurements for Family Physicians Managing Mildly Uncontrolled Asthma Patients

SESSION TITLE: Asthma Outcomes SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 25, 2015 at 07:30 AM - 08:30 AM PURPOSE: To evaluate the utility of FeNO, a measure of eosinophilic airway inflammation, for family physicians assessing patients with symptomatic asthma. METHODS: Asthma patients with symptoms despite their usual therapy were seen by their family physicians for management after submitting sputum for analysis of eosinophils, measurement of exhaled nitric oxide (FeNO), spirometry and completion of the Asthma Control Questionnaire(ACQ). The family physician was given the results of spirometry and peak flow (PEF) and the FeNO measurement with an accompanying algorithm to interpret the FeNO result (Taylor DR. Thorax 2006;61:817-27). They were blinded to the sputum eosinophil count. The patients were reassessed after three weeks and medication changes were recorded. The physicians completed a questionnaire evaluating the benefits of FeNO compared to symptoms, PEF/spirometry and how often they would use FeNO to manage asthma exacerbations. RESULTS: 33 patients(11 M, 22F) were assessed and completed the study. Successful sputum results were obtained in 82%, FeNO in 98%. Visit 1 mean FeNO was 37.4 ppb, eosinophils 10.5%. 15 subjects had >30 ppb FeNO and 17 had a ACQ > 1.5. At visit 2 the mean FeNO was 33.8 (13 had FeNO > 30), eosinophils 7.4% and 8 subjects had an ACQ >1.5. 30/33 had inhaled corticosteroids(ICS) prescribed at baseline but only 22/33 used them regularly. 18/33 had changes made in their ICS therapy: 12 increased their ICS dose, 5/12 were new starts and 6 had a decrease in dose, 4/6 stopped ICS. Overall 54.5% had changes made in their ICS therapy, the FeNO algorithm would have predicted a change in 54-61% of subjects. 42% of physicians found the FeNO extremely or very helpful compared to symptoms alone, only 25% when compared to spirometry or PEF. 52% of physicians would use the FeNO sometimes or often and 17% would use it most of the time (>75%) when treating exacerbations. CONCLUSIONS: The family physicians found FeNO measurements to be helpful in managing mild exacerbations of asthma, in particlular when compared to the use of symptoms alone. There were actual changes in ICS therapy in over 50% of patients with improvement in symptoms and markers of inflammation. The changes in ICS therapy by physicians correlated with suggested changes by a FeNO algorithm. CLINICAL IMPLICATIONS: The use of an FeNO is likely to be helpful in addition to clinical evaluation for family physicians to increase or decrease ICS therapy for patients with mild exacerbations of asthma. DISCLOSURE: The following authors have nothing to disclose: Mark Turner, Susan Attridge No Product/Research Disclosure Information

Inhaled Corticosteroid Prescribing From the Emergency Department for Children With Asthma

In the article "Frequency of Prescription of Inhaled Corticosteroids to Children With Asthma in U.S. Emergency Departments," the authors conducted a secondary data analysis from the National Hospital Ambulatory Medical Care Survey database to examine inhaled corticosteroid prescribing patterns of providers caring for children with asthma visiting emergency departments. We review and critique this article and use a case study module to illustrate the importance of the research findings and how they relate to practice in the emergency department in light of current national guidelines for managing asthma exacerbations.

Preventing Emergency Department Visits and Hospitalizations for Asthma by Use of Oral Corticosteroids at Home: Are We Adhering to National Guidelines?

Background: Oral corticosteroids (OCS) in the home management of asthma exacerbations have been recommended in the NIH/NHLBI guidelines since 1991. As a routine component of written action plans, OCS treatment at home is associated with reduced emergency department (ED) visits and hospitalizations as well as decreased mortality. Methods: A literature search of English language journals from 1991 to 2009 was performed using several databases, including PubMed, EMBASE, and SCOPUS. We assessed studies that evaluated adherence to national guidelines for home management of asthma exacerbations. Results: Our review of the literature found that several studies reveal that a small percentage (<3–26%) of patients are receiving OCS at home to manage asthma exacerbations prior to an ED visit. Additional studies were found showing very low use of written action plans, strongly suggesting lack of OCS for home management of asthma exacerbations. Conclusions: Despite evidence of reduced ED visits and hospitalizations and the recommendations of national and international guidelines, the home use of OCS in managing asthma exacerbations remains unacceptably low. New strategies are needed to ensure home use of OCS as part of written action plans to prevent ED visits and hospitalizations for asthma exacerbations.

Advances in pediatric asthma in 2009: Gaining control of childhood asthma

This year's summary will focus on recent advances in pediatric asthma as reported in Journal of Allergy and Clinical Immunology publications in 2009. New National Asthma Education and Prevention Program asthma guidelines were released in 2007, with a particular emphasis on asthma control. Now that we have worked with the principals of the guidelines for 2 years, new insights are reported on how to implement the guidelines into clinical practice. This year's report will focus on gaps in management that need to be addressed, including health disparities, methods to improve asthma management through opportunities available in school-based asthma programs, and more information on the development of asthma in childhood. This information brings us closer to the point of managing children with controllable asthma and understanding reasons why asthma is not controlled in the remaining children. If we can close these gaps through better communication, improvements in the health care system, and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children.

Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations

This article summarizes the recommendations regarding the management of asthma exacerbations presented in the Expert Panel Report 3 (EPR3). The evidence supporting these recommendations can be found in the report itself. All of the recommendations in this article are strong recommendations, unless indicated by the term conditional. Asthma exacerbations consist of acute or subacute episodes of progressively worsening shortness of breath, coughing, wheezing, and chest tightness or any combination thereof. These episodes differ from poor asthma control in that diurnal variability in airflow, a key marker of poor asthma control, might not change during an exacerbation. An important advance in the new National Asthma Education and Prevention Program (NAEPP) EPR3 guidelines is the creation of a chapter devoted to the management of asthma exacerbations. Moreover, the new EPR3 guidelines present different spirometry cut points for assessing the severity of acute asthma (exacerbations) versus chronic asthma. These and other changes underscore the distinction between acute and chronic asthma management. Two patient populations at particular risk during an asthma exacerbation include patients with 1 or more risk factors for asthma-related death (Table I) and infants, who are at greater risk

Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations

First Page

Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations

This article summarizes the recommendations regarding the management of asthma exacerbations presented in the Expert Panel Report 3 (EPR3). The evidence supporting these recommendations can be found in the report itself. All of the recommendations in this article are strong recommendations, unless indicated by the term conditional. Asthma exacerbations consist of acute or subacute episodes of progressively worsening shortness of breath, coughing, wheezing, and chest tightness or any combination thereof. These episodes differ from poor asthma control in that diurnal variability in airflow, a key marker of poor asthma control, might not change during an exacerbation. An important advance in the new National Asthma Education and Prevention Program (NAEPP) EPR3 guidelines is the creation of a chapter devoted to the management of asthma exacerbations. Moreover, the new EPR3 guidelines present different spirometry cut points for assessing the severity of acute asthma (exacerbations) versus chronic asthma. These and other changes underscore the distinction between acute and chronic asthma management. Two patient populations at particular risk during an asthma exacerbation include patients with 1 or more risk factors for asthma-related death (Table I) and infants, who are at greater risk

Formulating an Effective and Efficient Written Asthma Action Plan

Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician's busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.

Management of asthma exacerbations

The 1997 Expert Panel Report 2 from the National Asthma Education and Prevention Program details principles and goals for managing asthma exacerbations, based on scientific literature and the opinion of the panel. The panel's recommendations are summarized here, along with approaches to the evaluation and management of patients with asthma exacerbations. Methods to assess and classify the severity of asthma exacerbations are discussed, and treatment objectives for mild, moderate, and severe exacerbations are presented, along with a discussion of postinfectious acute airway hyperresponsiveness. A review of pharmacologic agents used in the treatment of asthma exacerbations is also included. Key points in the management of asthma exacerbations include the notion that early treatment is the best strategy for management. Important elements of early treatment include recognition of early signs of worsening asthma, a written action plan to guide patient self-management, appropriate intensification of therapy, and prompt communication between patient and provider about deterioration in asthma control. Other key points include the use of inhaled β 2-adrenergic agonists to provide prompt relief of airflow obstruction, the early use of systemic corticosteroids for patients with moderate to severe exacerbations or for patients who fail to respond promptly and completely to an inhaled f2-adrenergic agonist, and monitoring response to therapy with serial measurements of lung function.

Management of asthma exacerbations

The 1997 Expert Panel Report 2 from the National Asthma Education and Prevention Program details principles and goals for managing asthma exacerbations, based on scientific literature and the opinion of the panel. The panel's recommendations are summarized here, along with approaches to the evaluation and management of patients with asthma exacerbations. Methods to assess and classify the severity of asthma exacerbations are discussed, and treatment objectives for mild, moderate, and severe exacerbations are presented, along with a discussion of postinfectious acute airway hyperresponsiveness. A review of pharmacologic agents used in the treatment of asthma exacerbations is also included. Key points in the management of asthma exacerbations include the notion that early treatment is the best strategy for management. Important elements of early treatment include recognition of early signs of worsening asthma, a written action plan to guide patient self-management, appropriate intensification of therapy, and prompt communication between patient and provider about deterioration in asthma control. Other key points include the use of inhaled beta 2-adrenergic agonists to provide prompt relief of airflow obstruction, the early use of systemic corticosteroids for patients with moderate to severe exacerbations or for patients who fail to respond promptly and completely to an inhaled beta 2-adrenergic agonist, and monitoring response to therapy with serial measurements of lung function.

Recent innovations in asthma therapy.

Guidelines for the diagnosis and management of asthma have been published since 1990 and already new versions are being published. The recommendations for the treatment of asthma were organized around four components of effective asthma management: i) use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy, ii) environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or exacerbations, iii) comprehensive pharmacologic therapy for long-term management designed to reverse and prevent the airway inflammation characteristic of asthma as well as pharmacologic therapy to manage asthma exacerbations, and iv) patient education that fosters a partnership among the patient, family and clinicians. Newly released medications include anti-leukotriene (LTs) agents which function either by blocking the interaction of LTs with receptors (receptor antagonists) or by inhibiting leukotriene synthesis (synthesis inhibitors). Representatives of the antagonists discussed here are zafirlukast, pranlukast and montelukast. Zafirlukast (20 mg twice daily) improves pulmonary function indices and days without symptoms and decreases the asthma exacerbation frequency. Pranlukast, the first leukotriene receptor antagonist to be marketed, improves lung function and symptoms when 450 mg twice daily is used. A study with montelukast demonstrated similar positive results irrespective of the use of concomitant inhaled corticosteroid. This indicates that leukotriene receptor antagonists may have additive effects to steroid therapy. They may also be a potential alternative to inhaled steroids, although more studies need to be performed before defining the role of receptor antagonists in the treatment of asthma. Zileuton, a leukotriene synthesis inhibitor, has been shown to improve lung function, reduce symptoms and reduce use of beta-agonists and asthma exacerbations. These positive effects are dose-dependent and liver function abnormalities seem to be a relevant issue during zileuton use in some patients. Other compounds that inhibit LTs synthesis are in development and, like zileuton, need more tests. Phosphodiesterases (PDE), enzymes that break down cAMP and cGMP, have been a target for new compounds developed to treat asthma. Inhibition of PDE enzymes increases intracellular cAMP or cGMP which then produces bronchodilation. Recent studies have also shown antiinflammatory effects by suppressing some PDE isoenzymes, including PDE III and PDE IV. These effects were detected by studies in vitro and in animal models. Clinical trials are necessary to determine which PDE inhibitors can be useful for the treatment of asthma.