Severe Life-threatening Asthma Research Articles

Subcutaneous terbutaline as an alternative to metered-dose inhalers for asthma during the COVID-19 pandemic.

In a well-written and informative article, Whittle et al1 “Respiratory Support for Adult Patients with COVID-19,” correctly recommend against using nebulizer therapy for asthmatics and suggests metered-dose inhalers. During the COVID-19 epidemic, asthmatics will continue to have exacerbations, frequently requiring emergency room care in a physician's office, urgent care center, or emergency department of a hospital. It is recommended that asthmatic patients continue to be managed according to asthma guideline recommendations.2 Nebulizer use is discouraged unless essential during a pandemic because nebulized therapy is more likely to aerosolize SARS-CoV-2 and increase risk of contagion. As such, asthma therapy delivered by a metered-dose inhaler would be more appropriate in the healthcare setting.3 Nevertheless, some patients are so tight that using a metered-dose inhaler, even with a spacer, might be problematic, particularly if they have uncontrolled coughing, have severe life-threatening asthma, or those who are uncooperative or unable to follow directions required for the metered-dose inhaler, even with a spacer. A recent article4 demonstrated that, in a prospective study, 85 asthmatic patients treated with subcutaneous terbutaline significantly improved after already receiving multiple albuterol treatments with either nebulized aerosols or albuterol metered-dose inhalers. Advantages of terbutaline over epinephrine include: (1) a more pronounced effect with a longer duration of action on forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC),5 and (2) preferred over epinephrine in pregnancy.6 Terbutaline is inexpensive and readily accessible, even though a previous survey of physicians in the Cleveland area reveal that 98% of physicians rarely or never use subcutaneous terbutaline for an exacerbation of asthma.7 From a colleague in New York City reading about my work with terbutaline, “This is great! Not only that, but the feasibility of subcutaneous terbutaline as an administration route during a high-volume/war-like situation is underappreciated.” Additionally, the American College of Allergy, Asthma, and Immunology (ACAAI) has reported that some areas around the country are experiencing shortages in albuterol inhalers as a result of an increased demand, because hospitals are using inhalers rather than nebulizers to treat COVID-19 patients.8 Finally, although metered-dose inhalers frequently work, the use of subcutaneous terbutaline would obviate the need for these inhalers or aerosols.

Severe life-threatening asthma precipitated by a topical nonsteroidal anti-inflammatory drug

Severe life-threatening asthma precipitated by a topical nonsteroidal anti-inflammatory drug

Part 12: Cardiac Arrest in Special Situations

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

The use of neuromuscular blockers to facilitate mechanical ventilation in severe asthma

Ensuring adequate oxygenation and ventilation in patients with severe asthma can be challenging. Although no randomized trials have been performed, neuromuscular blockade is a useful adjunct in the care of severe life-threatening asthma with respiratory failure. Neuromuscular blockers can prevent respiratory dysynchrony, help lower peak pressures and allow longer expiratory times to reduce dynamic hyperinflation and its attendant risk of barotraumas and pneumothorax. Patients with severe life-threatening asthma and respiratory failure are often young, male and can be difficult to sedate.

Part 10.5: Near-Fatal Asthma

Asthma accounts for >2 million emergency department visits and 5000 to 6000 deaths annually in the United States, many occurring in the prehospital setting.1 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.2 This section focuses on the evaluation and treatment of patients with near-fatal asthma. The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Cardiac causes of death are less common. Wheezing is a common physical finding, but severity does not correlate with the degree of airway obstruction. The absence of wheezing may indicate critical airway obstruction, whereas increased wheezing may indicate a positive response to bronchodilator therapy. Oxygen saturation (Sao2) levels may not reflect progressive alveolar hypoventilation, particularly if O2 is being administered. Note that the Sao2 may initially fall during therapy because β-agonists produce both bronchodilation and vasodilation and may initially increase intrapulmonary shunting. Other causes of wheezing are pulmonary edema, chronic obstructive pulmonary disease (COPD), pneumonia, anaphylaxis,3 foreign bodies, pulmonary embolism, bronchiectasis, and subglottic mass.4 Patients with severe life-threatening asthma require urgent and aggressive treatment with simultaneous administration of oxygen, bronchodilators, and steroids. Healthcare providers must monitor these patients closely for deterioration. Although the pathophysiology of life-threatening asthma consists of bronchoconstriction, inflammation, and mucous impaction, only bronchoconstriction and inflammation are amenable to drug treatment. If the patient does not respond to therapy, consultation or transfer to a pulmonologist or intensivist is appropriate. ### Primary Therapy #### Oxygen Provide oxygen to all patients with severe asthma, even those with normal oxygenation. Titrate to maintain Sao2 >92%. As noted above, successful …

Case-control study of severe life threatening asthma (SLTA) in adults: psychological factors

Background: Severe life threatening asthma (SLTA) is important in its own right and as a proxy for asthma death. In order to target hospital based intervention strategies to those most...

Beyond Our Pages

Beyond Our Pages

Case-control study of severe life threatening asthma (SLTA) in adults: demographics, health care, and management of the acute attack

BACKGROUNDSevere life threatening asthma (SLTA) is important in its own right and as a proxy for asthma death. In order to target hospital based intervention strategies to those most likely...

Rapid onset asthma: a severe but uncommon manifestation

BACKGROUNDStudies of asthma death and severe life threatening asthma (SLTA) include reports of patients who had rapid onset asthma. A study was undertaken to determine the relative frequency of rapid...

Fenoterol does not increase risk of severe life-threatening asthma

Fenoterol does not increase risk of severe life-threatening asthma

Fenoterol does not increase risk of severe life-threatening asthma

Fenoterol does not increase risk of severe life-threatening asthma

Intravenous magnesium sulfate in acute, life-threatening asthma

Magnesium, a physiologic calcium antagonist, is known to have a direct effect on calcium uptake in smooth muscle, resulting in smooth muscle relaxation. Studies of magnesium sulfate infusions in patients with mild or moderate-to-severe acute asthma have shown that it may have a significant bronchodilatory effect, similar to that of salbutamol (albuterol). We present the case of a patient with acute severe life-threatening asthma (initially in cardiorespiratory arrest) who responded to an IV infusion of magnesium sulfate after aggressive pharmacologic management failed to result in clinical improvement.

Letter: Intracardiac short circuit.

<b>Background:</b> Distinct risk factors for asthma death have not been identified in developing communities. This study was conducted to distinguish risk factors for severe life threatening asthma (SLTA), a proxy for asthma death, in a developing country. <b>Methods:</b> A case-control study was performed at a University Hospital serving developing communities in the Western Cape Province, South Africa, over the period October 1997 to April 2000. Thirty consecutive patients with SLTA admitted to the intensive care unit (ICU) were compared with 60 chronic asthmatic patients, without a history of SLTA, who had attended the hospital outpatient respiratory clinic over the same period. <b>Results:</b> The risk of SLTA in comparison with controls increased with female sex (odds ratio (OR) 3.3, 95% CI 1.2 to 9.6, p = 0.02), rural residence (OR 8.1, 95% CI 2.6 to 25.3, p = 0.0005), and absence of a formal income (OR 5.7, 95% CI 2 to 16.6, p = 0.002). Cases were more likely to have had more than one hospital admission in the previous year (OR 8, 95% CI 2.5 to 25.2, p = 0.0009) and more than one emergency room visit in the previous year (OR 4.4, 95% CI 1.19 to 16.4, p = 0.04). Patients with SLTA were less likely to use inhaled corticosteroids (OR 5.6, 95% CI 1.9 to 16.5, p = 0.003) and more likely to use inhaled fenoterol (OR 6, 95% CI 2.2 to 16.2, p = 0.0004). Patients with SLTA also had lower mean (SE) forced expiratory volume in 1 second (FEV₁) measurements (66.9 (9.5)% predicted <i>v</i> 82.5 (4.0)% predicted; p = 0.03) and lower FEV₁/FVC ratios (60.7 (4.1)% predicted <i>v</i> 69.6 (1.9)% predicted; p = 0.05) documented before the episode of SLTA. <b>Conclusions:</b> Risk factors for SLTA that are mainly analogous to those distinguished in other environments have been identified in a geographical area characterised by a third world socioeconomic context. Rural residence and poverty may increase the risk of SLTA.