Severe Status Asthmaticus Research Articles

Outcomes in patients who received ECMO and/or volatile anesthetics as rescue therapies for status asthmaticus

Background: In the state of Kentucky many status asthmaticus (SA) patients require care in the Pediatric Intensive Care Unit (PICU) and a fraction of these patients may receive “rescue therapies” with inhaled volatile anesthetics (IVA) and/or Extracorporeal Membrane Oxygenation (ECMO). Our objective was to compare the clinical parameters of individual patients who received either or both therapies. Methods: Children between 2-18 years of age admitted to our PICU from January 2014- July 2020 with SA were reviewed categorized as 1) patients who received IVA alone 2) patients who received IVA and then subsequently ECMO and 3) patients on ECMO alone. Results: 1772 children with SA episodes were identified with a mortality of 13 patients. 7 children with SA were identified who received either IVA, ECMO or both. One patient received only IVA, 5 received both IVA and ECMO and one received only ECMO. All received standard asthma therapies of steroids, albuterol, magnesium sulphate and aminophylline prior to escalation. Six out of seven refractory SA received IVA, and five (83%) of those were subsequently escalated to ECMO. pCO2 levels had no improvement after IVA administration but decreased by an average of 20 points after ECMO. Patients peak inspiratory pressures decreased within the 1 st 24 hours of ECMO cannulation from a mean of 30 to 18. There were no other complications related to ECMO placement. Conclusion: While we cannot decisively draw any conclusions from our study due to small sample, it was noted that there was no clear advantage of using IVA prior to ECMO in our patients. Most patients who received IVA were escalated to ECMO indicating that early ECMO cannulation may be beneficial. Given the high cost and potential complications of both, there is a need for the development of well-defined guidelines for severe SA management in the PICU.

Differences and similarities in severe bronchiolitis and status asthmaticus

Bronchiolitis and status asthmaticus are common diagnoses encountered in the pediatric intensive care unit setting with overlapping clinical manifestations that can create perplexity in treatment following hospital admission. While there are clear first-line therapies for each of these medical conditions, the use of adjunct therapies has been inconsistent and more dependent on provider preference at times. In this review, a brief introduction to the epidemiology, clinical presentation, and diagnosis allows for a review of proposed therapies to highlight the distinctions between these two entities.

Near fatal asthma: Acute effect of omalizumab in paediatric patient undergoing extracorporeal carbon dioxide removal (ECCO2R)

Objective: status asthmaticus not responsive to therapy are not a prerogative of severe asthma. We report the case of a severe status asthmaticus refractory to medical therapy, undergoing Invasive Mechanical Ventilation (IMV) and extra-corporeal carbon dioxide removal

Standardized Protocol Is Associated With a Decrease in Continuous Albuterol Use and Length of Stay in Critical Status Asthmaticus.

The primary aim of this study was to reduce duration of continuous albuterol and hospital length of stay in critically ill children with severe status asthmaticus. Observational prospective study from September 2012 to May 2016. Medicine ICU and intermediate care unit. Children greater than 2 years old with admission diagnosis of status asthmaticus admitted on continuous albuterol and managed via a standardized protocol. The protocol was an iterative algorithm for escalation and weaning of therapy. The algorithm underwent three revisions. Iteration 1 concentrated on reducing duration on continuous albuterol; iteration 2 concentrated on reducing hospital length of stay; and iteration 3 concentrated on reducing helium-oxygen delivered continuous albuterol. Balancing measures included adverse events and readmissions. Three-hundred eighty-five patients were treated as follows: 123, 138, and 124 in iterations 1, 2, and 3, respectively. Baseline data was gathered from an additional 150 patients prior to protocol implementation. There was no difference in median age (6 vs 8 vs 7 vs 7 yr; p = 0.130), asthma severity score (9 vs 9 vs 9 vs 9; p = 0.073), or female gender (42% vs 41% vs 43% vs 48%; p = 0.757). Using statistical process control charts, the mean duration on continuous albuterol decreased from 24.9 to 17.5 hours and the mean hospital length of stay decreased from 76 to 49 hours. There was no difference in adverse events (0% vs 1% vs 4% vs 0%; p = 0.054) nor in readmissions (0% vs 0% vs 1% vs 2%; p = 0.254). Implementation of a quality improvement protocol in critically ill patients with status asthmaticus was associated with a decrease in continuous albuterol duration and hospital length of stay.

Enoximone in status asthmaticus

In a patient with severe status asthmaticus, enoximone, a phosphodiesterase-3 inhibitor, caused immediate bronchodilation http://bit.ly/38UYpUn

Safety of prolonged magnesium sulphate infusions during treatment for severe paediatric status asthmaticus

Safety of prolonged magnesium sulphate infusions during treatment for severe paediatric status asthmaticus

Safety of prolonged magnesium sulfate infusions during treatment for severe pediatric status asthmaticus.

Magnesium sulfate (Mg) is one of several "second-tier" therapies for treating severe status asthmaticus. Pediatric reports primarily describe bolus use with limited data regarding prolonged infusions. We sought to describe the safety of prolonged Mg infusions during therapy of status asthmaticus in critically ill children. Single center, retrospective study. Thirty-four-bed tertiary level medical/surgical/cardiac surgical pediatric intensive care unit. Pediatric patients 2 to 18 years of age admitted with status asthmaticus receiving Mg infusion for more than 24 hours. None. A total of 154 children received Mg infusions for a median of 53.4 hours (interquartile range = 36.6-74.8). The most common adverse event (AE) was hypotension (48.1%), almost exclusively diastolic (94%), and was mostly limited to 1 blood pressure measurement (78%). 2.9% of events required intervention (fluids, decrease Mg infusion). Other AEs included nausea/emesis (22.7%), transient weakness (14.9%), and flushing (6.5%). Five patients experienced serious AEs including hypotonia (n = 1), escalation to continuous or bilevel positive airway pressure (n = 3), and sedation (n = 1), all attributed to progression of underlying medical disease. No patient required endotracheal intubation. Supratherapeutic levels (>6 mg/dL) were uncommon (2%) and were not more likely to be associated with AEs. Most (81%) patients were therapeutic by the 2nd Mg level check. Prolonged Mg infusions were well tolerated in pediatric status asthmaticus patients. While diastolic hypotension was not uncommon, rarely were interventions deemed necessary. No serious AEs were attributed to Mg. Toxicity was uncommon suggesting that Mg levels could potentially be checked less frequently than historically reported.

Status asthmaticus requiring extracorporeal membrane oxygenation associated with rhinovirus infection

Objective: Evolving research links human rhinovirus (HRV) with status asthmaticus (SA) as well as severe respiratory illness in patients with atopy and asthma. This case series reviews five episodes of HRV-associated SA that required extracorporeal membrane oxygenation (ECMO). Methods: Charts of four patients, five total episodes of ECMO, with SA secondary to HRV were reviewed in this IRB-approved case series. Outcomes included demographic information, past medical history, clinical parameters and spirometry. Results: Patients (three male, one female), mean age 9 years (range 7–12 years) at the time of admission, were African American, on Medicaid, carried a diagnosis of persistent asthma, and had documented non-adherence to prescribed, daily controller medications. One patient had passive smoke exposure. All patients had a mean IgE of 734 (range 12–2497) with seasonal allergic rhinitis was diagnosed in three patients. Cases occurred in spring (3/5) and fall (2/5). Venous/venous ECMO (4/5) or venous/arterial ECMO (1/5) was continued for a mean duration of 4.2 days (range 3–7 days). Spirometry after hospitalization had a mean FEV1 of 1.59 L (81% predicted, range 69%–91%), and an FEF25%–75% 1.13 L (47.5% predicted, range 41%–65%) at an average of 16.7 weeks post ECMO. Conclusions: This case series highlights the association between persistent, poorly controlled asthma and severe SA with HRV infection resulting in ECMO. Despite life-threatening illness, these patients did not demonstrate significant large-airway obstruction following infection. However, patients showed persistently abnormal small airway function, which could be a risk factor or early evidence of vulnerability to infection.

Demonstrating the Significance of Immediate Availability of VV-ECMO as a Life Saving Treatment for Status Asthmaticus

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Status asthmaticus is a life threatening condition that presents as severe hypercapnic respiratory acidosis. The majority of patients respond to mechanical ventilation and medical management, however severe status asthmaticus can fail traditional management. In these cases, VV-ECMO has shown to reduce mortality. We present several cases of status asthmaticus in which patients were treated with VV-ECMO. CASE PRESENTATION: Case 1: 29-year-old female with multiple asthma exacerbations admitted with respiratory failure, pH of 6.76 and pCO2 of 152 despite mechanical ventilation. She was emergently placed on VV-ECMO in the ED. During initiation of VV-ECMO patient had cardiac arrest and was resuscitated. Normalization of blood gases was achieved within 2 hours and patient was liberated off VV-ECMO in 4 days. Case 2: 24-year-old man with a history of asthma with no previous intubations suffered a PEA arrest and was resuscitated in the field. On presentation to emergency department had respiratory acidosis with a pH of 6.8, he suffered a second PEA arrest, emergently was started on VV-ECMO, follow-up blood gases showed rapid resolution of acidosis and patient was able to be decannulated within 36 hours of initiation of treatment. Case 3: 28-year-old man with untreated asthma initially presented with worsening SOB symptoms over several weeks. Patient started traditional treatment for asthma exacerbation, but progressed to respiratory failure and was intubated. Initial ABG pH of 7.24 with pCO2 of 44. Despite mechanical ventilation pH decreased to 7.10 with pCO2 of 78. VV-ECMO was initiated and patient had rapid improvement of acidosis and was weaned off VV-ECMO within 48 hours. Case 4: 15-year-old male brought by EMS with ongoing CPR for cardiac arrest, VV-ECMO was immediately started, initial pH of 6.82 and pCO2 of 96. Despite quick return of circulation and complete normalization of blood gases within one hour, our patient sustained anoxic brain death due prolonged CPR prior to arrival to ED. DISCUSSION: Severe status asthmaticus can become refractory to mechanical support and medical therapy, these cases demonstrate the need for early intervention to prevent progression and if nonresponsive to traditional treatment, the need to initiate VV-ECMO as quickly as possible. ECMO does carry with it risks of serious complications for those undergoing therapy, but the benefits to mortality are so significant to show the necessity of personnel and equipment to initiate this treatment to prevent death. CONCLUSIONS: Availability of a relatively new technology like VV-ECMO in our institution and the ability of trained personnel to emergently initiate it can save patients lives when they do not respond to maximal medical treatment and mechanical ventilation. Reference #1: Perfusion. 2014 Jan;29(1):26-8. Extracorporeal carbon dioxide removal for refractory status asthmaticus: experience in distinct exacerbation phenotypes. Brenner K1, Abrams DC, Agerstrand CL, Brodie D. DISCLOSURE: The following authors have nothing to disclose: Kyle Long, Marina Dolina No Product/Research Disclosure Information

Influenza A triggered status asthmaticus requiring emergency ECMO

We describe a case of acute respiratory failure due to severe pneumonia triggered by the influenza A virus, rapidly evolving into a refractory status asthmaticus requiring emergent ECMO assistance, in order to facilitate the clinical management of patients suffering from this rare but life-threatening condition. This case report demonstrates that infection with influenza A virus can present with severe pneumonia and status asthmaticus refractory to medical and ventilatory treatment. When medical treatment and mechanical ventilation fail, extracorporeal membrane oxygenation therapy should not be delayed as it will avoid injury resulting from inadequate mechanical ventilation and lung hyperinflation.

O-203a Inhaled Magnesium For Moderate And Severe Paediatric Asthma

Background Intravenous magnesium sulfate, a rescue therapy added to combined bronchodilator and systemic steroid therapy for moderate and severe asthma, is uncommonly administered. We hypothesised that nebulized magnesium sulfate would confer benefit without undue risk. Methods Patients aged 2 to 14 y with moderate and severe status asthmaticus (PRAM severity score >4) admitted to infirmary care were randomised double-blind to 800 mg nebulized magnesium sulfate or normal saline placebo via Aeroneb Pro and Idehaler, after intensive therapy with combined albuterol-ipratropium and intravenous methylprednisolone. Time to medical readiness for discharge was the primary outcome; sample size was chosen to detect a 10% improvement. Improvement over time in PRAM severity score and other secondary outcomes were compared for the overall group and severe asthma subset. Results 191 magnesium sulfate and 174 placebo patients met criteria for analysis. The groups were similar with mean baseline PRAM scores >7. Blinded active therapy significantly increased blood magnesium level 2 h post-treatment 0.85 (SD 0.07) vs 0.82 (SD 0.06) mmol/L, p = 0.001). There were no important adverse effects. However, accelerated failure time analysis showed a non-significantly shortened time to medical readiness for discharge of 14% favouring the magnesium sulfate group, OR=1.14, 95% CI 0.93 to 1.40, p = 0.20. Mean times until readiness for discharge were 14.6 h [SD 9.7] vs 15.6 h [SD 11.3] for the investigational and placebo groups, respectively, p = 0.9. Conclusions Adding nebulized magnesium sulfate to combined nebulized bronchodilator and systemic steroid therapy fails to provide evident benefit for patients with moderate or severe status asthamticus.

Definition of critical asthma syndromes.

Urgent visits to the clinic and emergency department for acute severe asthma exacerbations are all too frequent. Existing national guidelines do not present consistent or specific recommendations for the evaluation and treatment of individual asthma patients in respiratory distress. In this vein, we propose the term "critical asthma syndrome" (CAS) to describe any child or adult who is at high risk for fatal asthma. Acute severe asthma, refractory asthma, status asthmaticus, and near-fatal asthma all describe CAS where physical exhaustion from the overwhelming work of breathing leads to respiratory arrest and death from hypoxia or related complications. The authors of this supplement seek to emphasize the importance of early recognition, prompt and coordinated evaluation, and treatment of CAS in the emergency department, hospital, and intensive care units by experienced healthcare provider teams. CAS is not severe persistent asthma where control of symptoms and prevention of exacerbations are targets of chronic disease management in the outpatient setting. The authors address the distinctions between the two entities throughout the supplement, and elaborate on the considerations important in the care of a critically ill patient, including the common errors to avoid. In addition, gaps in knowledge and clinical experience in regards to critical asthma are highlighted. Knowledge gaps include a lack of understanding of how to recognize CAS, how to coordinate and integrate hospital and outpatient resources, when to further phenotype patients with critical asthma in order to facilitate effective treatment, and how to prevent future acute exacerbations. Lastly, CAS is complicated by the fact that asthma care in diverse healthcare settings is haphazard. We recommend that primary care physicians refer patients promptly to an asthma specialist for consultation to reduce the frequency of acute exacerbations and prevent the development of CAS.

BiPAP for treating moderate and severe asthma exacerbations in a PED

BiPAP utilization for the treatment of severe refractory status asthmaticus patients has become an accepted therapy but is not well described for moderate exacerbations. We sought to analyze outcomes from our BiPAP quality database for children presenting in status asthmaticus at varying levels of severity.

Ketamine in status asthmaticus: A review

Background and AimsStatus asthmaticus is a common cause of morbidity and mortality. The addition of ketamine to the standard treatment regimen of severe asthma has shown to improve outcome and alleviate the need for mechanical ventilation. The purpose of this review is to determine the pulmonary effects of ketamine and to determine whether sufficient evidence exists to support its use for refractory status asthmaticus.Data Source:MEDLINE, EMBASE, Google Scholar, and Cochrane data bases (from their inception to Jan 2012) using key words “ketamine”, “asthma”, “bronchospasm”, “bronchodilator”, and “mechanical ventilation” were searched to identify the reports on the use of ketamine as a bronchodilator in acute severe asthma or status asthmaticus, and manual review of article bibliographies was done. Relevant databases were searched for the ongoing trials on use of ketamine as a bronchodilator. Outcome measures were analyzed using following clinical questions: Indication, dose and duration of ketamine use, main effects on respiratory mechanics, adverse effects, and mortality.Results:Twenty reports illustrating the use of ketamine as a bronchodilator were identified. In total, 244 patients aged 5 months to 70 years received ketamine for bronchospasm. Twelve case reports, 3 double-blind randomized placebo-controlled trials, 2 prospective observational studies, 2 clinical evaluation study, and 1 retrospective chart review were retrieved. Most of the studies showed improved outcome with use of ketamine in acute severe asthma unresponsive to conventional treatment. Patients who received ketamine improved clinically, had lower oxygen requirements, and obviated the need for invasive ventilation. Mechanically-ventilated patients for severe bronchospasm showed reduction in peak inspiratory pressures, improved gas exchange, dynamic compliance and minute ventilation, and could be weaned off successfully following introduction of ketamine.Conclusion:In various studies, ketamine has been found to be a potential bronchodilator in severe asthma. However, a large prospective clinical trial is warranted before laying down any definitive recommendations on its use in status asthmaticus.

Bronchoscopy as a rescue therapy in patients with status asthmaticus: Two case reports and review of literature

Management of status asthmaticus requires more than guidelines-guided therapy. Occasionally, uncommon therapeutic interventions and procedures may provide significant benefits. The role of bronchoscopy in fatal asthma is still not clearly defined. We illustrate two cases of severe status asthmaticus on mechanical ventilation who showed remarkable improvement after therapeutic bronchoscopy.

Emergence of Oseltamivir-Resistant Pandemic H1N1 in an Immunocompetent Child with Severe Status Asthmaticus

Introduction. Pandemic influenza A (H1N1) may cause severe illness in pediatric patient with chronic lung disease. Case Report. We describe the emergence of oseltamivir resistance in an immunocompetent child with status asthmaticus triggered by pandemic influenza A (H1N1). This case highlights the possible relationship between influenza viral load and risk of resistance emergence in children with asthma. Influenza vaccination should continue to be emphasized as the mainstay of prevention in children with chronic lung disease. Conclusion. Influenza virus can lead to severe status asthmaticus and can develop oseltamivir resistance in immunocompetent children.

Safety and efficacy of intratracheal DNase with physiotherapy in severe status asthmaticus

Diffuse airway plugging with thick viscous secretions is recognised in acute severe asthma, and contributes to airflow limitation in ventilated asthmaticus. Since 2004, we have used intratracheal DNase with physiotherapy as second-line therapy in mechanically ventilated children with severe status asthmatics who are refractory to conventional medical management. Our aim is to report the safety profile and efficacy of intratracheal DNase mucolytic therapy in this cohort.

Status asthmaticus

The successful application of a pumpless extracorporeal lung assist procedure ("interventional lung assist, iLA) in three cases of severe refractory status asthmaticus, which could not be solved with conventional pharmacological and respiratory therapy is reported. After an individual risk-benefit analysis such a therapy can be used to reduce lung injury due to invasive mechanical ventilation. Because of the complexity of this therapy it should only be applied in special medical centers with sufficient experience in dealing with extracorporeal lung assist procedures.

Intensive Care Unit Management of Status Asthmaticus

In Brief Patients with severe asthma exacerbations, status asthmaticus (SA), or near-fatal asthma, account for almost 2 million emergency department visits annually in the United States, 497,000 hospital admissions, and 5000 deaths. Approximately, 2% to 70% (mean, 30%) of ICU admissions for asthma require mechanical ventilation, and the mortality rate of mechanically ventilated patients can range from 6% to 42% in high-risk populations. Risk stratifying patients presenting with a severe exacerbation is difficult. In this article, the pathophysiology of near-fatal asthma and SA is reviewed. Many patients who died of SA lack the typical risk factors for death. The 2 phenotypes of severe asthma (acute and subacute onset) are similar with respect to presenting signs but their demographics and rate of decline differ after illness onset. The clinical evaluation and risk stratification of patients presenting with severe asthma exacerbations are a vital and challenging component of their care. The rational use of inhaled and systemic therapies is also required to minimize complications and maximize benefits. Strategies for the use of mechanical ventilation that minimize the risk of barotrauma and use of permissive hypercapnia are a key to reduce mortality. The use of extrinsic positive end expiratory pressure is not contraindicated and may benefit a subset of patients. At this time, the use of noninvasive mechanical ventilation in the most severe asthma exacerbations cannot be recommended. The use of sedatives, inhalational anesthetics, and paralytics as adjuncts to mechanical ventilation have potential risks and their use must be individualized. Status asthmaticus and near fatal asthma are life-threatening entities. The care requires an assessment of risk and, often, a critical care environment. This review discusses the intensive care management of patients presenting with severe asthma exacerbations.

Helium/oxygen-driven albuterol nebulization in the management of children with status asthmaticus: A randomized, placebo-controlled trial*

We investigated the effect of heliox-powered albuterol therapy on hospital length of stay and clinical status in children with moderate to severe status asthmaticus. Prospective, randomized, placebo-controlled trial. Twenty-five-bed pediatric intensive care unit at an academic children's medical center. Forty-two children (2-21 yrs of age) with moderate to severe status asthmaticus. Patients were randomized to receive either heliox-powered nebulized albuterol or air/oxygen-powered nebulized albuterol (placebo) until they were transitioned to albuterol delivered by a metered dose inhaler. Clinical asthma scores were recorded on enrollment and every 4 hrs thereafter. Patients in the heliox group (n = 22) and the control group (n = 20) had similar ages (mean +/- sem: 88 +/- 9.9 vs. 98 +/- 11.1 months, respectively; p = .51), time to study enrollment (618 +/- 70.4 vs. 597 +/- 84.1 mins, respectively; p = .72), and clinical asthma scores at study entry (5.9 +/- 0.2 vs. 5.7 +/- 0.3, respectively; p = .72). There were no significant differences between groups in time to eligibility to hospital discharge (66.2 +/- 8.7 vs. 63.4 +/- 8.6 hrs, respectively; p = .61), time to clinical asthma score <3 (22 +/- 2.8 vs. 21.2 +/- 5.3 hrs, respectively; p = .27), or time to eligibility for intensive care unit discharge (34.4 +/- 6.8 vs. 33.3 +/- 8.2 hrs, respectively; p = .64). There were no significant differences in adverse events between groups. Despite the previously demonstrated effects of heliox on improved aerosol particle delivery into the distal airways, heliox-powered nebulized albuterol therapy for children admitted to the hospital with moderate to severe status asthmaticus does not shorten hospital length of stay or hasten rates of clinical improvement when compared with air/oxygen-powered nebulized albuterol.