Severe Acute Asthma Exacerbation Research Articles

Effectiveness of Nebulized Magnesium Sulphate as an Adjuvant Therapy (With Salbutamol) in the Management of Acute Asthma

Background: Although the treatment of acute asthma in the emergency department varies, the administration of magnesium sulfate (MgSO4) is usually recommended adjacent to corticosteroids and bronchodilators. This study aims to ascertain the influence of inhaled MgSO4 as complement treatment with salbutamol regarding treatment of urgent asthma exacerbations. Methods: A single-blind randomized control study was carried out, from 1st January 2017 to 30th June 2017, involving asthmatic patients presenting to Ziauddin Hospital and Jinnah Hospital in Karachi, with severe acute asthma exacerbations. The Sealed Envelope calculator was used to calculate a sample size of 84 patients, and data was collected through non-probability consecutive sampling. Both batches were administered salbutamol and ipratropium, with Batch A patients also receiving nebulization with MgSO4. Dyspnea, respiratory rate, pulse, peak expiratory flow rate, and oxygen saturation were recorded for each participant. An independent sample t-test was used to assess the effectiveness of MgSO4, as a significant means of improving asthma treatment, with a p<0.05 interpreted as significant. Results: A sum of 115 patients was included in the research, out of which 63.5% had a family history of asthma. Treatment with MgSO4 was seen as significant (p<0.01). MgSO4 administration showed significant improvement in mean pulse rate (p = 0.001), peak expiratory flow rate (p = 0.004) and mean respiratory rate (p = 0.003), as compared to treatment with salbutamol only. Conclusion: Treatment outcomes between the two groups differed significantly. Intervention with MgSO4 showed significant improvement in pulse rate, respiratory rate, dyspnea, and peak flow, without any observed side effects.

Serum metalloproteinases-9 in asthmatic children

Background Serum matrix metalloproteinases (MMPs) are widely investigated markers of inflammation that are used to evaluate the severity of bronchial asthma in children, and may be the targets of new therapeutic options aiming at improving the management of such disease. Aim The aim of this study was to evaluate serum levels of MMP-9 in acute asthma exacerbation in children and its correlation with severity of acute attack and peak flow meter measurement in asthmatic children. Patients and methods One hundred asthmatic children, aged 6–14 years, with acute exacerbation (mild and moderately severe attacks) were evaluated during their visit to emergency department unit for serum MMP-9 (measured by enzyme-linked immunosorbent assay) and peak expiratory flow (measured by peak flow meter) before receiving any treatment. There were 46 male and 54 female patients. A total of 50 controls were taken as the control group for serum MMP-9. Results Serum MMP-9 was significantly higher in asthmatic children compared with the control group, and significantly higher in patients with moderate than with mild exacerbation. Moreover, serum MMP-9 was negatively correlated with peak expiratory flow in asthmatic children. Conclusion Serum MMP-9 may be used as an inflammatory marker for diagnosing and evaluating the severity of acute asthma exacerbation in children.

Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management.

Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.

Novel pediatric-automatedrespiratory score using physiologic data and machine learning in asthma.

Manual clinical scoring systems are the current standard used for acute asthma clinical care pathways. No automated system exists that assesses disease severity, time course, and treatment impact in pediatric acute severe asthma exacerbations. machine learning applied to continuous vital sign data could provide a novel pediatric-automated asthma respiratory score (pARS) by using the manual pediatric asthma score (PAS) as the clinical care standard. Continuous vital sign monitoring data (heart rate, respiratory rate, and pulse oximetry) were merged with the health record data including a provider-determined PAS in children between 2 and 18 years of age admitted to the pediatric intensive care unit (PICU) for status asthmaticus. A cascaded artificial neural network (ANN) was applied to create an automated respiratory score and validated by two approaches. The ANN was compared with the Normal and Poisson regression models. Out of an initial group of 186 patients, 128 patients met inclusion criteria. Merging physiologic data with clinical data yielded >37 000 data points for model training. The pARS score had good predictive accuracy, with 80% of the pARS values within ±2 points of the provider-determined PAS, especially over the mid-range of PASs (6-9). The Poisson and Normal distribution regressions yielded a smaller overall median absolute error. The pARS reproduced the manually recorded PAS. Once validated and studied prospectively as a tool for research and for physician decision support, this methodology can be implemented in the PICU to objectively guide treatment decisions.

Prediction of acute asthma exacerbation severity and interrater reliability of manual pulsus paradoxus measurement

Prediction of acute asthma exacerbation severity and interrater reliability of manual pulsus paradoxus measurement

Low-dose l-isoproterenol versus salbutamol in hospitalized pediatric patients with severe acute exacerbation of asthma: A double-blind, randomized controlled trial

BackgroundAlthough the guidelines in most countries do not recommend continuous inhalation of l-isoproterenol to treat pediatric patients with acute severe exacerbation of asthma, lower dose of l-isoproterenol has been widely used in Japan. To determine whether the efficacy of low-dose l-isoproterenol was superior to that of salbutamol, we conducted a double-blind, randomized controlled trial. MethodsHospitalized patients aged 1–17 years were eligible if they had severe asthma exacerbation defined by the modified pulmonary index score (MPIS). Patients were randomly assigned (1:1) to receive inhalation of l-isoproterenol (10 μg/kg/h) or salbutamol (500 μg/kg/h) for 12 hours via a large-volume nebulizer with oxygen. The primary outcome was the change in MPIS from baseline to 3 hours after starting inhalation. Trial registration number UMIN000001991. ResultsFrom December 2009 to October 2013, 83 patients (42 in the l-isoproterenol group and 41 in the salbutamol group) were enrolled into the study. Of these, one patient in the l-isoproterenol group did not receive the study drug and was excluded from the analysis. Compared with salbutamol, l-isoproterenol reduced MPIS more rapidly. Mean (SD) changes in MPIS at 3 hours were −2.9 (2.5) in the l-isoproterenol group and −0.9 (2.3) in the salbutamol group (difference −2.0, 95% confidence interval −3.1 to −0.9; P < 0.001). Adverse events occurred in 1 (2%) and 11 (27%) patients in the l-isoproterenol and salbutamol groups, respectively (P = 0.003). Hypokalemia and tachycardia occurred only in the salbutamol group. ConclusionsLow-dose l-isoproterenol has a more rapid effect with fewer adverse events than salbutamol.

Certification Is for You ….

Certification Is for You ….

Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial.

In moderate-severe asthma exacerbation, salbutamol by inhaler (MDI) is superior to salbutamol delivered by nebulizer (NEB); however, to our knowledge, no studies in children with exclusively severe exacerbations were performed. To compare the efficacy of salbutamol and ipratropium bromide by MDI versus by NEB in severe asthma exacerbations. We performed a clinical trial enrolling 103 children (2-14 years of age) with severe asthma exacerbations (defined by the Pulmonary Score ≥ 7) seen at the emergency room in Asuncion, Paraguay. One group received salbutamol and ipratropium (two puff every 10 min for 2 h and then every 30 min for 2 h more) by MDI with a valved-holding chamber and mask along with oxygen by a cannula separately (MDI-SIB); and the other received nebulization with oxygen (NEB-SIB) of salbutamol and ipratropium (1 every 20 min for 2 h and then every 30 min for 2 h more). Primary outcome was the rate of hospitalization (Pulmonary Score ≥ 7) after 4 h and secondary outcome was oxygen saturation. Fifty two children received MDI-SIB and 51 NEB-SIB. After the 4th hour, children on MDI-SIB had significantly (P = 0.003) lower rate of hospital admission than on NEB-SIB (5.8% vs 27.5%, RR: 0.21 [0.06-0.69], respectively). Similarly, a significant improved clinical score after 60 min and increase in oxygen saturation after 90 min of treatment was observed in MDI-SIB versus NEB-SIB group (4.46 ± 0.7 vs 5.76 ± 0.65, P < 0.00001; and 90.5 ± 1.7 vs 88.43 1 ± 1, P < 0.00001, respectively). Even in severe asthma exacerbations administration of salbutamol and ipratropium by MDI with valved-holding chamber and mask along with oxygen by a cannula separately was more effective than by a nebulizer.

Case report of influenza-induced acute severe asthma exacerbations

对温州医科大学附属第二医院、育英儿童医院收治的1例流感病毒感染致支气管哮喘急性重度发作并气胸患儿的临床资料进行回顾性分析。患儿，男，5岁，其临床特点为发热、咳嗽、进行性呼吸困难、哮喘持续状态。查体：精神差，口唇微绀，呼吸促、费力，两肺听诊从广泛呼气相哮鸣音转为呼吸音减弱，哮鸣音几乎未及，颈部、腋部、前胸壁皮下捻发感。痰液免疫荧光法检测乙型流感病毒抗原阳性，鼻咽拭子反转录PCR检测乙型流感病毒RNA阳性，胸片提示左、右侧气胸，双侧颈部、腋部及胸壁广泛气肿。入院后予以神经氨酸酶抑制剂、抗炎平喘、双侧胸腔闭式引流、呼吸支持、保持水电解质酸碱平衡等综合治疗，喘息逐步缓解，0.5个月后气胸、皮下气肿基本吸收。提示哮喘急性发作是儿童流感呼吸系统较为常见并发症；哮喘患者感染流感病毒后，可出现严重呼吸道症状；对于呼吸困难进行性加重的哮喘急性发作患儿，必须考虑排除气胸、纵隔气肿的可能，早诊断、早治疗可取得较好疗效。

Study of Clinical Characteristics and Cytokine Profiles of Asthmatic Children with Rhinovirus Infection during Acute Asthma Exacerbation at National Hospital of Pediatrics.

Background In children with asthma, the viral infection of airways is usually a main cause of acute asthma exacerbation and hospitalization. However, few studies on clinical and biomolecular characteristics of asthmatic children in this field have been done, especially in emergent countries. Objective This study described the clinical and biological characteristics of asthmatic children who had acute asthma exacerbation and rhinovirus (RV) infection. Methods Children under 15 years of age hospitalized for acute asthma exacerbation were included. They underwent clinical examination and peripheral blood analyses for the cytokine profile. The severity of acute asthma exacerbation was evaluated by Pediatric Asthma Score (PAS). Healthy children under 15 years of age were also invited in this study. Results One hundred fifteen asthmatic children were included in this study. There were 18.2% of mild PAS, 37.4% of moderate PAS, and 44.4% of severe PSA. Among them, 63/115 (54.8%) asthmatic children had positive RV infection (RV+). The percentages of asthmatic children with RV+ had increased polymorphonuclear leucocytes were significantly higher than asthmatic children with RV−. There were no significant differences of the concentrations of non-Th2-related cytokines in asthmatic children with RV− and RV+. The concentration of Th2-related cytokines (IL-5 and IL-13) in asthmatic children with RV+ was significantly higher than those with RV−. However, there was no significant difference for the cytokine profile between mild, moderate, and severe asthma. Conclusion RV infection is a main cause of acute asthma exacerbation in children with asthma. The increase of Th2-related cytokines, especially IL-5 and IL-13, is a relevant biomarker for RV infection in asthmatic children with severe exacerbation.

Prevalence of Mycoplasma pneumoniae infection in pediatric patients with acute asthma exacerbation.

Mycoplasma pneumoniae may be involved in refractory asthma exacerbation. To determine the prevalence of Mycoplasma pneumoniae infection in patients with acute asthma exacerbation. Material and method. A prospective, crosssectional, observational, case-control study was carried out in patients older than 2 years old and younger than 12. Immunoglobulin M (IgM) antibodies were serologically determined for M. pneumoniae, using the NovaLisa® NovaTec kit for enzyme-linked immunosorbent assay (ELISA). Test results ≥ 11 NTU (NovaTec units) were regarded as positive. The statistical analysis was performed by means of the analysis of variance (ANOVA) and the χ² test, with a significance level of p < 0.05. One hundred and eighty children were studied, of which 130 had asthma and 50 comprised the control group. Specific IgM was positive for 60 patients, that is 46.15% of the asthmatic children (p < 0.001). The severity of the exacerbation was directly related to IgM levels (p < 0.001). Hospitalization rate was 75%, and it was significantly associated to specific IgM levels (p < 0.001). Our data suggest that children with acute asthma show a high prevalence (46%) of Mycoplasma pneumoniae infection and that there is a close relation between severe acute asthma exacerbation and the presence of Mycoplasma pneumoniae infection. These findings might result in therapeutic implications centered in the use of specific antibiotics to fight this atypical organism. Key words: acute asthma, exacerbation, Mycoplasma pneumoniae.

Improving Management of Severe Asthma: BiPAP and Beyond

Acute severe asthma exacerbations present unique challenges in the pediatric emergency department. While most children presenting to the emergency department respond to standard asthma therapy including inhaled β2-agonists, ipratropium, and systemic corticosteroids, some children remain refractory to these treatments and require adjunct therapies. Here we provide a review of the most recent National Asthma Education and Prevention Program guidelines, Global Initiative for Asthma guidelines, as well as recent evidence guiding the management of severe asthma exacerbations in the pediatric emergency department.

Spontaneous pneumomediastinum complicating severe acute asthma exacerbation in adult patients

ABSTRACTObjectives: The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods: The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO2) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results: Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17–21) vs 49.5 (20–73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4–12) vs 7 (3–15) days; p = 0.6939]. Conclusions: PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.

Effects of procalcitonin-guided treatment on antibiotic use and need for mechanical ventilation in patients with acute asthma exacerbation: Meta-analysis of randomized controlled trials

ObjectiveThe primary outcome was to determine whether serum procalcitonin-guided antibiotic therapy can reduce antibiotic exposure in patients with an acute exacerbation of asthma presenting to the primary care facility or emergency department, or during hospital admission. The secondary outcome was the need for mechanical ventilation. MethodsAn extensive literature search was performed to identify randomized controlled clinical trials (published in English) that compared serum procalcitonin-guided antibiotic therapy versus antibiotic use according to physician’s discretion for adult participants with mild, moderate, or severe acute asthma exacerbations. ResultsFour randomized controlled trials evaluating 457 patients were included in this meta-analysis, with significant homogeneity observed among these studies. Procalcitonin-based protocols decreased antibiotic prescriptions (relative risk 0.58, 95% confidence interval 0.50–0.67). The conclusion regarding the difference between the two groups in the need for mechanical ventilation (relative risk 1.10, 95% confidence interval 0.62–1.94) was guarded due to inadequate power and the potential for type II error. The overall quality of evidence was also limited by the lack of double-blinding. ConclusionsThese data suggest a potential benefit for the use of serum procalcitonin in guiding antibiotic therapy in patients with an acute asthma exacerbation and advocates the need for more randomized controlled trials.

High-flow nasal cannula therapy versus non-invasive ventilation in children with severe acute asthma exacerbation: An observational cohort study

IntroductionThe present study describes our experience with the high-flow humidified nasal cannula (HFNC) versus non-invasive ventilation (NIV) in children with severe acute asthma exacerbation (SA). MethodsAn observational study of a retrospective cohort of 42 children with SA admitted to a Pediatric Intensive Care Unit (PICU) for non-invasive respiratory support was made. The primary outcome measure was failure of initial respiratory support (need to escalate from HFNC to NIV or from NIV to invasive ventilation). Secondary outcome measures were the duration of respiratory support and PICU length of stay (LOS). ResultsForty-two children met the inclusion criteria. Twenty (47.6%) received HFNC and 22 (52.3%) NIV as initial respiratory support. There were no treatment failures in the NIV group. However, 8 children (40%) in the HFNC group required escalation to NIV. The PICU LOS was similar in both the NIV and HFNC groups. However, on considering the HFNC failure subgroup, the median length of respiratory support was 3-fold longer (63h) and the PICU LOS was also longer compared with the rest of subjects exhibiting treatment success. ConclusionsDespite its obvious limitations, this observational study could suggest that HFNC in some subjects with SA may delay NIV support and potentially cause longer respiratory support, and longer PICU LOS.

Adapting an Evidence-Based Pediatric Acute Asthma Exacerbation Severity Assessment Tool for Pediatric Primary Care

IntroductionThe purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care. MethodThe three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool. ResultsThe criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care. DiscussionThe adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.

Benzalkonium Chloride: A Bronchoconstricting Preservative in Continuous Albuterol Nebulizer Solutions.

For convenience, many pediatric hospitals are preparing solutions for continuous nebulized albuterol using the 0.5% 20-ml multidose albuterol dropper bottle. This product contains benzalkonium chloride (BAC) that, by itself, produces bronchospasm that is dose dependent and cumulative. The bronchoconstrictive effects of BAC are greater in patients with more severe airway obstruction and increased airway responsiveness. Use of BAC-containing albuterol during severe acute asthma exacerbations may antagonize the bronchodilator response to albuterol, prolong treatment, and increase the risk of albuterol-related systemic adverse effects. Such a deleterious effect of BAC is difficult to detect because some patients improve slowly or may even worsen during treatment. We recommend that only preservative-free albuterol products be used.

High-flow nasal cannula therapy versus non-invasive ventilation in children with severe acute asthma exacerbation: An observational cohort study

IntroductionThe present study describes our experience with the high-flow humidified nasal cannula (HFNC) versus non-invasive ventilation (NIV) in children with severe acute asthma exacerbation (SA). MethodsAn observational study of a retrospective cohort of 42 children with SA admitted to a Pediatric Intensive Care Unit (PICU) for non-invasive respiratory support was made. The primary outcome measure was failure of initial respiratory support (need to escalate from HFNC to NIV or from NIV to invasive ventilation). Secondary outcome measures were the duration of respiratory support and PICU length of stay (LOS). ResultsForty-two children met the inclusion criteria. Twenty (47.6%) received HFNC and 22 (52.3%) NIV as initial respiratory support. There were no treatment failures in the NIV group. However, 8 children (40%) in the HFNC group required escalation to NIV. The PICU LOS was similar in both the NIV and HFNC groups. However, on considering the HFNC failure subgroup, the median length of respiratory support was 3-fold longer (63h) and the PICU LOS was also longer compared with the rest of subjects exhibiting treatment success. ConclusionsDespite its obvious limitations, this observational study could suggest that HFNC in some subjects with SA may delay NIV support and potentially cause longer respiratory support, and longer PICU LOS.

The profile of leucocytes, CD3+, CD4+, and CD8+ T cells, and cytokine concentrations in peripheral blood of children with acute asthma exacerbation.

ObjectiveTo determine the leucocyte profile and cytokine concentrations in the peripheral blood of children with an acute asthma exacerbation (AAE).MethodsThis descriptive, cross-sectional study enrolled paediatric patients admitted to hospital for AAE. The severity of AAE was assessed using the paediatric asthma score (PAS). Peripheral blood samples were collected for automatic quantification of white blood cell counts, CD3+, CD4+, and CD8+ T cells populations by flow cytometry and cytokine concentrations by flow cytometry-assisted immunoassay.ResultsA total of 127 children with AAE and 30 healthy control subjects were included in the study. The proportion of paediatric patients with decreased CD3+, CD4+ and CD8+ T cells was significantly higher in those with severe AAE compared with those with mild-to-moderate AAE. The concentrations of interleukin (IL)-2, IL-8, IL-12, and IL-4 in paediatric patients with rhinovirus infection were significantly higher than in those without rhinovirus infection. IL-2, IL-4, IL-6, TNF-α and GM-CSF concentrations during AAE were significantly lower than control. IL-5 and IL-13 concentrations during AAE were significantly higher than control.ConclusionsThe decrease of CD3+, CD4+, CD8+ T cells and IL-2, IL-4, IL-6, TNF-α, and GM-CSF combined with the increase of IL-5 and IL-13, were associated with AAE in children with asthma.

Rhinovirus and serum IgE are associated with acute asthma exacerbation severity in children

Rhinovirus and serum IgE are associated with acute asthma exacerbation severity in children