Status Asthmaticus Research Articles

Evaluation of cardiac biomarkers in children with acute severe bronchial Asthma-A prospective study from tertiary care center in northern India

ObjectivesDuring the attacks of acute severe bronchial asthma there are marked cardiopulmonary changes leading to hypoxia. The study aims to find the incidence of myocardial dysfunction in patients of acute severe bronchial asthma based on cardiac enzyme levels at admission and see whether the myocardial damage is transient or persistent even after stabilization of the patient based on enzyme levels at discharge. Materials and methodsThis prospective, case control study was done at Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University between October 2016 to May 2018. Sixty pediatric patients of acute severe bronchial asthma were taken as cases and 15 age and sex matched children served as controls. Blood samples were collected in Ethylene diamine tetra acetic acid vials before the start of treatment, for measurement of cardiac biomarkers Troponin I (TnI), Brain natriuretic peptide (BNP) and Creatine Kinase-muscle/brain (CK-MB) and repeat samples were taken before discharge. ResultsFifty percent of the cases had abnormal TnI levels, 15% had abnormal CK-MB levels and 8.3% had abnormal BNP levels at admission. At discharge, only 1 (1.7%) case had abnormal levels of CK-MB, whereas the levels of TnI and BNP normalized in all. The level of cardiac biomarkers were significantly raised at admission when compared to discharge values (p value < 0.001). ConclusionsThe raised cardiac biomarkers suggest myocardial stress during acute exacerbation of bronchial asthma. Though, the present study showed that the changes are of transient nature, larger follow up studies are required to document any permanent damage to myocardium.

Variability of outcome measures in trials of intravenous therapy in acute severe paediatric asthma: a systematic review

ObjectiveTo determine the variability of primary and secondary outcomes used in trials of intravenous bronchodilators in children with acute severe paediatric asthma.MethodsSystematic search of MEDLINE, EMBASE, Cochrane CENTRAL and the...

Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma

To compare the efficacy of a breath-enhanced and a conventional jet nebulizer in the treatment of children with moderate to severe acute asthma. We enrolled subjects between 6 and 18 years of age presenting to the emergency department (ED) with acute asthma and an initial forced expiratory volume in 1 second (FEV1) <70% of predicted. We excluded patients with chronic disease, who required immediate resuscitation, or failed spirometry. Subjects were randomized to breath-enhanced or conventional jet delivery of a 5-mg albuterol treatment. Our primary outcome was change in FEV1, and secondary outcomes included change in clinical asthma scores, ED length of stay, disposition, and side effects. Student t test and multivariable linear regression were used to evaluate the primary outcome. In total, 497 patients were assessed for eligibility with 118 enrolled and 107 subjects available for analysis of the primary outcome. Improvement in FEV1 was significantly greater with conventional jet nebulizer (mean ΔFEV1 +13.8% vs +9.1%, P = .04). This difference remained significant after adjustment for baseline differences. Subgroup analysis of 57 subjects with spirometry meeting American Thoracic Society/European Respiratory Society guidelines yielded similar results (mean ΔFEV1 +14.5% vs +8.5%, P=.03). There were no significant differences in clinical asthma scores, ED length of stay, disposition, or side effects. Albuterol delivered via conventional jet nebulizer resulted in significantly greater improvement in FEV1 than albuterol delivered by breath-enhanced nebulizer, without significant differences in clinical measures. Conventional jet nebulizers may deliver albuterol to children with acute asthma more effectively than breath-enhanced nebulizers. ClinicalTrials.gov: NCT02566902.

Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus.

To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation. Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory University between 2004 and 2015. Large, free-standing academic quaternary care children's hospital in Atlanta, GA. Children 6-18 years old with physician-diagnosed and confirmed asthma. None. A total of 579 children were analyzed with 170 children (29.4%) being admitted to the PICU for an asthma exacerbation in their lifetime. Of these 170 children with a history of critical asthma, 24.1% were classified as having mild-to-moderate asthma, and 83 of 170 children (48.8%) had been intubated and experienced near-fatal asthma. Multiple logistic regression was used to identify risk factors associated with increased odds of PICU admission with or without endotracheal intubation. Hospitalization within the prior 12 months of survey (odds ratio, 8.19; 95% CI, 4.83-13.89), a history of pneumonia (odds ratio, 2.56; 95% CI, 1.52-4.29), having a designation of increased chronic asthma severity on high-dose inhaled corticosteroids (odds ratio, 2.76; 95% CI, 1.62-4.70), having a father with asthma (odds ratio, 2.15; 95% CI, 1.23-3.76), living in a region with a higher burden of poverty (odds ratio, 1.28; 95% CI, 1.02-1.61), and being of black race (odds ratio, 2.01; 95% CI, 1.05-3.84) were all associated with increased odds of PICU admission with or without intubation. Our findings suggest that there are factors associated with critical and near-fatal asthma, distinct from the chronic asthma severity designations, that should be the focus of future investigation.

Emergencies in Migrant and Refugee Health 2015-2018

Sir, Several papers in Clinical Social Work and Health Interventions have been related to spectrum of either communicable or non-communicable diseases (1-4). However none of them report emergency situations. They have been suspected to be related to PTSD, asthma, coronary heart disease, hypertension and diabetes; all diseases which will exacerbate with acute stress; conditions refugees and migrants must tolerate during their stressful journey to EU. Table 1 shows the commonest emergencies in various Health Checkpoints and Health Centers near Refugee Camps, for example in Hegyeshalom (HU), Dobova (SLO), Veria (GR), Lesbos (GR). The commonest emergency was diabetic coma, followed by status asthmaticus, acute bleeding during birth and hypertension crisis. Surprisingly, no death was recorded in any of those events despite of the large number of migrants coming via the Balkan Route.

NATIONAL OUTCOMES OF STATUS ASTHMATICUS AMONG THE ELDERLY

SESSION TITLE: Critical Care 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Asthma is an unrecognized entity in the elderly with a prevalence of 13%. Acute asthma exacerbation (AAE) in this population presents a significant risk of morbidity and mortality. Status asthmaticus (SA) represents the most severe presentation of this disease, in which asthma attacks occur continuously without remission. Outcomes of AAE and SA in the elderly are not well studied. We sought to investigate the impact of SA among elderly patients in a large national dataset. METHODS: The National Inpatient Sample (NIS) was investigated for geriatric patients admitted with SA and AAE between 2009 and 2014. Demographic and clinical characteristics, including age, sex, race, income groups, comorbidity, and hospital types were compared between groups. We then compared across clinical outcomes of interest, including use of non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), prolonged IMV > 96 hours, in-hospital mortality and discharge to home. All estimates utilized appropriate complex survey methods, such that estimates were nationally representative. Significant differences between groups were tested using Rao-Scott Chi-Square. RESULTS: There were 475,770 weighted discharges for asthma exacerbation over the study period, of which 15,318 (3.2%) were SA. Overall, female sex (72.3%), was predominant in our cohort with multiple comorbidities (78.3%), and highest prevalence in the winter (29.3%) and spring (27.0%) months. Patients with SA tended to be slightly younger than those with AAE (AAE mean 75.9 y vs SA mean 74.7 y, p<0.0001) and had a longer length of stay (AAE mean 4.6 d vs SA 5.5 d, p<0.0001). Although there were similar rates of NIMV use (AAE 4.5% vs SA 5.4%, p = 0.05), there was a more than two-fold difference in the rate of IMV (AAE 1.5% vs SA 4.4%, p<0.0001). Despite this, among patient who did receive IMV, there were no significant differences in prolonged IMV >96 hours (AAE 34.3% of IMV vs SA 31.5% of IMV, p=0.52). Furthermore, though there were similar rates of in-hospital mortality in patients admitted with SA (AAE 0.9% vs SA 1.2%, p = 0.06), SA patients were significantly more likely to be discharged to home without services (AAE 65.9% vs SA 71.4%, p <0.0001). CONCLUSIONS: Patients admitted with SA were more likely to receive IMV than their AAE counterparts, yet were more frequently discharged home without services. SA in the elderly is associated with a high mortality and warrants aggressive interventions. Clinicians should be aware and have a low threshold for ventilator support when appropriate to avoid adverse clinical outcomes. CLINICAL IMPLICATIONS: There is need to keep a low threshold for ventilator support, NIMV or IMV in the elderly with SA. DISCLOSURES: No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Raymond Jean, source=Web Response No relevant relationships by Sathish Pondaiah, source=Web Response No relevant relationships by Bertin Salguero, source=Web Response No relevant relationships by Fernando Vazquez de Lara, source=Web Response

Successful Use of Extracorporeal Membrane Oxygenation for Status Asthmaticus in a Woman With a Periviable Pregnancy

Status asthmaticus is a severe asthma exacerbation with persistent airway obstruction despite standard therapy. Use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in pregnancy is exceedingly rare. We describe a case of ECMO for treatment of status asthmaticus in woman with a periviable pregnancy culminating in a term delivery. The patient was a 33-year-old woman, gravida 3 para 1, admitted at 23 2/7 weeks of gestation with respiratory failure secondary to status asthmaticus. Venovenous ECMO was initiated and continued for 6 days. After hospital discharge, she had no further respiratory issues. She ultimately developed fetal growth restriction and gestational hypertension and underwent a repeat cesarean delivery at 38 weeks of gestation. Venovenous ECMO can be used successfully for status asthmaticus during a periviable pregnancy and enable delivery at term.

Prospective study of serum and ionized magnesium pharmacokinetics in the treatment of children with severe acute asthma.

Intravenous (IV) magnesium sulfate (MgSO4) is clinically useful as adjunct therapy in treating acute asthma exacerbations. Despite its clinical utility, the disposition of magnesium in children is poorly described. The purpose of this study is to describe the pharmacokinetics (PK) of ionized and total serum magnesium following IV MgSO4 administration in children with severe acute asthma. Thirty-two children receiving 50mg/kg IV MgSO4 for acute asthma exacerbations at Primary Children's Hospital in Salt Lake City, UT, were prospectively enrolled in the study. Blood samples were collected before, as well as 30min and 2h after each child's IV MgSO4 dose, and used to determine total serum and ionized magnesium concentrations. The collected data were analyzed using population PK techniques using NONMEM® software. Total serum magnesium concentrations were used to externally validate our previously published model constructed with retrospective data (median prediction error 10.3%, median absolute prediction error 18.1%). The mean (%CV) observed endogenous ionized magnesium concentration was calculated to be 6.0mg/L (12%), approximately one third of the same value for endogenous total serum magnesium (17.6mg/L (22%)) in this dataset. Weight was a significant predictor of both clearance and volume in a population PK model describing ionized magnesium concentrations. No adverse events were observed in this pediatric cohort. This prospective study supports and extends our previous PK analysis of total serum magnesium concentrations. Ionized and total serum magnesium followed similar PK profiles following IV MgSO4 administration in children. A single bolus infusion of IV MgSO4 was safe in this small sample of children receiving it for acute asthma.

Prevalence of anaphylaxis among adults admitted to critical care for severe asthma exacerbation

BackgroundIn asthmatics, making a diagnosis of anaphylaxis could be challenging as respiratory symptoms are a common feature of both conditions. Identifying anaphylaxis is important to providing appropriate care. A prior...

Effect of Implementing Nursing Guidelines About Acute Severe Asthma on Patients' Outcomes in Emergency Unit.

Effect of Implementing Nursing Guidelines About Acute Severe Asthma on Patients' Outcomes in Emergency Unit.

Evaluation of the Risk Factors and Emergency Management Plan of Status Asthmatics in Children: A Simple Literature Review

Significant research papers were published to assess different risk factors associated with development of status asthmaticus (SA) in children and prevention. Understanding the different risk factors associated with SA development in children will help in the early prediction of the cases that might develop SA in future which may cause death in few cases.

Use of Antihypertensive Medications and Uterotonics During Delivery Hospitalizations in Women With Asthma

To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations. We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed. Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01). There may be an opportunity to reduce use of β-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.

Antibiotics for exacerbations of asthma.

Antibiotics for exacerbations of asthma.

Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To examine the effectiveness and safety of intramuscular (IM) versus oral corticosteroids in the treatment of acute asthma after discharge from a hospital emergency department (ED) or equivalent acute care setting.

Critical Care Interventions for Asthmatic Patients Admitted From the Emergency Department to the Pediatric Intensive Care Unit.

The aim of this study was to assess the frequency and predictors of critical interventions in asthmatic patients admitted to the pediatric intensive care unit (PICU) at a tertiary-care pediatric hospital. We conducted a retrospective chart review of patients admitted from our emergency department (ED) to the PICU for treatment of status asthmaticus between January 1, 2008, and March 31, 2013. Patients with concomitant medical conditions and those who received a critical intervention, other than continuously aerosolized albuterol, in the ED before admission were excluded. Data collected included patient demographics, clinical characteristics including clinical asthma scores (CASs), hospital course, and adverse events. A total of 384 patients were included in the analyses (mean age, 8.2 ± 4.5 years). Thirty-four patients (8.9%) received at least 1 critical intervention. No patients were intubated, had central venous catheter placement, and developed circulatory collapse or pneumothoraxes. Independent predictors associated with an increased likelihood of receiving a critical intervention included age above 8 years (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.9-9.4), previous PICU admission (OR, 3.2; 95% CI, 1.5-6.6), altered mental status on ED arrival (OR, 4.5; 95% CI, 1.5-13.4), CAS on ED arrival of 5 or greater (OR, 3.4; 95% CI, 1.3-9.1), and CAS on PICU admission of 5 or greater (OR, 4.3; 95% CI, 1.8-10.2). Patients admitted to the PICU for status asthmaticus infrequently require critical interventions if they have not been initiated in the ED. Patients with a CAS of less than 5 may be safely managed with continuously aerosolized albuterol on non-critical care units with low risk for clinical deterioration.

Replace “Have to” With “Want to”

Replace “Have to” With “Want to”

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.

An Assessment of Asthma Therapy in the Pediatric ICU.

To describe asthma management, investigate practice variation, and describe asthma-associated charges and resource use during asthma management in the PICU. Children ages 2 to 18 years treated for status asthmaticus in the PICU from 2008 to 2011 are included in this study. This is a retrospective, single-center, cohort study. Data were collected by using the Intermountain Healthcare Enterprise Data Warehouse. There were 262 patients included and grouped by maximal respiratory support intervention. Seventy percent of the patients did not receive escalation of respiratory support beyond nasal cannula or nonrebreather mask, and the majority of these patients received only first-tier recommended therapy. For all patients, medical imaging and laboratory charge fractions accounted for <3% and <5% of the total charges, respectively. Among nonintubated patients, the majority of these diagnostic test results were normal. Fifteen patients were intubated during our study period; 4 were intubated at our facility. Compared with outside hospital intubations, these 4 patients had longer time to intubation (>3 days versus <24 hours) and significantly longer median PICU length of stay (12.7 days versus 2.6 days). In our study, the vast majority of patients with severe asthma were treated with minimal interventions alone (nasal cannula or nonrebreather mask and first-tier medications). Minimizing PICU length of stay is likely the most successful way to decrease expense during asthma care.

Characteristics and Outcomes of Children with Clinical History of Atopic Versus Non-atopic Asthma Admitted to a Tertiary Pediatric Intensive Care Unit

Background:Children admitted to the Pediatric Intensive Care Unit (PICU) with status asthmaticus have variable clinical courses, and predicting their outcomes is challenging. Identifying characteristics in these patients that may require more intense intervention is important for clinical decision-making.Objective:This study sought to determine the characteristics and outcomes, specifically length of stay and mortality, of atopic versus non-atopic asthmatics admitted to a PICU with status asthmaticus.Methods:A retrospective study was conducted at a children’s hospital from November 1, 2008 to October 31, 2013. A total of 90 children admitted to the PICU were included in the analysis. Patients were divided into two groups based on the presence of specific historical data indicative of a clinical history of atopy. Children were considered to be atopic if they had a parental history of asthma, a personal history of eczema, or a combined history of wheezing (apart from colds) and allergic rhinitis (diagnosed by a medical provider). The median hospital Length Of Stay (LOS), PICU LOS, cardiopulmonary arrest, and mortality were compared between atopic and non-atopic asthma groups. Regression models were used to estimate the LOS stratified by atopic or non-atopic and by history of intubation in present hospitalization.Results:Median hospital LOS for atopic children was 5.9 days (IQR of 3.8-8.7) and 3.5 days (IQR of 2.2-5.5) for non-atopic asthmatics (z = 2.9, p = 0.0042). The median PICU LOS was 2.5 days (IQR 1.4-6.1) for atopic asthmatics and 1.6 days (IQR 1.1-2.4) for non-atopic asthmatics (z = 2.5, p = 0.0141). The median LOS was significantly higher for atopic intubated patients compared to non-atopic intubated patients (p=0.021). Although there was an increased tendency towards intubation in the atopic group, the difference was not significant. There was no significant difference in cardiopulmonary arrest or mortality.Conclusion:A clinical history of atopic asthma in children admitted to the PICU with status asthmaticus was associated with longer length of stays The longest LOS was observed when atopic patients required intubation.

Medication Regimens for Managing Acute Asthma.

Asthma exacerbation is defined as a progressive increase in symptoms of shortness of breath, cough, or wheezing sufficient to require a change in therapy. After ruling out diagnoses that mimic an asthma exacerbation, therapy should be initiated. Short-acting β2 agonists and short-acting muscarinic antagonists are effective as bronchodilators for asthma in the acute setting. Systemic corticosteroids to reduce airway inflammation continue to be the mainstay therapy for asthma exacerbations, and, unless there is a contraindication, the oral route is favored. Based on the current evidence, nebulized magnesium should not be routinely used in acute asthma. The evidence favors the use of intravenous magnesium sulfate in selected cases, particularly in severe exacerbations. Methylxanthines have a minimum role as therapy for asthma exacerbations but may be considered in refractory cases of status asthmaticus with careful monitoring of toxicity. Current guidelines recommend the use of helium-oxygen mixtures in patients who do not respond to standard therapies or those with severe disease.