Therapy For Acute Asthma Research Articles

The Effect of High Flow Nasal Cannula Therapy in Exercised-Induced Asthma of Children

High flow nasal cannula (HFNC) therapy is a non-invasive oxygen delivery mode which is safe and well tolerated by adults and children with respiratory distress. HFNC is increasingly used in children with respiratory distress due to mucus retention, such as bronchiolitis and acute asthma. However, he effectiveness of this therapy in acute asthma has not been well researched. To evaluate HFNC for acute childhood asthma, we designed a randomized prospective crossover trial. In the trial, children aged 6–18 years, with a forced expiratory volume in one second (FEV1) lability of ≥30% during an exercise challenge test (ECT) are included. The time of fully recovered lung function within 10% of the baseline after peak fall of FEV1 is compared with and without HFNC therapy. A 50% reduction of recovery time during HFNC therapy compared to recovery time without HFNC is considered clinically relevant, with a power of 80% and a significance level of 5%. Secondly, the pressure used by the HFNC device to deliver the constant present flow is evaluated. A relationship between the measured pressure and the degree of recovery may reveal a working mechanism behind HFNC.

Budesonide Nebulization Added to Systemic Prednisolone in the Treatment of Acute Asthma in Children: A Double-Blind, Randomized, Controlled Trial

Inhaled corticosteroids, known to be effective as a maintenance medication in chronic asthma, have also been suggested as a therapy for acute asthma when given at high doses. A double-blind, randomized, placebo-controlled trial was conducted in children aged 2 to 12 years with moderate or severe acute asthma, as determined based on a clinical score of 5 to 15 points, where 15 is the most severe. We compared the addition of budesonide 1,500 μg vs placebo to standard acute asthma treatment, which included salbutamol, ipratropium bromide, and a single dose of prednisolone 2 mg/kg given at the beginning of therapy. The primary outcome was hospital admission rate within 4 h. A total of 906 ED visits by children with moderate or severe acute asthma were evaluated. Seventy-five cases out of 458 (16.4%) in the budesonide group vs 82 of 448 (18.3%) in the placebo group were admitted (OR, 0.84; 95% CI, 0.58-1.23; P=.38). However, among cases with high baseline clinical score (≥13), significantly fewer children were admitted in the budesonide group (27 of 76 [35.5%]) than in the placebo group (39 of 73 [53.4%]; OR, 0.42; 95% CI, 0.19-0.94; P=.03). The addition of budesonide nebulization did not decrease the admission rate of children with acute asthma overall. However, it may decrease the admission rate of children with severe acute asthma. ClinicalTrials.gov; No.: NCT01524198; URL: www.clinicaltrials.gov

Pediatric fiberoptic bronchoscopy as adjunctive therapy in acute asthma with respiratory failure

Status asthmaticus respiratory failure is associated with thickened mucus secretions necessitating aggressive pulmonary clearance. The role of bronchoscopy in pediatric mechanically ventilated asthmatic patients has not been published. A chart review was performed on all pediatric intensive care unit (PICU) asthmatics with respiratory failure over 13 years. Forty-four patients were identified. Patients were managed per standardized guidelines for status asthmaticus with mechanical ventilation. Ventilator management prioritized spontaneous breathing with pressure support. Extubation criteria included spontaneous tidal volumes of 5-7 cm(3) /kg on low-pressure support. Standard endotracheal tube pulmonary toilet were implemented. Twenty-nine patients underwent bronchoscopy as an adjunctive therapy. Indications for bronchoscopy included: Pathogen identification via bronchoalveolar ravage, atelectasis, mucus obstruction resulting in severe air trapping, suspected aspiration, and poor response to standard therapy. Clinical outcomes of this intervention were compared to the fifteen patient cohort who did not undergo bronchoscopy. Bronchoscopies revealed thick mucus plugs, secretions, and bronchial casts. The large airways were lavaged for clearance of obstructive secretions with normal saline. All patients tolerated the procedure without any complications. Demonstrable improvement in pulmonary compliance was noted. The median time of intubation for the bronchoscopy group was 10 hr compared to 20.5 hr for the control group (P < 0.0005). The mean intensive care unit length of stay was 3.06 days for the bronchoscopy group versus 3.4 days for the non-bronchoscopy group (P < 0.05). Flexible bronchoscopy with bronchial lavage is a safe adjunctive therapy in pediatric asthmatics with respiratory failure resulting in reduced mechanical ventilation and intensive care length of stay. Restoring lung volume in certain asthmatics during respiratory failure may be deemed beneficial. Further validated studies are necessary to recommend bronchoscopy to the present, accepted treatment regimen in pediatric asthmatic respiratory failure.

Predicting response to therapy in acute asthma

To analyze the prediction of response of therapy into the context of acute adult asthma assessment in the emergency department (ED) setting. Close monitoring of the patient's condition at presentation (static assessment) and response to treatment (dynamic assessment), including serial measurements of lung function, is an essential part of the acute asthma care in the ED. The severity of airflow obstruction cannot be accurately judged by patient's symptoms and physical examination alone. Accordingly, it is very important to use an objective measure of airway obstruction (spirometry or peak flow meter). Although spirometry can be performed in acutely ill ED asthmatics, measurement of peak expiratory flow, with values expressed as predicted normal values, represents an alternative if spirometry is not available. Failure of initial therapy to improve expiratory flow predicts a more severe course and need for hospitalization. Although several score systems have been developed, different factors limit their applicability in the ED setting. Thus, peak expiratory flow rate measures at 15-60 min of treatment, joined with continuous monitoring of oxygen saturation may be the best ways to assess patients with acute asthma.

Antileukotrienes as Adjunctive Therapy in Acute Asthma

The leukotriene receptor antagonists (LTRAs) are a comparatively new class of asthma drugs that exhibit both bronchodilator and anti-inflammatory properties. There is a substantial body of evidence for their benefit in the management of chronic asthma in both adults and children, and particularly in specific types of asthma such as exercise-induced and aspirin-sensitive asthma. Despite best practice using current treatment guidelines for the management of acute asthma, a significant proportion of patients require continued treatment and are unable to be discharged from the emergency department; many require a short course of oral corticosteroids. The relatively rapid onset of action of LTRAs after oral administration and their additive effect to beta(2)-adrenoceptor agonists led to the hypothesis that they might be of benefit in acute asthma. This review examines the available evidence for the effect of LTRAs in acute asthma. Although the evidence is limited, it suggests that treatment with LTRAs provides additional bronchodilator effect to nebulised and inhaled beta(2)-adrenoceptor agonists. Short-term therapy with LTRAs results in fewer treatment failures and readmissions for patients with acute asthma, and less need for additional therapies such as nebulisers and corticosteroids.

A Randomized Controlled Trial of Inhaled Flunisolide in the Management of Acute Asthma in Children

Inhaled corticosteroids (ICS) may provide benefit in the therapy of acute asthma. The purpose of this study was to test the hypothesis that ICS are as effective as oral corticosteroids (OCS) in the management of acute childhood asthma. A randomized, masked, placebo-controlled study was conducted in children aged 6 to 16 years seeking emergent care for an acute exacerbation of asthma. Patients were randomized into one of two groups: group 1 (OCS), oral prednisone, 2 mg/kg (maximum of 60 mg/d) for 7 days, and placebo pressurized metered-dose inhaler with valved holding chamber, four inhalations bid; and group 2 (ICS), flunisolide, four inhalations (1 mg) bid for 7 days, and daily placebo tablets. Spirometry (FEV(1)) was performed at baseline, day 3, and day 7 of the study. A symptom diary and twice-daily peak expiratory flow were recorded. A total of 58 subjects receiving ICS (n = 27) or OCS (n = 28) were enrolled. Baseline asthma severity, race, gender, and age were balanced between the two groups. chi(2) showed no significant difference in symptom severity between the two groups at any time during the study. FEV(1) percentage of predicted was lower in the ICS group on day 3 (65% vs 78%, p = 0.03) and on day 7 (77% vs 95%, p = 0.002). ICS were found to be useful in the management of acute asthma in children; however, spirometry data suggested a more rapid resolution of asthma with OCS.

Efficacy and safety of a home‐made non‐valved spacer for bronchodilator therapy in acute asthma

The aim of this study was to assess the efficacy and safety of an alternative spacer to deliver salbutamol in acute asthma. A prospective randomized study was performed with 196 patients with acute asthma, aged 4–15 y. The clinical features, oxygen saturation (S aO2) and the best of three peak expiratory flow rate (PEFR) measurements were recorded in a standardized questionnaire. Each patient received up to three conventional doses of salbutamol through an alternative homemade non‐valved spacer (NVS) (500 ml mineral water plastic bottle) or an oxygen‐driven nebulizer (ODN). The clinical and functional respiratory parameters (PEFR and S aO2) were assessed 15 min after each administration of the bronchodilator. In the ODN (n= 99) and NVS (n= 97) groups, PEFR (p &lt; 0.05) and S aO2 (p &lt; 0.05) measurements improved in all stages of the treatment. During the asthma attacks, the ODN group needed a prolonged observation in the emergency room (p= 0.000000). Side effects of salbutamol, e.g. increased heart rate, were observed in 17.2% of the patients in the ODN group and 4.1% in the NVS group (p= 0.003). Conclusion: Both devices showed comparable efficacy in mild and moderate acute attacks, but the use of the alternative NVS resulted in a shorter observation period in the emergency room. The frequency of side effects was significantly higher in the ODN group than in the NVS group.

Nebulized salbutamol with and without ipratropium bromide in the treatment of acute asthma

Background: Routine addition of ipratropium bromide to β-agonist therapy in acute asthma is of uncertain benefit. Objective: This study was carried out to evaluate: (1) whether nebulized ipratropium (0.5 mg) plus salbutamol (2.5 mg) (Combivent) confers additional bronchodilation over nebulized salbutamol (2.5 mg) alone in patients with acute asthma and (2) whether adjustment for prognostic indicators of outcome influences any benefit seen with ipratropium. Methods: A double-blind, two-center, randomized, single-dose study was performed in 338 patients with asthma, aged 18 to 55 years, who attended the emergency department for treatment of acute asthma. The primary end point was FEV 1 at 90 minutes. Results: The mean absolute difference in FEV 1 at 90 minutes for Combivent compared with salbutamol was 113 ml (SEM ± 48 ml, p < 0.05). Independent of the study drug received, a poor response to treatment was predicted by frequent use of inhaled β-agonist before presentation ( p < 0.0001), severity of the attack ( p < 0.05), and longer duration of attack ( p < 0.05). Subjects who had taken more than 10 puffs of inhaled β-agonist through a metered-dose inhaler or who had serum salbutamol levels of greater than 2 mmol/L on presentation demonstrated no benefit from the addition of ipratropium. Patients with an FEV 1 less than 1 L on presentation also responded less well to Combivent, which was explained by the association between severity of attack and greater use of inhaled β-agonist therapy. Conclusion: A single dose of nebulized Combivent confers additional bronchodilation over salbutamol alone ( p < 0.05) in acute asthma. Patients who exhibited most benefit from the addition of ipratropium were those who had consumed the least inhaled β-agonist before presentation, not those with the most severe asthma. (J Allergy Clin Immunol 1997;100:165-70.)

Rapid infusion of magnesium sulfate obviates need for intubation in status asthmaticus

Rapid infusion of intravenous magnesium sulfate (MgSO 4) was given to two young adults with impending respiratory failure caused by status asthmaticus. The infusion of 2 g of MgSO 4 during a 2-minute period was associated with an immediate, dramatic reversal of their severe bronchospasm. This treatment obviated the need for intubation. Continuous β 2-agonist therapy was performed simultaneously, taking advantage of the MgSO 4-induced bronchodilation to deliver the β 2-agonist to the target tissues. Rapid infusion of intravenous MgSO 4 has been documented as safe in standard obstetric literature. Previous reports of MgSO 4 therapy for acute asthma have used slow infusion. This is the first report of rapid infusion of MgSO 4 for the emergency department management of asthma. In both cases, this therapy obviated the need for endotracheal intubation and mechanical ventilation.

Questioning Asthma Treatment Study

To the Editor.— The article "Methylprednisolone Therapy for Acute Asthma in Infants and Toddlers: A Controlled Clinical Trial" by Tal et al1 is interesting, but it does have some weak areas which perhaps the authors can address. First of all, the outcome which seems to be most emphasized in the study, ie, percent admitted, is a fairly weak outcome measure when compared with other more objective measures such as changes in pulmonary function. Note that the decision to discharge was made by the senior resident in charge of the emergency department.

Pulse steroid therapy offers no advantage over oral therapy in acute asthma

Pulse steroid therapy offers no advantage over oral therapy in acute asthma

Nebulised bronchodilators should remain the first-line therapy for acute asthma

Nebulised bronchodilators should remain the first-line therapy for acute asthma

Principles of nebulizer-delivered drug therapy for asthma

The principles of aerosol drug delivery by compressed-air nebulization are described, and the therapeutic agents administered by this process for management of asthma are reviewed. For therapy of acute and chronic asthma, aerosol inhalation has become the primary method of drug administration. Aerosolized particles with aerodynamic diameters of 1 to 5 microns are most efficiently deposited in the lower respiratory tract. Delivery systems for therapeutic aerosols include compressed-air nebulizers and metered-dose inhalers. Compressed-air nebulizers are less efficient than metered-dose inhalers; therefore, the drug dosages recommended for nebulizer solutions are 3 to 10 times higher than those delivered by a metered-dose inhaler. Because many asthma patients are treated with nebulization drug therapy at home, both patients and pharmacists must understand how to use the equipment correctly. Drugs used in aerosol therapy of acute and chronic asthma include the beta 2-receptor agonists epinephrine, isoproterenol, isoetharine, metaproterenol, terbutaline, and albuterol; cromolyn sodium; and the anticholinergic agents atropine and ipratropium bromide. Terbutaline and albuterol have longer durations of action and greater beta 2-receptor selectivity than metaproterenol, isoetharine, and isoproterenol. Cromolyn is a first-line prophylactic agent for asthma management. Atropine is indicated for maintenance therapy of chronic asthma and in combination with the beta 2-receptor agonists for therapy of acute asthma; ipratropium bromide is a new agent similar to atropine but with substantially fewer adverse effects. Acute and chronic asthma may be managed by aerosol administration of beta 2-receptor agonists, cromolyn, and atropine, alone or in combination. Inhalation is the preferred route of drug delivery because small doses of medication provide maximal therapeutic benefit with minimal adverse effects.

Therapy of acute asthma

Therapy of acute asthma

Asthma

Asthma is an extremely common disease that the emergency physician handles on a daily basis. Accurate clinical assessment from the history and physical examination is very important to assess the severity of the disease. Some measure of airway resistance of either FEV1 or PEFR should be done in every patient initially, at repeated intervals, and at discharge, to have a parameter to follow in therapy as well as a tool to use to warn the physician of a severe amount of airway obstruction. The inhaled beta agonists are the first line of therapy in acute asthma and can be delivered by either the nebulizer or the MDI with or without a spacer. Aminophylline will be continued to be used acutely even though it appears there is no improvement in bronchospasm in the first few hours of treatment when aminophylline is added to therapy. Anticholinergic agents will gain a wider role in acute asthma, especially when used in combination with a beta agonist. Corticosteroids continue to have a role in severe attacks of asthma, and earlier use may prevent relapse. Fatal asthma still occurs, however, and the emergency physician must use strict criteria to recognize status asthmaticus or the patient who is not doing well and admit them to the hospital. Using a stepwise, logical approach to the treatment of the asthmatic patient will lead to better patient satisfaction and fewer errors on part of the emergency physician.

Sympathomimetics in acute severe asthma: inhaled or parenteral, nebulizer or spacer?

It is accepted today that all patients with acute asthma should be treated with a sympathomimetic, irrespective of previous therapy. This short review addresses the question of the optimal mode of administration of these drugs in acute severe asthma. Inhaled sympathomimetics are as effective as subcutaneous adrenaline, or intravenous salbutamol or terbutaline, and, as they produce fewer side-effects, are recommended as the best mode of administration. However, self-medication with a ready to use subcutaneous preparation may be indicated in those patients prone to very abrupt attacks. The conventional mode of inhalation therapy in acute asthma is nebulization, but equally effective bronchodilatation may be obtained with metered-dose inhalers combined with valved spacers. Tachypnoeic patients unable to perform a conventional inhalation manoeuvre can use one-way valve inhalation devices with repeated tidal breaths. Finally, sequential or even continuous inhalation techniques have recently been advocated, particularly in patients with impending respiratory failure.

Oral vs. repository corticosteroid therapy in acute asthma

Oral vs. repository corticosteroid therapy in acute asthma

Oral vs Repository Corticosteroid Therapy in Acute Asthma

Acutely ill asthmatic patients treated in the usual fashion in an emergency room setting and discharged within six hours were studied to determine whether therapy with a single injection of a repository corticosteroid (methylprednisolone sodium acetate) could be as effective as a tapering course of oral corticosteroids in decreasing asthma symptomatology and relapse within seven days. Seventeen patients (18 episodes of asthma) formed the study population. Eight episodes occurred in patients who received depot methylprednisolone (group 1) and ten episodes in patients who received oral corticosteroid treatment (group 2). All patients in both groups improved following emergency room treatment. Relapse occurred in two of ten patients in group 2 and none in group 1. Symptoms attributable to asthma recurred in significantly more patients in group 2 than in group 1 (9 vs 0, p less than .01). Side effects from therapy with corticosteroids were rare. This study indicates that intramuscular repository corticosteroids are at least as effective as oral corticosteroids in the management of the acute asthmatic outpatient, with a distinct advantage with regard to patient compliance.

NEBULISED SALBUTAMOL IN ACUTE ASTHMA - EFFECT ON OXYGENATION

The effect of oxygenation of nebulised salbutamol, given with compressed air, was studied in 18 patients (aged 18 months to 9 years) with acute asthma. A Radiometer TCM2 transcutaneous oxygen monitor was used, preliminary studied having shown that this accurately reflects trends in arterial oxygen tension. Heart and respiratory rates were measured at 10 minute intervals and transcutaneous oxygen (TcO2) continuously. Values of TcO2 were averaged over 10 minute periods. Given when baseline TcO2 was stable, nebulised salbutamol was associated with a rise of TcO2 in 9 children (range 1.1 - 13.3 mmHg, mean 5.2) and a fall in 4 (range 1.1 - 7.3 mmHg, mean 4.7) at 10-20 minutes after nebulised therapy. 5 children fell asleep during or shortly after treatment, and all of these showed a fall in TcO2 (Range 5.4 - 19, mean 9.8) with the onset of sleep. Heart rate increased in all, this effect being maximal immediately after nebulisation. The changes in TcO2 were not predictable on the basis of age, initial TcO2, heart or respiratory rate, though children who fell asleep tended to have higher initial pulse and respiratory rates. These results emphasise the need for caution in the use of home nebulised therapy in acute asthma.

The antidiuretic hormone response to therapy for acute asthma.

The plasma antidiuretic hormone concentrations in eight asthmatic children were measured at the onset of an acute severe attack and were repeated 24 h later. Conventional therapy and maintenance fluid intake resulted in a significant fall in antidiuretic hormone concentrations without abnormal changes in other biochemical indicators of dehydration.