Treatment Of Acute Severe Asthma Research Articles

Status asthmaticus

Severe acute asthma (SAA) is life threatening and warrants fast and effective intervention. The severity of SAA can be assessed through a focused and concise clinical examination. Important signs of a life threatening attack are decreased consciousness, imminent exhaustion, oxygen saturation below 85% and diminished air movement on auscultation (silent chest). The severity of SAA can be expressed in an asthma score. The relative contribution of airway inflammation, bronchoconstriction and mucusplugging must be weighed for treatment choices. The pillars of treatment of SAA in the general pediatric practice are oxygen, continuous nebulization of salbutamol, systemic corticosteroids, intravenous magnesium sulphate and perhaps intravenous salbutamol. Further steps in treatment of unresponsive SAA should be initiated in consultation with the pediatric intensive care. Reasons for transfer to a pediatric intensive care are imminent exhaustion and/or respiratory insufficiency, need for mechanical ventilation and intravenous salbutamol.

Continuous Levalbuterol and Albuterol Comparable

Source: Andrews T, McGintee E, Mittal MK, et al. High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial. J Pediatr. 2009;155(2):205–210; doi:10.1016/j. jpeds.2009.01.073Investigators from the Children’s Hospital of Philadelphia performed a randomized, double-blind, controlled trial comparing continuous administration of nebulized albuterol 20 mg/hr or levalbuterol ([R]-albuterol) 10 mg/hr to children aged 6 to 18 years admitted to the hospital with status asthmaticus. Study eligibility required participants to have an established diagnosis of asthma. Patients in status asthmaticus who did not show a substantial clinical improvement with standardized care in the emergency department, including three 5-mg doses of nebulized albuterol, two 500-mcg doses of ipratropium bromide, and a 2 mg/kg dose (to a maximum of 60 mg) of either oral prednisolone or parenteral methylprednisolone, were eligible for enrollment. In addition to the study medications, enrolled children received oral prednisone/prednisolone or intravenous methylprednisolone and they continued at home doses of inhaled corticosteroids. Patient response to treatment as measured by the Pediatric Asthma Severity Score1 was used to wean asthma medications. The primary outcome was duration of continuous nebulized β-agonist therapy. Blood samples were taken from the first 40 children to assess serum concentration of (S)- and (R)-albuterol, blood glucose, and potassium.One hundred forty-three patients were approached for potential enrollment and 81, with a mean age of 10 years, were enrolled. More than 90% were African American. The median duration of continuous inhaled β-agonists was not significantly different, 18.3 hours for albuterol and 16 hours for levalbuterol. The median time to be ready for discharge did not differ significantly (45 hours vs 46 hours) between the groups. There were no differences in mean or maximum heart rate, mean glucose, or serum potassium concentrations between groups. (S)-albuterol concentrations were significantly greater in the albuterol group at all time points measured; however, (R)-albuterol concentrations were similar in both groups.The authors conclude that both continuous albuterol and levalbuterol treatments were well tolerated in patients who had failed initial albuterol therapy and had similar efficacy.Dr Ibsen has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Asthma is a leading cause of hospitalization of children, and costs related to asthma care, particularly those associated with emergency and hospital-based treatment, are increasing. Systemic corticosteroids combined with frequent repeated administration of short-acting β-adrenergic agonists remain the basis of most acute asthma treatments. Continuous administration of β-agonists, utilized in severely ill patients, results in increased bronchodilation compared with intermittent treatment.2Albuterol is available as a racemic mixture of (R)-albuterol and (S)-albuterol. (R)-albuterol is the therapeutically active form with significantly higher affinity for β2-agonist receptors, and produces bronchodilation as well as tachycardia and tremor. (S)-albuterol has been shown in vitro to promote inflammatory cell and smooth muscle proliferation, to increase intracellular calcium, and to enhance airway hyper-responsiveness. The commercial availability of pure (R)-albuterol, levalbuterol, has led to evaluation of the therapeutically active form. However, studies comparing levalbuterol with racemic albuterol report inconsistent findings.3,4Levalbuterol is substantially more expensive than racemic albuterol so it is worth understanding if there is clinical benefit to its use. The study institution had a well-defined asthma protocol that included continuous albuterol for approximately 40% of hospitalized patients, and care and progression of patients in the study continued to be directed by the standard inpatient asthma protocol.The authors concluded that there were no significant differences in either clinical effectiveness or adverse effects between continuous levalbuterol and racemic albuterol. Interestingly, nine patients (11% of those enrolled) required re-institution of continuous therapy after weaning to intermittent therapy, six in the racemic group and three in the levalbuterol group. Although the numbers are small, this may represent an effect of the long-acting (S)-albuterol on airway responsiveness.This study expands our understanding of the place for levalbuterol in the treatment of severe pediatric asthma. There appears to be no benefit for the routine use of continuous levalbuterol over albuterol in the treatment of severe acute asthma. Because all patients in the study were exposed to (S)-albuterol prior to study entry, further investigation may yet demonstrate some benefit to using levalbuterol as initial therapy for severe acute asthma.

Emergency presentation and management of acute severe asthma in children.

Acute severe asthma is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition. In this article we present a summary of the pathophysiology as well as guidelines for the treatment of acute severe asthma in children. The cornerstones of the management of acute asthma in children are rapid administration of oxygen, inhalations with bronchodilators and systemic corticosteroids. Inhaled bronchodilators may include selective b2-agonists, adrenaline and anticholinergics. Additional treatment in selected cases may involve intravenous administration of theophylline, b2-agonists and magnesium sulphate. Both non-invasive and invasive ventilation may be options when medical treatment fails to prevent respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.

An under-recognized complication of treatment of acute severe asthma

A 39-year-old man presented to the emergency department (ED) in severe respiratory distress. He had a prior diagnosis of brittle asthma and had been admitted on several occasions but never previously ventilated. Therapy given in the first 3 hours of arrival included nebulized salbutamol (5 mg, x5), ipratropium bromide (0.5 mg), intravenous hydrocortisone (200 mg), and magnesium sulfate (2 g). His arterial blood gases continued to deteriorate. He was then given an intravenous bolus of salbutamol (250 microg) and heliox via facemask. His worsening status necessitated invasive ventilation. His hypercapnia and resultant respiratory acidosis improved rapidly, but there was a concurrent accumulation of lactic acid resulting in acidemia. This patient had lactic acidosis as a direct effect of administration of salbutamol. The development of hazardous salbutamol-induced toxicity in acute severe asthma is discussed.

Treatment of acute severe asthma in children

重症哮喘(severe asthma)患儿在临床上较为常见.由于严重的支气管痉挛、黏液过度分泌和气道炎症、水肿等影响,如不及时治疗可发展至呼吸衰竭甚至死亡,是临床急症之一.重症哮喘在全球仍是收入PICU患儿的常见疾病,并仍然有很高的病死率.有资料报道,美国15岁以下哮喘患儿病死率从1979年的1.2/10万上升至1995年的2.1/10万.我国目前尚无全国性流行病学调查数据.高度重视、早期确诊、恰当治疗、减少并发症是降低病死率的关键[1]。

Systemic Steroids for the Treatment of Acute Asthma

In Brief Despite over 50 years of clinical experience, many uncertainties persist with respect to the onset of action, dose–response characteristics, duration of treatment, and optimal route of administration of systemic steroids when used in the treatment of severe acute asthma. Studies show that treating severe acute asthma with systemic corticosteroids within 1 hour of presentation to the emergency department lowers hospitalization rates and improves pulmonary function. The onset of action may be seen in as little as 2 hours in studies using peak flow, but may be delayed as much as 6 hours in studies using forced expiratory volume in 1 second as the pulmonary function outcome measure. A clear dose–response is seen at doses below 40 mg per day of methylprednisolone or equivalent; however, there is limited evidence for any added efficacy when doses above 60 to 80 mg per day are administered. There is no clear benefit of intravenous systemic steroids over oral steroids for treatment of severe acute asthma. High-dose inhaled corticosteroids may have a potential role, but further studies are needed to confirm efficacy. There is good evidence that a short course of oral systemic steroids for 3 to 7 days after initial steroid therapy prevents rebound asthma symptoms; no steroid taper is required if the patient was receiving inhaled steroids. Intramuscular steroids are at least equally effective and may be useful in patients who poorly adhere to their medication regimens; however, they are associated with more side effects than oral therapy. After more than 50 years of clinical experience using systemic corticosteroids for severe, acute asthma, there remains considerable uncertainty as to the onset of action, dose–response characteristics, duration of treatment, and optimal route of administration. A review of the literature offers guidance but many questions remain.

Anticholinergic agents in asthma: chronic bronchodilator therapy, relief of acute severe asthma, reduction of chronic viral inflammation and prevention of airway remodeling

It is difficult to identify specific groups of asthmatic patients who may benefit from acute or chronic use of anticholinergic agents. Therefore, an important consideration is how anticholinergic agents can be used to achieve clinically effective treatment of asthma. A genotype-stratified study revealed that greater bronchoprotective effect of anticholinergic agents was observed in asthmatic patients with the Arg/Arg genotype of the beta2-adrenergic receptor. Anticholinergic agents could add to the bronchodilation obtained with beta2-agonists on acute severe asthma. CD8+ T lymphocytes induced by chronic hepatitis C viral infection causes chronic obstructive pulmonary disease-like inflammation in asthma. Virus-specific CD8+ T lymphocytes may induce cholinergic activation in asthma through M2 receptor dysfunction. Therefore, anticholinergic agents are highly effective for asthma associated with chronic viral infection. In contrast, asthma with chronic obstructive pulmonary disease-like inflammation appears to be poorly responsive to beta2-agonists and can lead to partially irreversible airflow limitation. Moreover, a recent report suggested that treatment with inhaled tiotropium bromide markedly inhibited the increase in airway smooth muscle mass, myosin expression, and contractility in asthma. Anticholinergic agents may benefit stable asthmatics, particularly those who have the Arg/Arg genotype. These agents have a demonstrated role in combination with beta2-agonists in the treatment of acute severe asthma, and may benefit asthmatics with chronic obstructive pulmonary disease-like inflammation. Moreover, these agents could be also beneficial in preventing airway remodeling in asthmatic airways.

Measuring Health-Related Quality of Life in Adults During an Acute Asthma Exacerbation

Acute severe asthma can be distressing for patients. It is important to be able to identify the causes of the distress so that these can receive attention in conjunction with the conventional treatment of the airways. To modify the Asthma Quality of Life Questionnaire (AQLQ) for evaluating patients with acute severe asthma and to test the measurement properties of the Acute Asthma Quality of Life Questionnaire (Acute AQLQ). The Acute AQLQ contains the symptom and emotional function items of the AQLQ (n = 11), which are capable of changing over short periods of time. The measurement properties were tested during a clinical trial to compare formoterol and salbutamol in the treatment of acute severe asthma in hospital emergency departments. The 88 patients in the clinical trial provided evidence that the Acute AQLQ has high internal consistency (Cronbach alpha = 0.90) and is very responsive to change in status (p < 0.00001) with a responsiveness index of 2.5. Correlations between the Acute AQLQ and other measures of clinical status provided evidence of the validity of the instrument. The Acute AQLQ has strong measurement properties and can be used with confidence to identify the problems that are distressing to patients during an acute asthma exacerbation and to evaluate the effectiveness of interventions.

The effect of nebulized magnesium sulfate on the treatment of acute asthma

Most previous studies have shown a significant bronchodilating effect of intravenous magnesium sulfate (MgSO4) in the treatment of acute severe asthma. However, the role of inhaled MgSO4 in such cases is less well defined. In this randomized, double-blind, placebo-controlled trial, 52 individuals with acute, severe asthma exacerbations were treated by nebulization with either 2.5 ml of isotonic MgSO4 or isotonic saline solution on 3 occasions at 30-minute intervals. Other treatments, including nebulized albuterol, were given to all subjects through use of a standard protocol. After this 90-minute treatment period, the FEV1 was significantly greater after MgSO4 treatment than after saline treatment (mean, 1.96 vs 1.55 L; P = .003). The authors conclude that the use of isotonic magnesium as an adjuvant to nebulized albuterol results in an enhanced bronchodilator response in the treatment of severe asthma. However, it is unclear from their findings whether the frequency of in-patient admissions would be decreased significantly in those treated with nebulized MgSO4. In addition, other studies have concluded that MgSO4 treatment does not significantly enhance the rate or degree of improvement in the therapy of mild to moderate asthma flares.

Triple Inhaled Drug Protocol for the Treatment of Acute Severe Asthma

This study tests the hypothesis that the administration of multiple doses of inhaled albuterol (A), ipratropium bromide (IB), and flunisolide (F) provides an additional benefit to adults with acute severe asthma compared with the administration of A plus IB (A/IB) or A plus F (A/F). Randomized, double-blind, prospective trial. One hundred seventy-two patients who presented to an emergency department were assigned to receive A, IB, and F (ie, triple drug treatment [TDG]; 56 patients), A/IB (60 patients), or A/F (56 patients). All drugs were administered through a metered-dose inhaler and spacer at 10-min intervals for 3 h. Patients who received TDG had an overall 64% greater improvement (95% confidence interval [CI], 24 to 103%; p = 0.002) in FEV(1) (mean [+/- SD], 2.1 +/- 0.6 L) than those who received A/F (mean, 1.7 +/- 0.6 L), and a 41% greater improvement (95% CI, 1 to 80%; p = 0.04) than those who received A/IB (mean, 1.8 +/- 0.6 L). Differences between groups increased with time (p = 0.001). At 3 h, there was a trend toward a reduction in hospital admission rates (A/IB group, 25%; A/F group, 20%; and TDG group, 11%). The patients who were the most likely to benefit (ie, those with a greater improvement in pulmonary function and a significant reduction in the hospitalization rate) from TDG were those with more severe obstruction (ie, FEV(1), < 30% of predicted). The benefit of TDG was equally evident independent of the patient's previous use of corticosteroids. The data suggest that there was a therapeutic benefit from the addition of IB and F to A administered in high doses, particularly in those patients in whom the FEV(1) was < 30% of the predicted value.

Inhaled therapy for acute adult asthma.

To evaluate recent developments on emergency department inhalotherapy in non-intubated acute adult asthma patients. There is evidence that high-flow oxygen can be associated with hypercarbia, and that full humidification of the inspired gases should be recommended. On the contrary, there is a lack of evidence to support the role of heliox in the initial treatment of acute asthma. Specific short-acting inhaled beta(2)-agonists are the drugs of choice. A more rapid and profound bronchodilatation with fewer side effects and less time of treatment can be achieved when sufficient doses are given using pressurized meter dose inhalers and large-volume valved-spacers, particularly in patients with the most severe obstruction. Findings argue against the routine use of continuous nebulization. High and repetitive doses of ipratropium bromide in combination with beta(2)-agonists are indicated as first line treatment of severe acute asthma. There is insufficient evidence that inhaled corticosteroids alone are as effective as systemic corticosteroids. Finally, the combination of nebulized magnesium and albuterol provides no benefit in addition to that provided by therapy with albuterol in patients with mild-to-moderate asthma exacerbations. According to the latest evidence, the goals of treatment may be summarized as follows: maintenance of adequate arterial oxygen saturation with supplemental oxygen, relief of airflow obstruction by administration of inhaled beta-agonists and anticholinergics, and reduction of airway inflammation and prevention of future relapses by using early administration of systemic corticosteroids.

Treatment of acute severe asthma and chronic obstructive pulmonary disease in Danish hospitals. Do national recommendations improve on the quality of the treatment?

Studies have demonstrated suboptimal treatment of acute severe asthma and chronic obstructive pulmonary disease COPD). We examined the quality of treatment in Denmark and the effect of intervention, by publication of recommendations for standardised treatment. All 70 hospitals in Denmark with emergency facilities participated in a telephone questionnaire, examining treatment behaviours among house officers. The survey was repeated 3 years later, after publication of national recommendations for treatment of acute exacerbations of asthma and COPD. The response rate in both surveys was 100%. An insufficient handling of nebulisers, a huge variation in the delivered dose of bronchodilators and a suboptimal use of corticosteroids was found. A significant trend towards more liberate use of oxygen was seen in both asthma (3.2 l min −1 versus 4.8 l min −1, P<0.001) and COPD (1.5 l min −1 versus 1.9 l min −1, P=0.047). Further, a huge difference in treatment behaviours was revealed from this survey. The knowledge among house officers of basic principles of treatment was insufficient. Treatment behaviour was only moderately affected by national publication of detailed recommendations for treatment. This study indicates a need for implementing tools for quality control.

Oxygen, ??2-agonists and corticosteroids the backbone of treatment for acute severe asthma in hospitalised children

Oxygen, ??2-agonists and corticosteroids the backbone of treatment for acute severe asthma in hospitalised children

IV Magnesium Sulfate in the Treatment of Acute Severe Asthma: A Multicenter Randomized Controlled Trial

Studies of IV magnesium sulfate as a treatment for acute asthma have had mixed results, with some data suggesting a benefit for acute severe asthma, but not for mild-to-moderate asthma. In a multicenter cohort, this study tests the hypothesis that administration of magnesium sulfate improves pulmonary function in patients with acute severe asthma. Placebo-controlled, double-blind, randomized clinical trial. Emergency departments (EDs) of eight hospitals. Patients aged 18 to 60 years presenting with acute asthma and FEV1 < or = 30% predicted on arrival to the ED. All patients received nebulized albuterol at regular intervals and IV methylprednisolone. Two grams of IV magnesium sulfate or placebo were administered 30 min after ED arrival. The primary efficacy end point was FEV1 at 240 min, and the data analysis was intent to treat. Two hundred forty-eight patients were included, and the mean FEV1 on ED arrival was 22.9% predicted. At 240 min, patients receiving magnesium had a mean FEV1 of 48.2% predicted, compared to 43.5% predicted in the placebo-treated group (mean difference, 4.7%; 95% confidence interval [CI], 0.29 to 9.3%; p = 0.045). A regression model confirmed the effect of magnesium compared to placebo was greater in patients with a lower initial FEV1 (p < 0.05). If the initial FEV1 was < 25% predicted, the final FEV1 was 45.3% predicted in the magnesium-treated group and 35.6% predicted in the placebo-treated group (mean difference, 9.7%; 95% CI, 4.0 to 15.3%; p = 0.001). If the initial FEV was > or = 25% predicted, magnesium administration was not beneficial; the final FEV1 was 51.1% predicted in the magnesium-treated group and 53.9% predicted in the placebo-treated group (mean difference, - 2.9%, 95% CI, - 9.4 to 3.7; p = not significant). Overall, the use of magnesium sulfate did not improve hospital admission rates. Administration of 2 g of IV magnesium sulfate improves pulmonary function when used as an adjunct to standard therapy in patients with very severe, acute asthma.

Drug therapy approaches in the treatment of acute severe asthma in hospitalised children.

Acute severe paediatric asthma remains a serious and debilitating disease throughout the world. The incidence and mortality from asthma continue to increase. Early, effective and aggressive outpatient therapy is essential in reducing symptoms and preventing life-threatening progression. When complications occur or when the disease progresses to incipient respiratory failure, these children need to be managed in a continuous care facility where aggressive and potentially dangerous interventions can be safely instituted to reverse persistent bronchospasm. The primary drugs for acute severe asthma include oxygen, corticosteroids, salbutamol (albuterol) and anticholinergics. Second-line drugs include heliox, magnesium sulfate, ketamine and inhalational anaesthetics. Future therapies may include furosemide, leukotriene modifiers, antihistamines and phosphodiesterase inhibitors. This review attempts to explore the multitude of medications available with emphasis on pharmacology and pathophysiology.

Comparison of the effects of intravenous and oral montelukast on airway function: a double blind, placebo controlled, three period, crossover study in asthmatic patients

BACKGROUNDMontelukast, a leukotriene receptor antagonist, improves parameters of asthma control including forced expiratory volume in one second (FEV1) when given orally to patients aged six years or older. This study...

Randomized Controlled Trial of Ipratropium Bromide and FrequentLow Doses of Salbutamol in the Management of Mild and Moderate AcutePediatric Asthma

Ducharme FM, Davis GMJ Pediatr.1331998479485Previous studies have demonstrated the benefit of inhaled ipratropium as an adjunct to inhaled β2 bronchodilators in the treatment of acute severe asthma in children. The purpose of this study was to observe children with mild to moderate exacerbations of asthma, comparing the efficacy, safety, and possible synergy of inhaled salbutamol with or without inhaled ipratropium.Two hundred ninety-eight events in 275 patients were analyzed. The children were 3 to 17 years of age and presented to a single emergency room facility with mild to moderate exacerbations of asthma over a 2½-year period of time. To qualify they also had to be able to reproducibly perform forced oscillometry (a noneffort dependent, quiet breathing/tidal volume measurement of airway resistance) and they required more than one salbutamol treatment.The study was blinded, randomized, and placebo-controlled for the ipratropium. Patients were excluded if they had a severe asthma exacerbation, or significant comorbidity such as heart disease or cyctic fibrosis. Eligible patients were randomized to one of four treatment groups: high-dose salbutamol (0.15 mg/kg q 60 minutes; maximum dose 5 mg) with or without 250 μg ipratropium; frequent low-dose salbutamol (0.075 mg/kg q 30 minutes) with or without ipratropium. Ipratropium or placebo were given only once 30 minutes after the first salbutamol treatment. The primary endpoint was the change from baseline in respiratory resistance as measured by forced oscillometry. Values were ascertained at the time of the peak effect of both drugs; 30 minutes after salbutamol and 60 minutes after ipratropium. Secondary endpoints were oxygen saturation, the need for oral corticosteroids as a discharge medication, hospital admission, and relapse within 10 days. Prior home treatment and maintenance medications were cofactored into the analysis.The use of forced oscillometry allowed 69% of the children to participate who would have otherwise been excluded by the inability to reproducibly perform standard spirometry. All treatment groups improved significantly from baseline to 90 minutes (P < .001). There were no differences in the acute management at home nor the physician assessment of severity among the four treatment groups. No group differences were observed in the magnitude of improvement or in the number of patients who required an additional hour of treatment. In a subgroup of children in whom cough and rhonchi were prominent features, the anticholinergic effects of ipratropium did not provide additional benefit beyond salbutamol alone. There were no group differences in the need for corticosteroids, oxygen saturation, hospitalization rates, or relapse rates. The frequent, low-dose regimen of salbutamol was associated with a greater incidence of vomiting than hourly, high-dose salbutamol. There were no group differences in the incidence of other side effects.In children with a mild to moderate exacerbation of asthma neither frequent low-dose salbutamol nor the addition of inhaled ipratropium provided additional beneficial effect compared with hourly high-dose salbutamol alone.This is the largest study of its kind and unique in its ability to objectively evaluate changes in lung function in young children who represent a significant population of pediatric asthma patients presenting for acute care for mild to moderate exacerbations. Previous studies have demonstrated the benefit of frequent low-dose albuterol and the synergistic effect of inhaled ipratropium in children with severe exacerbations. This study suggests that these intense strategies may not be necessary for children with mild to moderate exacerbations, economizing on provider time and materials without sacrificing patient outcomes. However, it is possible that higher or more frequent doses of ipratropium may have shown a greater improvement in lung function as suggested in recent studies (Querishi FA, et al. Ann Emerg Med. 1997;29:205–211 and Schuh S, et al. J Pediatr. 1995;126:639–645).

Effect of Nebulized Ipratropium on the Hospitalization Rates ofChildren With Asthma

1. Qureshi F, 2. Pestian J, 3. Davis P, 4. et al. (1998) N Engl J Med. 339:1030–1035. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] #### Purpose β-agonists have been identified as primary therapy for acute asthma and adjunctive therapy with anticholinergic agents has yielded variable results. This study evaluates the addition of ipratropium to β-agonist in the treatment of acute asthma. ##### Study Population A double-blind study of 434 children (2–18 years) … [1]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DQureshi%26rft.auinit1%253DF.%26rft.volume%253D339%26rft.issue%253D15%26rft.spage%253D1030%26rft.epage%253D1035%26rft.atitle%253DEffect%2Bof%2BNebulized%2BIpratropium%2Bon%2Bthe%2BHospitalization%2BRates%2Bof%2BChildren%2Bwith%2BAsthma%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJM199810083391503%26rft_id%253Dinfo%253Apmid%252F9761804%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1056/NEJM199810083391503&link_type=DOI [3]: /lookup/external-ref?access_num=9761804&link_type=MED&atom=%2Fpediatrics%2F104%2FSupplement_2%2F394.2.atom [4]: /lookup/external-ref?access_num=000076294800003&link_type=ISI

Severe acute asthma in the child

OBJECTIVE: To present a current review about diagnosis and treatment of severe acute asthma, based on the reviewed publications and the authorś personal experience. METHODS: We reviewed the most relevant articles about diagnosis and management of severe acute asthma. RESULTS: Severe acute asthma is an important cause of morbidity in children and it can usually lead to respiratory failure. The diagnostic (clinical manifestations and lung function tests) and treatment (oxygen, bronchodilators and steroids) are now well determined by the literature, and are very important for a good prognosis of every patient. CONCLUSIONS: Considering severe acute asthma a prevalent condition in pediatric emergency room and intensive care unit, the ability to make an early diagnosis of this condition, associated with a prompt treatment, are essential for an effective reduction in morbimortality rates.

Salbutamol treatment of acute severe asthma in the ED: MDI versus hand-held nebulizer

The objectives of this study were to compare the efficacy of salbutamol delivered by either metered-dose inhaler plus spacer (MDI-spacer) or by wet nebulization (NEB), and to determine the relationships between physiologic responses and plasma salbutamol concentrations. Asthmatic patients presenting to the emergency department (ED) with acute severe asthma (forced expiratory volume in the first second [FEV 1] less than 50% of predicted) were enrolled in a randomized, double-blind, parallel-group study. The MDI-spacer group received salbutamol, delivered via MDI into a spacer device, in four puffs actuated in rapid succession at 10-minute intervals (2.4 mg/h). The NEB group was treated with nebulized salbutamol, 1.5 mg, via nebulizer at 15-minute intervals (6 mg/h). Doses were calculated on the basis of the percentage of total dose that reaches the lower airway with both methods. The protocol involved 3 hours of this treatment. Mean peak expiratory flow rate (PEFR) and FEV 1 improved significantly over baseline values for both groups ( P = .01). However, there were no significant differences between both groups for PEFR and FEV 1 at any point studied. The examination of the relationships between cumulative dose of salbutamol and change in FEV 1 showed a significant linear relationship ( P = .01) for both methods (MDI r = .97; NEB r = .97). The regression equations showed that for every 1 mg of salbutamol by MDI-spacer, 2.5 mg are needed from nebulization to have equal therapeutic response. At the end of treatment, the salbutamol plasma levels were 10.1 ± 1.6 ng/ml for the MDI-spacer group and 14.4 ± 2.3 ng/ml for the NEB group ( P = .0003). Both groups showed a nonsignificant heart rate decrease. A significant group-by-time interaction means that differences between groups increased with time ( P = .04). Additionally, the NEB group presented a higher incidence of tremor ( P = .03) and anxiety ( P = .04), reflecting larger systemic absorption of salbutamol. These data indicate that when doses used are calculated on the basis of the percentage of total drug that reaches the lower airway, there was equivalent bronchodilatation after salbutamol administered by either MDI-spacer or nebulization in patients with acute severe asthma. However, nebulizer therapy produced greater side effects related to the increase in salbutamol absorption and higher plasma level.