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Chest Feb 2018Asthma during pregnancy poses a common, increasingly prevalent threat to the health of women and their children. The present article reviews recent insights gained from... (Review)
Review
Asthma during pregnancy poses a common, increasingly prevalent threat to the health of women and their children. The present article reviews recent insights gained from the epidemiology of asthma during pregnancy, demonstrating the many short- and long-term risks to mother and fetus incurred by poorly controlled maternal asthma. We further discuss emerging evidence that active management of asthma during pregnancy can positively influence and perhaps completely mitigate these poor outcomes. Recent high-quality trials examining best methods for asthma treatment are reviewed and synthesized to offer an evidence-based pathway for comprehensive treatment of asthma in the outpatient setting. Safe and effective medications, as well as nonpharmacologic interventions, for asthma during pregnancy are discussed, and treatment options for related conditions of pregnancy, including depression, rhinitis, and gastroesophageal reflux, are presented. Throughout, we emphasize that an effective treatment strategy relies on a detailed patient evaluation, patient education, objective measurement of asthma control, and frequent and supportive follow-up. The cardiovascular and respiratory physiology of pregnancy is reviewed, as well as its implications for the management of patients with asthma, including patients requiring intubation and mechanical ventilation. For the situation when outpatient asthma management has failed, an approach to the critically ill pregnant patient with status asthmaticus is detailed. Multidisciplinary teams that include pulmonary specialists, obstetricians, primary care providers, nurses, pharmacists, and asthma educators improve the care of pregnant women with asthma.
Topics: Adrenal Cortex Hormones; Anti-Asthmatic Agents; Asthma; Bronchodilator Agents; Female; Humans; Patient Education as Topic; Pregnancy; Pregnancy Complications; Respiration, Artificial; Respiratory Function Tests
PubMed: 28867295
DOI: 10.1016/j.chest.2017.08.029 -
Pediatrics Mar 2014Dexamethasone has been proposed as an equivalent therapy to prednisone/prednisolone for acute asthma exacerbations in pediatric patients. Although multiple small trials... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVE
Dexamethasone has been proposed as an equivalent therapy to prednisone/prednisolone for acute asthma exacerbations in pediatric patients. Although multiple small trials exist, clear consensus data are lacking. This systematic review and meta-analysis aimed to determine whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. The primary outcome of interest was return visits or hospital readmissions.
METHODS
A search of PubMed (Medline) through October 19, 2013, by using the keywords dexamethasone or decadron and asthma or status asthmaticus identified potential studies. Six randomized controlled trials in the emergency department of children ≤18 years of age comparing dexamethasone with prednisone/prednisolone for the treatment of acute asthma exacerbations were included. Data were abstracted by 4 authors and verified by a second author. Two reviewers evaluated study quality independently and interrater agreement was assessed.
RESULTS
There was no difference in relative risk (RR) of relapse between the 2 groups at any time point (5 days RR 0.90, 95% confidence interval [CI] 0.46-1.78, Q = 1.86, df = 3, I2 = 0.0%, 10-14 days RR 1.14, 95% CI 0.77-1.67, Q = 0.84, df = 2, I2 = 0.0%, or 30 days RR 1.20, 95% CI 0.03-56.93). Patients who received dexamethasone were less likely to experience vomiting in either the emergency department (RR 0.29, 95% CI 0.12-0.69, Q = 3.78, df = 3, I2 = 20.7%) or at home (RR 0.32, 95% CI 0.14-0.74, Q = 2.09, df = 2, I2 = 4.2%).
CONCLUSIONS
Practitioners should consider single or 2-dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.
Topics: Acute Disease; Anti-Inflammatory Agents; Asthma; Child; Clinical Trials as Topic; Dexamethasone; Humans
PubMed: 24515516
DOI: 10.1542/peds.2013-2273 -
Respiratory Care Aug 2021High-flow nasal cannula (HFNC) has been used in the treatment of pediatric asthma, although high-quality data comparing HFNC to aerosol mask nebulizer are lacking. We...
BACKGROUND
High-flow nasal cannula (HFNC) has been used in the treatment of pediatric asthma, although high-quality data comparing HFNC to aerosol mask nebulizer are lacking. We hypothesized that HFNC would perform similarly to the aerosol mask for meaningful clinical outcomes in children with critical asthma.
METHODS
We retrospectively reviewed the medical records of children with critical asthma (age 2-17 y) with a modified pulmonary index score (MPIS) ≥ 8 admitted to our pediatric ICU as part of a quality improvement project. Patients were managed with our MPIS-based, respiratory therapist-driven protocol. Subjects were divided into 2 cohorts by initial respiratory support: HFNC or aerosol mask. Data included demographics, initial respiratory support, and MPIS over time. Primary outcome was hospital length of stay (LOS). Secondary outcome was difference in MPIS over time.
RESULTS
We included 171 subjects, with 104 in the HFNC group and 67 in the aerosol mask group. Median (interquartile range [IQR]) age was lower in the HFNC group (5 [IQR 4-9] vs 7 [IQR 5-10] y, = .006)], while other demographic characteristics were similar. Initial MPIS was similar between HFNC and aerosol mask groups (11 [IQR 9-12] vs 10 [IQR 9-12], = .15). There were no significant differences for hospital LOS (2.9 [IQR 2.1-3.9] vs 3.0 [IQR 2.3-4.4] d, = .47), pediatric ICU LOS (1.9 [IQR 1.4-2.8] vs 1.8 [IQR 1.5-3.0] d, = .92), or time to MPIS < 6 (1.0 [IQR 0.6-1.6] vs 1.3 [IQR 0.8-1.9) d, = .09) between the HFNC and aerosol mask groups, respectively. Median time on continuous albuterol was shorter in the HFNC group compared to the aerosol mask group (1.0 [IQR 0.7-1.8] vs 1.5 [IQR 0.9-2.3] d, = .048). Of note, 16 (24%) subjects in the aerosol mask group were eventually treated with HFNC. Use of a helium-oxygen mixture and noninvasive ventilation was similar between groups.
CONCLUSIONS
HFNC performed similarly to aerosol mask in pediatric patients with critical asthma.
Topics: Adolescent; Albuterol; Asthma; Cannula; Child; Child, Preschool; Humans; Nebulizers and Vaporizers; Noninvasive Ventilation; Oxygen Inhalation Therapy; Respiratory Insufficiency; Retrospective Studies
PubMed: 33975902
DOI: 10.4187/respcare.08740 -
American Journal of Respiratory and... Dec 2020Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been...
Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been well studied in asthma. To assess the association between noninvasive ventilation and subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted with asthma exacerbation to the ICU. We performed a retrospective cohort study using administrative data collected during 2010-2017 from 682 hospitals in the United States. Outcomes included receipt of invasive mechanical ventilation and in-hospital mortality. Generalized estimating equations, propensity-matched models, and marginal structural models were used to assess the association between noninvasive ventilation and outcomes. The study population included 53,654 participants with asthma exacerbation. During the study period, 13,540 patients received noninvasive ventilation (25.2%; 95% confidence interval [CI], 24.9-25.6%), 14,498 underwent invasive mechanical ventilation (27.0%; 95% CI, 26.7-27.4%), and 1,291 died (2.4%; 95% CI, 2.3-2.5%). Among those receiving noninvasive ventilation, 3,013 patients (22.3%; 95% CI, 21.6-23.0%) required invasive mechanical ventilation after first receiving noninvasive ventilation, 136 of whom died (4.5%; 95% CI, 3.8-5.3%). Across all models, the use of noninvasive ventilation was associated with a lower odds of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58). Those who received noninvasive ventilation before invasive mechanical ventilation were more likely to have comorbid pneumonia and severe sepsis. Noninvasive ventilation use during asthma exacerbation was associated with improved outcomes but should be used cautiously with acute comorbid conditions.
Topics: Adult; Aged; Asthma; Cohort Studies; Comorbidity; Critical Care; Critical Care Outcomes; Critical Illness; Disease Progression; Female; Hospital Mortality; Humans; Intubation, Intratracheal; Male; Middle Aged; Noninvasive Ventilation; Pneumonia; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Sepsis; Status Asthmaticus
PubMed: 32663410
DOI: 10.1164/rccm.201910-2021OC -
Critical Care (London, England) Feb 2002Severe asthma, although difficult to define, includes all cases of difficult/therapy-resistant disease of all age groups and bears the largest part of morbidity and... (Comparative Study)
Comparative Study Review
Severe asthma, although difficult to define, includes all cases of difficult/therapy-resistant disease of all age groups and bears the largest part of morbidity and mortality from asthma. Acute, severe asthma, status asthmaticus, is the more or less rapid but severe asthmatic exacerbation that may not respond to the usual medical treatment. The narrowing of airways causes ventilation perfusion imbalance, lung hyperinflation, and increased work of breathing that may lead to ventilatory muscle fatigue and life-threatening respiratory failure. Treatment for acute, severe asthma includes the administration of oxygen, beta2-agonists (by continuous or repetitive nebulisation), and systemic corticosteroids. Subcutaneous administration of epinephrine or terbutaline should be considered in patients not responding adequately to continuous nebulisation, in those unable to cooperate, and in intubated patients not responding to inhaled therapy. The exact time to intubate a patient in status asthmaticus is based mainly on clinical judgment, but intubation should not be delayed once it is deemed necessary. Mechanical ventilation in status asthmaticus supports gas-exchange and unloads ventilatory muscles until aggressive medical treatment improves the functional status of the patient. Patients intubated and mechanically ventilated should be appropriately sedated, but paralytic agents should be avoided. Permissive hypercapnia, increase in expiratory time, and promotion of patient-ventilator synchronism are the mainstay in mechanical ventilation of status asthmaticus. Close monitoring of the patient's condition is necessary to obviate complications and to identify the appropriate time for weaning. Finally, after successful treatment and prior to discharge, a careful strategy for prevention of subsequent asthma attacks is imperative.
Topics: Acute Disease; Adrenal Cortex Hormones; Adrenergic beta-Agonists; Anti-Asthmatic Agents; Asthma; Blood Gas Analysis; Electrocardiography; Hemodynamics; Hospitalization; Humans; Hypercapnia; Hypnotics and Sedatives; Intubation, Intratracheal; Monitoring, Physiologic; Prognosis; Radiography, Thoracic; Recurrence; Respiration, Artificial; Respiratory Function Tests; Respiratory Therapy; Risk Factors; Status Asthmaticus; Time Factors; Tomography, X-Ray Computed
PubMed: 11940264
DOI: 10.1186/cc1451 -
Revista Chilena de Pediatria Dec 2019There are few conclusive studies on the usefulness of High-Flow Nasal Cannula (HFNC) Oxygen Therapy in patients with asthmatic crises. (Randomized Controlled Trial)
Randomized Controlled Trial
INTRODUCTION
There are few conclusive studies on the usefulness of High-Flow Nasal Cannula (HFNC) Oxygen Therapy in patients with asthmatic crises.
OBJECTIVE
To determine the effectiveness of HFNC in chil dren older than 2 years of age that present severe and moderate asthmatic crises that do not respond to initial treatment.
PATIENTS AND METHOD
Open controlled randomized clinical trial of patients with asthma exacerbation in the Pediatric Emergency Department. Infection- and comorbidity-media ted crises were excluded. Subjects were randomized as follows: Group 1 HFNC (n:32) and Group 2 Conventional Oxygen Therapy (n:33). Both groups received the usual pharmacological treatment. The first cut-off point was the decrease of more than 2 points of the PIS after 2 hours of treatment; secondary points were PIS decrease at 6 hours, stay time in the Emergency Room, and PICU admis sion.
RESULTS
The patient's baseline characteristics were similar in both groups. The proportion of subjects with more than two points decrease in the PIS after two hours of treatment in Group 1 was 43.7% CI 95% (28-60) vs. Group 2 48.4%; CI 95% (32-64) p 0.447. The mean stay time was 24.8 ± 12.3 hours in Group 1 vs. 24 ± 14.8 hours in Group 2; CI 95% (7.56-5.96) p 0.37. We did not find differences in the respiratory effort score measurements every 2 hours. No patients were admitted to intensive care.
CONCLUSIONS
The incorporation of HFNC oxygen therapy in the treatment of patients with asthmatic crises in the Pediatric Emergency Department did not show clinical benefits nor did it diminish the stay time.
Topics: Adolescent; Cannula; Child; Child, Preschool; Emergency Service, Hospital; Female; Hospitals, Pediatric; Humans; Length of Stay; Male; Oxygen; Status Asthmaticus; Time Factors
PubMed: 32186587
DOI: 10.32641/rchped.v90i6.1145 -
ERJ Open Research Jan 2020http://bit.ly/38UYpUn.
http://bit.ly/38UYpUn.
PubMed: 32280667
DOI: 10.1183/23120541.00367-2019 -
Respiratory Care Jun 2017Asthma exacerbation is a common reason for children to present to the emergency department. If primary therapies fail to halt the progression of an asthma flare, status... (Review)
Review
Asthma exacerbation is a common reason for children to present to the emergency department. If primary therapies fail to halt the progression of an asthma flare, status asthmaticus often leads to hospital, and potentially ICU, admission. Following the initial administration of inhaled β agonists and systemic corticosteroids, a wide array of adjunct medical therapies may be used to treat status asthmaticus. Unfortunately, the data supporting the use of these adjunct therapies are often unclear, conflicting, or absent. This review will present the physiologic basis and summarize the supporting data for a host of adjunct therapies, including ipratropium, intravenous β agonists, methylxanthines, intravenous and inhaled magnesium, heliox (helium-oxygen mixture), ketamine, antibiotics, noninvasive ventilation, inhaled anesthetics, and extracorporeal membrane oxygenation. Finally, we present a suggested care map for escalating to these therapies in children with refractory status asthmaticus.
Topics: Administration, Inhalation; Anesthetics, Inhalation; Anti-Asthmatic Agents; Child; Combined Modality Therapy; Emergency Service, Hospital; Extracorporeal Membrane Oxygenation; Helium; Humans; Ipratropium; Oxygen; Respiration, Artificial; Respiratory Therapy; Status Asthmaticus
PubMed: 28546381
DOI: 10.4187/respcare.05174 -
Cleveland Clinic Journal of Medicine Dec 2022Extracorporeal carbon dioxide removal (ECCOR) uses mechanical systems to treat hypercapnic respiratory failure. Its utility has been investigated in acute respiratory... (Review)
Review
Extracorporeal carbon dioxide removal (ECCOR) uses mechanical systems to treat hypercapnic respiratory failure. Its utility has been investigated in acute respiratory distress syndrome (ARDS), acute exacerbations of chronic obstructive pulmonary disease (COPD), and status asthmaticus, and as a bridge to lung transplant. In this review, we discuss how it works, why it should help, and current evidence supporting its use.
Topics: Humans; Carbon Dioxide; Renal Dialysis; Lung Transplantation; Respiratory Distress Syndrome; Respiratory Insufficiency
PubMed: 36455974
DOI: 10.3949/ccjm.89a.21084