Outcomes of Extracorporeal Life Support (ECLS) in Acute Severe Asthma: A Narrative Review.

BACKGROUND: In this narrative review we aimed to explore outcomes of extracorporeal life support (extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R)) as rescue therapy in patients with status asthmaticus requiring mechanical ventilation. METHODS: Multiple databases were searched for studies fulfilling inclusion criteria. Articles reporting mortality and complications of ECMO and ECCO2R in mechanically ventilated patients with acute severe asthma (ASA) were included. Pooled estimates of mortality and complications were obtained by fitting Poisson's normal modeling. RESULTS: Six retrospective studies fulfilled inclusion criteria thus yielding a pooled mortality rate of 17% (13-20%), pooled risk of bleeding of 22% (7-37%), mechanical complications in 26% (21-31%), infection in 8% (0-21%) and pneumothorax rate 4% (2-6%). CONCLUSION: Our review identified a variation between institutions in the initiation of ECMO and ECCO2R in patients with status asthmaticus and discrepancy in the severity of illness at the time of cannulation. Despite that, mortality in these studies was relatively low with some studies reporting no mortality which could be attributed to selection bias. While ECMO and ECCO2R use in severe asthma patients is associated with complication risks, further studies exploring the use of ECMO and ECCO2R with mechanical ventilation are required to identify patients with favorable risk benefit ratio.

High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study.

INTRODUCTION: We aimed to describe patient characteristics and clinical outcomes for children hospitalized for status asthmaticus (SA) receiving high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). METHODS: We performed a single center, retrospective cohort study among 39 children admitted for SA aged 5-17 years from January 2016 to May 2019 to a quaternary pediatric intensive care unit (PICU). Cohorts were defined by BiPAP versus HFNC exposure and assessed to determine if differences existed in demographics, anthropometrics, comorbidities, asthma severity indices, historical factors, duration of noninvasive ventilation, and asthma-related clinical outcomes (i.e. length of stay, mechanical ventilation rates, exposure to concurrent sedatives/anxiolysis, and rate of adjunctive therapy exposure). RESULTS: Thirty-three percent (n = 13) received HFNC (33%) and 67% (n = 26) BiPAP. Children receiving BiPAP had greater age (10.9 ± 3.7 vs. 6.8 ± 2.2 years, P < 0.01), asthma severity (proportion with severe NHLBI classification: 38% vs. 0%, P < 0.01; median pediatric asthma severity score: 13[12,14] vs. 10[9,12], P < 0.01), previous PICU admissions (62% vs. 15%, P = 0.01), frequency of prescribed anxiolysis/sedation (42% vs. 8%, P = 0.02), and median duration of continuous albuterol (1.7[1,3.1] vs. 0.9[0.7,1.6] days, P = 0.03) compared to those on HFNC. Those on HFNC more commonly were treated comorbid bacterial pneumonia (69% vs. 19%, P < 0.01). No differences in NIV duration, mortality, mechanical ventilation rates, or LOS were observed. CONCLUSIONS: Our data suggest a trial of BiPAP or HFNC appears well tolerated in children with SA. Prospective trials are needed to establish modality superiority and identify patient or clinical characteristics that prompt use of HFNC over BiPAP.

Danger in the vapor? ECMO for adolescents with status asthmaticus after vaping.

Introduction: Electronic nicotine delivery systems (ENDS) use is on the rise in the adolescent and young adult populations, especially in the wake of sweet flavored ENDS solutions and youth-targeted marketing. While the extent of effect of ENDS use and aerosolized flavorings on airway epithelium is not known, there remains significant concern that use of ENDS adversely affects airway epithelial function, particularly in populations with asthma.Case Study: In this case series, we review two cases of adolescents with history of recent and past ENDS use and asthma who required veno-venous extracorporeal membrane oxygenation (VV-ECMO) for status asthmaticus in the year 2018.Results: Both patients experienced hypercarbic respiratory failure requiring VV-ECMO secondary to their status asthmaticus, with slow recovery on extensive bronchodilator and steroid regimens. They both recovered back to respiratory baseline and were counseled extensively on cessation of ENDS use.Conclusion: While direct causation by exposure to ENDS cannot be determined, exposure likely contributed to symptoms. Based on the severity of these cases and their potential relationship with ENDS use, we advocate for increased physician screening of adolescents for ENDS use, patient and parent education on the risks of use, and family cessation counseling.

Acute severe asthma (status asthmaticus).

Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy. It is a medical emergency that requires immediate recognition and treatment. Albuterol in combination with ipratropium bromide in the emergency department (ED) has been shown to decrease the time spent in the ED and the hospitalization rates. The benefits of ipratropium are not sustained after admission to the hospital. Oral or parenteral corticosteroids should be administered to all patients with acute severe asthma as early as possible because clinical benefits may not occur for a minimum of 6 to 12 hours. Viral respiratory infections are a common trigger for acute asthma; other causes include medical nonadherence, allergen exposure (especially pets and mold [e.g., Alternaria species]) in individuals who are severely atopic, nonsteroidal anti-inflammatory exposure in patients with aspirin allergy, irritant inhalation (e.g., smoke, paint), exercise, and insufficient use of inhaled or oral corticosteroids. The patient's history should focus on the acute assessment of asthma control and morbidity, including current use of oral or inhaled corticosteroids; the number of hospitalizations, ED visits, intensive care unit admissions, and intubations; the frequency of albuterol use; the presence of nighttime symptoms; activity intolerance; current medications; exposure to allergens; and other significant medical conditions. Severe airflow obstruction may be predicted by accessory muscle use, difficulty speaking, refusal to recline < 30°, a pulse of >120 beats/min, and decreased breath sounds. More objective measures of airway obstruction via peak flow or forced expiratory volume in 1 second and pulse oximetry before oxygen administration usually are helpful. Pulse oximetry values of >90% are reassuring, although CO2 retention and a low partial pressure of oxygen may be missed.

[Anesthetic management in bronchial asthma]. / Asthma bronchiale - Anästhesiologisches Management.

In daily practice, acute and chronic pulmonary diseases are common issues presenting to the anesthetist. Respiratory physiology in general is affected by both general and regional anesthesia, which results in an increased number of perioperative complications in pulmonary risk patients. Therefore, anesthetic management of patients with bronchial asthma needs to address different clinical topics: the physical appearance of pulmonary disease, type and extent of surgical intervention as well as effects of therapeutic drugs, anesthetics and mechanical ventilation on respiratory function. The present work describes important precautions in preoperative scheduling of the asthmatic patient. In the operative course, airway manipulation and a number of anesthetics are able to trigger intraoperative bronchial spasm with possibly fatal outcome. It is essential to avoid these substances to prevent asthma attack. If asthmatic status occurs, appropriate procedures according to therapeutic standards have to be applied to the patient. Postoperatively, sufficient pain therapy avoids pulmonary complications and improves outcome.

[Severe asthmatic crisis during general anesthesia in a patient with IgG4 related disease].

We experienced severe asthmatic crisis during general anesthesia in a 45-year-old man with IgG4-related disease, COPD and athma undergoing removal of submandibular gland. The ventilatiory failure was caused by the stimulation of the operation, sputum, and neostigmine. His serum IgG4 level was extremely high. IgG4 related disease is a recently emerging entity characterized by a diffuse or mass forming inflammatory reaction rich in IgG4-positive plasma cells associated with fibrosclerosis and obliterative phlebitis. It is associated with an elevated serum level of IgG4 and an allergic disease. We must be careful in perioperative management of the patients with IgG4-related disease because general anesthesia can induce asthmatic crisis.

Chapter 13: Potentially (near) fatal asthma.

Potentially (near) fatal asthma (PFA) defines a subset of patients with asthma who are at increased risk for death from their disease. The diagnosis of PFA should motivate treating physicians, health professionals, and patients to be more aggressive in the monitoring, treatment, and control of this high-risk type of asthma. A diagnosis of PFA is made when any one of the following are present: (1) history of endotracheal intubation from asthma, (2) acute respiratory acidosis (pH < 7.35) or respiratory failure from acute severe asthma, (3) two or more episodes of acute pneumothorax or pneumomediastinum from asthma, (4) two or more episodes of acute severe asthma despite the use of long-term oral corticosteroids and other antiasthma medications. There are two predominant phenotypes of near fatal exacerbations, the "subacute" exacerbation and the "hyperacute" exacerbation. The best way to "treat" acute severe asthma is 3-7 days before it occurs (i.e., at the onset of symptoms or change in respiratory function) and to optimize control of asthma by decreasing the number of symptomatic days and days/nights requiring rescue therapy and increasing baseline respiratory status in "poor perceivers." PFA is treated with a multifaceted approach; physicians should appreciate limitations of pharmacotherapy including combination inhaled corticosteroid/long-acting beta-agonist products as well as addressing nonadherence, psychiatric, and socioeconomic issues that complicate care.

Chapter 14: Acute severe asthma (status asthmaticus).

Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy such as inhaled albuterol, levalbuterol, or subcutaneous epinephrine. It is a medical emergency that requires immediate recognition and treatment. Oral or parenteral corticosteroids should be administered to all patients with acute severe asthma as early as possible because clinical benefits may not occur for a minimum of 6-12 hours. Approximately 50% of episodes are attributable to upper respiratory infections, and other causes include medical nonadherence, nonsteroidal anti-inflammatory exposure in aspirin-allergic patients, allergen exposure (especially pets) in severely atopic individuals, irritant inhalation (smoke, paint, etc.), exercise, and insufficient use of inhaled or oral corticosteroids. The patient history should be focused on acute severe asthma including current use of oral or inhaled corticosteroids, number of hospitalizations, emergency room visits, intensive-care unit admissions and intubations, the frequency of albuterol use, the presence of nighttime symptoms, exercise intolerance, current medications or illicit drug use, exposure to allergens, and other significant medical conditions. Severe airflow obstruction may be predicted by accessory muscle use, pulsus paradoxus, refusal to recline below 30°, a pulse >120 beats/min, and decreased breath sounds. Physicians' subjective assessments of airway obstruction are often inaccurate. More objective measures of airway obstruction via peak flow (or forced expiratory volume in 1 second) and pulse oximetry before oxygen administration usually are helpful. Pulse oximetry values >90% are less commonly associated with problems although CO(2) retention and a low Pao(2) may be missed.

Extracorporeal Life Support for Status Asthmaticus: Early Outcomes in Teens and Young Adults.

Extracorporeal life support (ECLS) may be life saving for patients with status asthmaticus (SA), a difficult-to-treat, severe subset of asthma. Contemporary ECLS outcomes for SA in teens and young adults are not well described. The Extracorporeal Life Support Organization (ELSO) Registry was reviewed (2009-2019) for patients (15-35 years) with a primary diagnosis of SA. In-hospital mortality and complications were described. Multivariable logistic regression was used to identify independent risk factors for hospital mortality. Overall, 137 patients, (26 teens and 111 young adults; median age 25 years) were included. Extracorporeal life support utilization for SA sharply increased in 2010, coinciding with increased ECLS utilization overall. Median ECLS duration and length of stay were 97 hours and 11 days, respectively. In-hospital mortality and major complication rates were 10% and 11%, respectively. Nonsurvivors were more likely to have experienced ECLS complications, compared to survivors (86% vs. 42%, p = 0.003). Independent risk factors for in-hospital mortality included pre-ECLS arrest and any renal and/or neurologic complication. Prospective studies designed to evaluate complications and subsequent failure to rescue may help optimize quality improvement efforts.

Friday asthma crisis in the daughter of two bakers.

The prevalence of sesame food allergy continues to increase worldwide. The diagnostic tools to confirm such allergy include skin prick tests, specific IgEs and food challenge. We report the case of a 7-year-old girl who presented recurrent episodes of wheezing and dyspnoea. After performing skin tests and evaluating specific IgEs we hypothesised an allergy to sesame. Our patient actually benefitted from avoiding any contact with sesame and sesame seeds. We confirmed our diagnosis through an inhalation food challenge. Further, by reviewing her personal history, we suspect inhalation was the mechanism in which the girl became sensitised to sesame.

Emergence of oseltamivir-resistant pandemic H1N1 in an immunocompetent child with severe status asthmaticus.

INTRODUCTION: Pandemic influenza A (H1N1) may cause severe illness in pediatric patient with chronic lung disease. CASE REPORT: We describe the emergence of oseltamivir resistance in an immunocompetent child with status asthmaticus triggered by pandemic influenza A (H1N1). This case highlights the possible relationship between influenza viral load and risk of resistance emergence in children with asthma. Influenza vaccination should continue to be emphasized as the mainstay of prevention in children with chronic lung disease. CONCLUSION: Influenza virus can lead to severe status asthmaticus and can develop oseltamivir resistance in immunocompetent children.

Developing a short-term prediction model for asthma exacerbations from Swedish primary care patients' data using machine learning - Based on the ARCTIC study.

OBJECTIVE: The ability to predict impending asthma exacerbations may allow better utilization of healthcare resources, prevention of hospitalization and improve patient outcomes. We aimed to develop models using machine learning to predict risk of exacerbations. METHODS: Data from 29,396 asthma patients was collected from electronic medical records and national registers covering clinical and epidemiological factors (e.g. comorbidities, health care contacts), between 2000 and 2013. Machine-learning classifiers were used to create models to predict exacerbations within the next 15 days. Model selection was done using the mean cross validation score of area under precision-recall curve (AUPRC). RESULTS: The most important predictors of exacerbation were comorbidity burden and previous exacerbations. Model validation on test data yielded an AUPRC = 0.007 (95% CI: ± 0.0002), indicating that historic clinical information alone may not be sufficient to predict a near future risk of asthma exacerbation. CONCLUSIONS: Supplementation with additional data on environmental triggers, (e.g. weather, pollen count, air quality) and from wearables, might be necessary to improve performance of the short-term predictive model to develop a more clinically useful tool.

Does the High Prevalence of Vitamin D Deficiency in African Americans Contribute to Health Disparities?

African Americans have higher incidence of, and mortality from, many health-related problems than European Americans. They also have a 15 to 20-fold higher prevalence of severe vitamin D deficiency. Here we summarize evidence that: (i) this health disparity is partly due to insufficient vitamin D production, caused by melanin in the skin blocking the UVB solar radiation necessary for its synthesis; (ii) the vitamin D insufficiency is exacerbated at high latitudes because of the combination of dark skin color with lower UVB radiation levels; and (iii) the health of individuals with dark skin can be markedly improved by correcting deficiency and achieving an optimal vitamin D status, as could be obtained by supplementation and/or fortification. Moderate-to-strong evidence exists that high 25-hydroxyvitamin D levels and/or vitamin D supplementation reduces risk for many adverse health outcomes including all-cause mortality rate, adverse pregnancy and birth outcomes, cancer, diabetes mellitus, Alzheimer's disease and dementia, multiple sclerosis, acute respiratory tract infections, COVID-19, asthma exacerbations, rickets, and osteomalacia. We suggest that people with low vitamin D status, which would include most people with dark skin living at high latitudes, along with their health care provider, consider taking vitamin D3 supplements to raise serum 25-hydroxyvitamin D levels to 30 ng/mL (75 nmol/L) or possibly higher.

[Case of tension pneumothorax associated with asthma attack during general anesthesia].

We report a case of tension pneumothorax associated with asthma attack during general anesthesia. An 86-year-old woman with dementia underwent cataract surgery under general anesthesia. At 70 min after the start of operation, airway pressure suddenly increased from 19 to 28 cm HO2O. In spite of bag ventilation with 100% oxygen, Sp(O2) decreased to 81%. Chest-Xp showed typical image of tension pneumothorax. Chest drainage was immediately performed, after which Pa(O2) recovered soon. She was extubated on postoperative day 1 without any neurological disorder. Hyperinflation of fragile alveoli by mechanical ventilation was likely a cause of tension pneumothorax.

The associations between area of residence, sexual violence victimization, and asthma episodes among US adult women in 14 states and territories, 2005-2007.

Gaps in understanding of how area-based differences in exposure to violence are associated with asthma prevalence may limit the development of effective prevention programs and the identification of risk for asthma episodes. The current investigation examines the associations between sexual violence victimization and asthma episodes among US adult women across three different metropolitan settings. The association between sexual assault victimizations and asthma attacks in the past year was examined using data from the 2005, 2006, and 2007 Behavioral Risk Factor Surveillance System surveys. Cross-sectional analyses were based on adult women with current asthma (n = 4,099). Multivariate logistic regression models were used to identify associations between four categories of sexual violence victimization and asthma episodes across three categories of metropolitan and non-metropolitan settings. Our findings show that unwanted touching, attempted unwanted intercourse, forced unwanted intercourse, and any sexual violence victimization (touching, attempted intercourse, or forced intercourse) were significantly associated with asthma episodes (OR(adj.) = 3.67, 95% CI, 1.76-7.69; OR(adj.) = 1.77, 95% CI, 1.32-2.37; OR(adj.) = 2.24, 95% CI, 1.64-3.05, and OR(adj.) = 1.93, 95% CI, 1.47-2.53, respectively). While no significant differences in the associations between asthma episodes and metropolitan status were found, a significant interaction between non-metropolitan areas and attempted sexual intercourse was identified (OR(adj) = 0.53, 95% CI, 0.29-0.96). Sexual victimization appears to be an important, but understudied, correlate of asthma morbidity among adult women in the USA, suggesting that additional research is needed to better understand the associations between sexual violence, psychological distress, and asthma.

Traffic exposure associated with allergic asthma and allergic rhinitis in adults. A cross-sectional study in southern Sweden.

BACKGROUND: There is conflicting evidence that traffic-related air pollution is a risk factor for allergic conditions. Few studies have investigated this in adults. In adults, a high proportion of asthma, rhinitis and eczema is triggered by non-allergic factors. We investigated traffic as a risk factor for allergic versus non-allergic asthma and rhinitis, and eczema, in adults. A questionnaire from 2000 (n = 9319, 18-77 years) provided individual data about disease outcome and self-reported traffic exposure. Additional exposure assessments were obtained using Geographical Informations Systems (GIS). Residential addresses were linked to the national Swedish Road Database and to a pollutant database with modelled annual means of NOx (Nitrogen Oxids). RESULTS: Living within 100 m from a road with a traffic intensity of >10 cars/min (24 hour mean) was associated with prevalence of current asthma reported to be triggered by allergic factors (OR = 1.83, 95% CI = 1.23-2.72) and with allergic rhinitis (OR = 1.30, 95%CI = (1.05-1.61). No relation was seen with asthma or rhinitis triggered by other factors. Living within 100 m of a road with >10 cars/min was also associated with hand-eczema during the last 12 months (OR = 1.63, 95% CI = 1.19-2.23), but not with allergic eczema or diagnosed hand-eczema. Consistent results were seen using self-reported traffic, but the associations with NOx were less consistent. CONCLUSION: Exposure to traffic was associated with a higher prevalence of allergic asthma and allergic rhinitis, but not with asthma or rhinitis triggered by non-allergic factors. This difference was suggested by the overall pattern, but only clear using GIS-measured traffic intensity as a proxy for traffic exposure. An association was also found with hand-eczema during the last 12 months. We suggest that asthma and rhinitis should not be treated as homogenous groups when estimating effects from traffic in adults.

Change in airflow among patients with asthma discussing relationship problems with their partners.

This study examined the covariation of negative emotions with airflow among 48 persons with asthma and their partners as they discussed relationship problems. Measures included self-reported questionnaires, airflow and behavior coded from videotaped discussions. Significantly increased self-reported hostility and statistically but not clinically significant declines in airflow were found post- versus pre-discussion. Self-reported responses to asthma symptoms of more anger and less loneliness predicted lower post-discussion airflow after accounting for pre-discussion airflow. The use of effort-independent measures of airflow and autonomic nervous system monitoring may inform future research regarding the physiological mechanisms through which mood and behavior affect airflow.

Barotrauma not related to type of positive pressure ventilation during severe asthma exacerbations in children.

BACKGROUND: Children with impending respiratory failure due to severe asthma may be treated with endotracheal intubation and mechanical ventilation. Barotrauma occurs in a significant number of these children. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy and potentially prevents intubation. However, the comparative risk of barotrauma associated with the use of NPPV has not been evaluated in this population. OBJECTIVE: To determine if the mode of positive pressure delivery per se affects the likelihood of development of barotrauma. METHODS: We retrospectively examined data from all children older than 2 years of age admitted to the Intensive Care Unit (ICU) with an asthma exacerbation between April 1997 and August 2006. RESULTS: Of the 293 children admitted to the ICU with asthma, 45 (17%) received treatment with positive pressure ventilation: 11 received only NPPV, 29 were intubated and mechanically ventilated, and 7 children received both of these therapies. Compared with those not requiring positive pressure, children receiving positive pressure were significantly more likely to develop barotrauma during hospitalization (OR 8.9; 95% CI 2.4-32.7). However, the incidence of barotrauma did not significantly differ according to the mode of positive pressure delivery: 9% in those who received only NPPV, 14% in those who were intubated, and 14% in those who received both therapies (p = 0.92). CONCLUSIONS: The use of positive pressure is associated with an increased risk of barotrauma in children with asthma, regardless of the mode of delivery.

[Predictive factors associated with severity of asthma exacerbations]. / Astim ataklarinda agirligi belirleyici risk faktörleri.

Several factors have been accused for asthma exacerbations, however, very few studies have evaluated whether different factors predict severity of asthma exacerbation. We aimed to determine the predictive factors for severity of asthma exacerbation. Retrospective analysis of data on 93 patients visited our emergency-department because of asthma exacerbation was reviewed. Hospitalization in intensive care unit and/or intubation because of asthma was accepted as the criteria for severe exacerbation. Logistic regression analysis estimated the strength of association of each variable, potentially related to severe asthmatic exacerbation, with severe/very severe as compared to mild/moderate asthmatic exacerbation. Independent variables included in the analysis were age, sex, smoking history, inhaler steroid using, compliance with medication, chronic asthma severity, presence of additional atopic diseases, prick test positivity, provocative factors, number of short-acting beta(2)-agonist using, number of visits to emergency department for asthma over one year period, previous severe exacerbation, pulmonary functions, and blood eosinophil count. 20 were severe/very severe and 73 mild/moderate asthmatic exacerbation. Frequent using of short-acting beta(2)-agonist (OR= 1.5, 95% CI= 1.08-5.3, p= 0.003), noncompliance with medication (OR= 3.6, 95% CI= 1.3-9.9, p= 0.013), previous severe asthmatic exacerbation (OR= 3.8, 95% CI= 1.48-10.01, p= 0.005) and recent admission to hospital (OR= 2.9, 95% CI= 1.07-8.09, p= 0.037) were found to be predictive factors for severe asthmatic exacerbation. Different predictive factors, in particular frequent using of short-acting beta(2)-agonist and noncompliance with medication may be associated with severe asthma exacerbations compared to milder exacerbations. This suggests different mechanisms are responsible for severity of asthma exacerbation.