COVID-19, rinovirus y asma... ¿Una mala combinación? / COVID-19, rhinovirus and asthma... a bad conmbination?

La pandemia de COVID-19 enfrentó a la humanidad a un gran desafío y hemos ido aprendiendo a medida que avanzó. La aparición de este virus, su comportamiento por si solo y en conjunto con los otros virus nos mantuvo alerta.. Los pacientes pediátricos asmáticos, a pesar de lo que se pensó en un principio, son menos afectados y hacen un cuadro clínico más leve. Objetivo: presentar un caso clínico de un paciente asmático, con una evolución tortuosa por co-infección SARS-CoV-2 y Rinovirus (RV) y revisión de la litaratura. Se trata de un escolar de 6 años, asmático con mal control, con 2 dosis de vacuna anti SARS-CoV-2, que presento un estado asmático por rinovirus y posterior evolución con neumonía grave por SARS-CoV-2, requiriendo ventilación mecánica invasiva y estadía en UCI Pediátrica. Es probable que la gravedad del caso presentado se deba al mal control del asma antes de la infección, ya que se ha visto que los niños asmáticos alérgicos presentan un factor protector para infección grave por SARS-CoV-2, lo cual esta supeditado a un buen control de su enfermedad basal.

The COVID-19 pandemic presented a great challenge and we have been learning as it has progressed. The appearance of this virus, its behavior by itself and in conjunction with the other viruses kept us alert. Pediatric asthmatic patients, despite what was initially thought, are less affected and present a milder clinical picture. Objective: to present a clinical case of an asthmatic patient, with a tortuous evolution due to SARS-CoV-2 and Rhinovirus (RV) co-infection and a literature review. This is a 6-year-old schoolboy, asthmatic with poor control, with 2 doses of the SARS-CoV-2 vaccine, who presents asthmatic status due to rhinovirus and subsequent evolution with severe pneumonia due to SARS-CoV-2, requiring invasive mechanical ventilation and stay in Pediatric ICU. It is likely that the severity of the case presented is due to poor asthma control before infection, since it has been seen that allergic asthmatic children present a protective factor for severe infection by SARS-CoV-2, which is subject to good control of his basal disease.

Characteristics of individuals with moderate to severe asthma who better respond to aerobic training: a cluster analysis / Características de indivíduos com asma moderada a grave que melhor respondem a treinamento aeróbio: análise de conglomerados

ABSTRACT Objective: To determine the characteristics of individuals with asthma who are responsive to aerobic training. Methods: This post hoc analysis of pooled data from previous randomized controlled trials involved 101 individuals with moderate to severe asthma who underwent aerobic training. Participants underwent a maximal cardiopulmonary exercise test and completed the Asthma Control Questionnaire and the Asthma Quality of Life Questionnaire before and after a 24-session aerobic training program. Better and worse responders to aerobic training were identified by cluster analysis. Results: Two clusters were identified according to the improvement in peak VO2 after aerobic training (better and worse responders). Characteristics of the better responder group were being older, being female, having higher BMI, and having higher cardiac reserve at baseline when compared with the worse responder group. Also, better responders had worse clinical control, worse quality of life, and lower physical capacity at baseline. After training, worse responders, in comparison with better responders, showed half the improvement in Δpeak VO2 (7.4% vs. 13.6%; 95% CI, −12.1 to −0.92%; p < 0.05) and worse asthma control. A weak, negative, but significant association (r = −0.35; p < 0.05) was observed between clinical control and aerobic fitness only in the better responder group. Both groups showed significant improvement in quality of life. Conclusions: Obese individuals with worse exercise capacity, clinical control, and quality of life showed improvement with aerobic training. Moreover, worse responders also improved with training, but to a lesser extent.

RESUMO Objetivo: Determinar as características de indivíduos com asma responsivos a treinamento aeróbio. Métodos: Esta análise post hoc de dados agrupados provenientes de ensaios clínicos controlados randomizados anteriores envolveu 101 indivíduos com asma moderada a grave submetidos a treinamento aeróbico. Os participantes foram submetidos a um teste de exercício cardiopulmonar máximo e responderam ao Asthma Control Questionnaire e ao Asthma Quality of Life Questionnaire antes e depois de um programa de treinamento aeróbio de 24 sessões. Melhores e piores respondedores ao treinamento aeróbio foram identificados por análise de conglomerados. Resultados: Foram identificados dois conglomerados de acordo com a melhora do VO2 de pico após o treinamento aeróbio (melhores e piores respondedores). As características do grupo melhor respondedor foram maior idade, sexo feminino, IMC mais elevado e maior reserva cardíaca basal em comparação com o grupo pior respondedor. Os melhores respondedores também apresentavam pior controle clínico, pior qualidade de vida e menor capacidade física basal. Após o treinamento, os piores respondedores, em comparação com os melhores respondedores, apresentaram metade da melhora no ΔVO2 de pico (7,4% vs. 13,6%; IC95%: -12,1 a -0,92%; p < 0,05) e pior controle da asma. Observou-se uma associação negativa fraca, mas significativa (r = −0,35; p < 0,05) entre controle clínico e aptidão aeróbia apenas no grupo melhor respondedor. Ambos os grupos apresentaram melhora significativa da qualidade de vida. Conclusões: Os indivíduos obesos com pior capacidade de exercício, controle clínico e qualidade de vida apresentaram melhora com o treinamento aeróbio. Além disso, os piores respondedores também melhoraram com o treinamento, mas em menor grau.

Remoción extracorpórea de CO2 en un paciente con estatus asmático que evoluciona con barotrauma / Extracorporeal CO2 Removal in a Patient with Status Asthmaticus who Evolved with Barotrauma

RESUMEN Paciente varón de 20 años, con diagnóstico de asma conocida, llegó al departamento de emergencias de un hospital de su localidad con historia de disnea 1 d antes de la admisión. Posteriormente, se torna taquicárdico, taquipneico y cianótico, por lo que fue intubado de emergencia. En la UCI del hospital general de tercer nivel, presentó bron coespasmo grave, presiones de vía aérea elevadas durante la ventilación mecánica e hipoperfusión grave. Recibió cristaloides y norepinefrina como resucitación. Al tercer día, presentó enfisema subcutáneo, neumotórax e hipercapnia con acidosis mixta. Se decidió utilizar ventilación mecánica ultraprotectora asociada con Novalung®. Con esta estrategia, logramos reducir las presiones de la vía aérea, la PEEPi, la potencia mecánica (PM) resistiva y mejorar la hipercapnia y la acidosis. El paciente permaneció 10 d en Novalung® y mostró buena evolución posterior. Finalmente, es extubado, dado de alta de la UCI y salió del hospital en buenas condiciones.

ABSTRACT A 20-year-old male with known asthma arrived at the emergency department in the first hospital with story of shortness of breath 1 day before admission. He suddenly became tachycardic, tachypneic and cyanotic, for which he was intubated. In the tertiary care general hospital ICU, he showed severe bronchospasm, high airway pressures during mechanical ventilation (MV) and severe hypoperfusion. He received crystalloids and norepinephrine. On the third day, he developed subcutaneous emphysema, pneumo thorax and hypercapnia with mixed acidosis. We decided to use ultra-protective me chanical ventilation concomitant with Novalung®. With this strategy, we could reduce airway pressures, PEEPi, resistive mechanical power and improve hypercapnia and acidosis. The patient stayed for 10 days in Novalung® and showed good evolution. He was later extubated and discharged of ICU, leaving the hospital in good conditions.

Enfisema mediastínico como complicación de una crisis asmática en paciente joven con COVID-19

El COVID-19 es el virus causante de la pandemia actual, su método de transmisión es aéreo y su tropismo por el aparato respiratorio hace que las personas con patologías de base a nivel pulmonar sean más susceptibles. En este caso produjo una exacerbación del asma bronquial y una complicación rara de éste es el neumomediastino.

COVID-19 is a virus that caused the current pandemic. Its airborne transmission and tropism for the respiratory system make people with lung-based pathologies more susceptible. In this case, it not only produced an exacerbation of bronchial asthma, but also pneumomediastinum, a rare complication of asthma.

Reacciones adversas por salbutamol en pacientes asmáticos: reflexiones acerca del uso en las exacerbaciones / Adverse reactions from salbutamol in asthmatic patients: reflections on its use and exacerbations / Reações adversas ao salbutamol em pacientes asmáticos: reflexões sobre o seu uso e exacerbações

Las afecciones respiratorias agudas son la primera causa de consulta e ingreso hospitalario en los meses de invierno, y entre ellas el asma ocupa un lugar preponderante. El salbutamol es un broncodilatador con eficacia demostrada en las exacerbaciones y se utiliza de primera línea en el tratamiento. El objetivo de la presente comunicación es analizar dos casos clínicos de niños asmáticos que presentaron efectos adversos al salbutamol y requirieron el ingreso en la Unidad de Terapia Intensiva. Se propone revisar los efectos adversos del salbutamol empleado en crisis asmáticas y analizar las alternativas terapéuticas en esta enfermedad. Los síntomas de los efectos secundarios pueden confundirse con los causados por la propia enfermedad, por lo que puede usarse el fármaco de modo excesivo y es importante conocer el perfil posológico y caracterizar los posibles efectos secundarios en los pacientes para usar de manera racional y segura este medicamento.

Acute respiratory conditions are the first cause of consultation and hospital admission in the Winter months, being asthma the most important. Salbutamol is a bronchodilator with proven efficacy in exacerbations used first-line in treatment. The objective of this paper is to analyze two clinical cases of asthmatic children who presented adverse effects to salbutamol and required admission to the Intensive Care Unit. It is proposed to review the adverse effects of salbutamol used in asthmatic crises and to analyze therapeutic alternatives in this disease. Symptoms of side effects can be confused with those caused by the disease itself, determining the excessive use of this drug, thus, it is important to know the dosage profile and characterize the possible side effects to make rational and safe use of this drug.

As doenças respiratórias agudas são a primeira causa de consultas e internações nos meses de inverno e a asma ocupa é a mais importante. O salbutamol é um broncodilatador com eficácia comprovada nas exacerbações e é usado como tratamento de primeira linha. O objetivo desta comunicação é analisar dois casos clínicos de crianças asmáticas que apresentaram efeitos adversos ao salbutamol e necessitaram de internação em Unidade de Terapia Intensiva. Propõe-se revisar os efeitos adversos do salbutamol utilizado na crise asmática e analisar as alternativas terapêuticas nessa doença. Os sintomas de efeitos colaterais podem ser confundidos com os causados pela própria doença, determinando o uso excessivo desse medicamento, sendo importante conhecer o perfil posológico e caracterizar os possíveis efeitos colaterais nos pacientes para fazer um uso racional e seguro desse medicamento.

Biologic Treatment of Severe Asthma / 대한내과학회지

Beyond the existing scope of asthma treatment, a number of biologics have recently been developed based on the immunopathological mechanism of severe asthma. Severe asthma has a wide variety of phenotypes or endotypes, more than half of which are associated with eosinophils or type 2 inflammation. This paper introduces newly developed biologics and those that are under development for treatment of asthma. The most successful biologics developed to date are anti-IgE and anti-interleukin (IL)-5 antibodies, followed by anti-IL-4, anti-IL-13, anti-prostaglandin D2 type 2 receptor, and anti-thymic stromal lymphopoietin antibodies. However, further studies on drugs that target type 1 inflammation are required.

Ventilación mecánica no invasiva en el manejo del estado asmático en pediatría / Noninvasive ventilation in the status asthmaticus in pediatrics

Resumen La ventilación mecánica no invasiva (VMNI) ha tenido interés creciente en los últimos 15 años como indicación en la insuficiencia respiratoria aguda hipoxemica en niños, adolescentes y adultos. Sin embargo, se adolece de revisiones sistemáticas y de estudios aleatorizados, doble ciegos y randomizados que fundamenten inequívocamente su utilidad, efectividad y eficiencia, aun mas en el escenario de asma aguda sumada a intervenciones protocolizadas desde los servicios de urgencia. En este artículo se revisan algunas consideraciones desde las justificaciones fisiopatológicas a resultados en investigación observacionales.

Summary Noninvasive ventilation (NIV) has gradually become more relevant in the last 15 years, being it indicated in the event of severe hypoxemic respiratory failure in children, adolescents and adults. However, there is a lack of systematic reviews, randomized and double blind studies that provide significant evidence on its usefulness, effectiveness and efficiency, especially in the event of severe acute asthma, in the context of intervention as per emergency services protocols.This study presents a review of a few considerations arising from pathophysiological justifications and observational studies findings.

Ventilación mecánica invasiva en el paciente pediátrico / Pediatric invasive mechanical ventilation

Mechanical ventilation (MV) is an essential tool in the management of severe respiratory failure, and its use is increasingly frequent in pediatric intensive care units. The main objective of mechanical ventilation is to replace the patient’s respiratory work, until thepatient is able to perform it by himself. The understanding of pediatric patient physiology, the pathophysiology of the underlying disease or condition, and the knowledge of how the mechanical ventilator operates and its interaction with the patient will lead to a proportionate management with reduced complications and successful extubation. In this article, we will review some aspects of its history, basic physiological concepts, general indications of onset, some modalities of MV, aspects of ventilatory management of obstructive and restrictivepulmonary pathology, and weaning or weaning and extubation.

La ventilación mecánica constituye una herramienta fundamental en el manejo de la falla respiratoria grave, siendo su uso cada vez más frecuente en las unidades de cuidado intensivo pediátrico. El objetivo principal de la ventilación mecánica, es sustituir el trabajorespiratorio del paciente, hasta que éste sea capaz de realizarlo por sí mismo. El entendimiento de la fisiología del paciente pediátrico, lafisiopatología de la enfermedad o condición de base y el conocimiento del funcionamiento del ventilador mecánico y su interacción conel paciente, conducirán a un manejo proporcionado, con disminución de las complicaciones y una extubación exitosa. En este artículo,revisaremos algunos aspectos de su historia, conceptos fisiológicos básicos, las indicaciones generales de inicio, algunas modalidades deVM, aspectos del manejo ventilatorio de la patología pulmonar obstructiva y restrictiva, y el proceso de “weaning” o destete y extubación.

Estado asmático en pediatría / Pediatric status asthmaticus

The status asmathicus is an important cause of morbidity in children, due to the increasing incidence of asthma in the pediatric population. Its mortality is relatively low, and it concentrates in patients with acute asfictic asthma and during the period of endotracheal peri-intubation in patients who require it. The treatment consists on oxygen therapy, bronchodilators and systemic corticosteroids, with other pharmacological alternatives in children who do not respond to the former treatments. Non-invasive ventilatory support improves gas exchange and reduces the work of breathing. Invasive mechanical ventilation is thus only used in children with severe refractory respiratory failure to the former measures, considering its associated morbidity and mortality.

El estado asmático es una causa importante de morbilidad en Pediatría, debido al aumento de la incidencia de asma en la población infantil. Su mortalidad es relativamente baja, y se concentra principalmente en aquellos pacientes con asma aguda asfíctica y en el período peri-intubación endotraqueal en aquellos pacientes que lo requieren. El tratamiento tiene como pilares el uso de oxígeno, broncodilatadores y corticoides sistémicos, existiendo otras alternativas farmacológicas para niños que no responden a las medidas anteriores. El soporte ventilatorio no-invasivo permite mejorar el intercambio gaseoso y disminuir el trabajo respiratorio, reservando la ventilación mecánica invasiva solamente para niños en falla respiratoria grave refractaria a medidas anteriores, considerando la morbimortalidad asociada a ésta.

Status Asmaticus: lenda ou realidade? Como tratar melhor? / Status Asmathicus: legend or reality? How to treat better?

A história natural do status asmaticus é na maioria das vezes de resolução com mortalidade geral menor que 1%. Cerca de 80% dos pacientes com exacerbação de asma brônquica são liberados da emergência nas primeiras duas horas de tratamento. No entanto, nos pacientes com necessidade de ventilação mecânica a mortalidade pode chegar a 8%. O tratamento rápido e eficaz é essencial para o sucesso do tratamento e a prevenção de complicações. Neste artigo são abordadas as recomendações atuais do tratamento das exacerbações graves de asma brônquica nos setores de emergência e terapia intensiva...

The natural history of status asthmaticus is, most of the time, sorted out with overall mortality less than 1%. About 80% of patients with exacerbation of asthma emergency are released within the first two hours of treatment. However, in patients requiring mechanical ventilation mortality can reach 8%. The rapid and effective treatment is essential for the success of the treatment and the prevention of complications. This paper addresses the current recommendations the treatment of severe exacerbations of asthma in the emergency department and intensive care...

Ventilación no invasiva en pacientes con estado asmático / Noninvasive ventilation in patients with status asthmaticus

Se realizó un estudio descriptivo, con componentes analíticos, y prospectivo de 21 pacientes con estado asmático, ingresados en la Unidad de Cuidados Intermedios del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde marzo de 2011 hasta enero de 2012, y que requirieron ventilación mecánica no invasiva (para postergar o evitar la ventilación mecánica invasiva), a fin de evaluar la efectividad de este tratamiento. En la casuística no hubo diferencias significativas (p>0,05) en cuanto a los grupos etarios, el sexo, el nivel de escolaridad y el grado de aceptación de la interfase, pero sí se observó significación respecto a los antecedentes de ventilación artificial mecánica (p<0,01) y la variación de todas las mensuraciones clínicas y hemogasométricas (p<0,05) luego de 24 horas de aplicada la modalidad terapéutica, con lo cual se demostró su eficacia en la mejoría de los pacientes asmáticos con agudización de la enfermedad

A descriptive and prospective study with analytical items was carried out in 21 patients presenting with status asthmaticus, admitted to the Intermediate Care Unit of Saturnino Lora Torres Provincial Teaching Clinical Surgical Hospital of Santiago de Cuba, from March 2011 to January 2012, who required noninvasive mechanical ventilation (to delay or prevent invasive mechanical ventilation), in order to evaluate the effectiveness of this treatment. There were not significant differences (p>0.05) in the case material in terms of age groups, sex, educational level and the degree of acceptance of the interface, but significance was observed regarding the history of artificial mechanical ventilation (p <0.01) and the variation of all clinical and hemogasometric measurements (p <0.05) 24 hours after the application of the therapeutic modality, thus demonstrating its effectiveness in improving asthmatic patients with exacerbation of disease

Application of bronchoscopy in the therapy of pediatric status asthmaticus / 中华全科医师杂志

Objective To explore the therapeutic value of bronchoscopy in pediatric status asthmaticus.Methods A total of 16 children with status asthmaticus received standard medical therapies (therapy group) from January 2008 to August 2010 in pediatric intensive care unit (PICU) at First Hospital,Xiamen University.However,l0 of them underwent fiberoptic bronchoscopy and bronchoalveolar lavage (BAL) (bronchoscopy group) along with standard medical therapies from September 2010 to July 2012.The values of oxygenation index (PaO2/FiO2),arterial partial pressure of carbon dioxide (PaCO2),blood oxygen saturation (SaO2),heart rate (HR),respiratory rate (RR) within 1 hour before bronchoscopy procedure,within 6 hour post procedure and within 24 hour post procedure were observed.The extinction time of wheezing sound,PICU length of stay and admission length of stay were observed between therapy and bronchoscopy groups.Results Bronchoscopies revealed a lot of thick mucus plugs and secretions.Large airways were lavaged for clearance of obstructive secretions with normal saline.Within BAL fluid counts of the bronchoscopy group,there were neutrophilia (n =8),eosinophilia (n =4) and neutrophilia/ eosinophilia (n =3).Within BAL fluid cultivation of the bronchoscopy group,4 patients had positive results for Streptococcus pneumoniae (n =2),Pseudomonas aeruginosa (n =1) and Staphylococcus aureus (n =1).In bronchoscopy group,the values of PaO/FiO2,PaCO2,SaO2,HR and RR were 319 ± 19,(40 ±4) mm Hg(1 mm Hg =0.133 kPa),(92.6 ± 1.5) ％,(128 ± 12) rates/min and (35 ± 4) breaths/min within 6 hour post procedure versus 255 ± 24,(54 ± 5) mm Hg,(89.2 ± 2.6) ％,(148 ± 10) rates/min and(50 ± 6)breaths/min within I hour before procedure (P ＜ 0.01).At 24 hour post procedure,the values of PaO2/FiO2,PaCO2,SaO2,HR,RR for bronchoscopy group were 354 ± 21,(40 ± 3) mm Hg,(93.4 ±1.1)％,(125±9)rates/min and(34 ±3)breaths/min versus 317 ±21,(46 ±4)mm Hg,(90.1±2.5) ％,(138 ± 8) rates/min and (43 ± 3) breaths/min respectively for therapy group (P ＜ 0.01).The extinction time of wheezing sound was (67 ± 22) hours for bronchoscopy group vs.(98 ± 23) hours for therapy group(P ＜ 0.01).The mean PICU length of stay was (1.6 ± 0.7) days for bronchoscopy group vs.(2.6 ± 0.7) days for therapy group (P ＜ 0.01).The mean admission length of stay was (5.0 ± 0.7) days for bronchoscopy group vs.(6.6 ± 1.2) days for therapy group(P ＜ 0.01).All patients for bronchoscopy group tolerated the procedure without any complications.Conclusion As a safe adjunctive therapy in pediatric status asthmaticus,flexible bronchoscopy with bronchial lavage may reduce the admission and PICU length of stay and alleviate clinical symptoms.

A Case of Brain Death Due to Asthma Exacerbation in a Noncompliant Patient with Refractory Asthma / 대한내과학회지

Although guideline-based asthma therapy has had a positive impact on fatalities due to asthma over the last few decades, some patients refractory to or noncompliant with asthma treatment remain at risk of fatality. A 45-year-old female with refractory asthma and poor compliance and with a frequent history of hospitalization for asthma exacerbations was taken to the emergency room because of cardiorespiratory arrest. Her family reported that she had suffered from an upper respiratory infection followed by severe dyspnea for a few days. The patient developed status asthmaticus, and in spite of intensive cardiopulmonary resuscitation, she was eventually declared brain dead. The patient had not taken medication for asthma regularly for several months before the attack. Refractory and difficult-to-treat asthma should be aggressively monitored to prevent severe asthma exacerbations, which can be fatal, especially in noncompliant patients.

Ventilação mecânica protetora no paciente com doença pulmonar obstrutiva / Protective mechanical ventilation in obstructive pulmonary disease patients

Justificativas e objetivos: várias doenças cursam com diminuição do calibre das vias aéreas, sejam elas superiores ou inferiores. Entre elas encontram-se a asma, a doença pulmonar obstrutiva crônica (DPOC), a fibrose cística, a bronquiectasia e a bronquiolite, sendo seus maiores expoentes a asma e a DPOC] O objetivo desta revisão é buscar evidências científicas que norteiem a ventilação mecânica protetora para os pacientes com doença pulmonar obstrutiva e sugerir estratégias para se ventilá-los adequadamente. Método: foi realizada revisão da literatura com base em artigos que englobam o uso de estratégias de ventilação mecânica em pacientes com doença pulmonar obstrutiva, com enfoque em asmáticos e portadores de DPOC. Conclusões: diferentes modalidades ventilatórias não se mostraram superiores, sendo necessária sempre a monitorização dos . padrões de pressão e volumes impressos ao paciente - pressão de platô, a ser mantida abaixo de 30-35 cm de água; pressão de pico, que não deve ultrapassar 50 cm de água; e o volume pulmonar ao final da inspiração, que deve ser inferior a I,4L. A aplicação de PEEP extrínseca não representa benefícios clínicos em pacientes sedados, não hipoxêmicos e bem adaptados à ventilação mecânica, mesmo na presença de autoPEEP...

Justitications and objectives: Several diseases develop with the reduction of either upper or lower airway caliber. Among them are asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, a bronchiectasis and bronchiolitis, with asthma and COPD as the most important ones. l The objective of this review is to search scientific evidence which guide protective mechanical ventilation for patients with obstructive pulmonary disease and suggest strategies to provide appropriate ventilation. Method: A review of the literature was carried out based on scientifie papers whieh deal with the use of strategies of mechanical ventilation in patients with obstructive pulmonary disease, focusing on asthma and COPD patients. Conclusions: Different ventilation modalities were not better, with the need to monitor patterns of pressure and volume delivered to the patient: plateau pressure, maintained below 30-35 em of HP; peak pressure, which should not be over 50 em of H20; and the pulmonary volume at the end of inspiration, which should be lower than 1.4L. Application of extrinsic positive end-respiratory pressure (PEEP) does not represent medical benefits to sedated, non-hypoxemie patients well adapted to meehanieal ventilation, even in the presence of auto-PEEP...

Management of Status Asthmaticus in Children.

Asthma is a common chronic inflammatory disorder of the airways characterized by recurrent wheezing, breathlessness, and coughing. Acute exacerbations of asthma can be life-threatening; annual worldwide estimated mortality is 250,000 and most of these deaths are preventable. While most of the acute exacerbations can be managed successfully in the emergency room, few children have severe exacerbations requiring intensive care. Mainstay of treatment for status asthmaticus are inhaled β2 agonist and anticholinergic agents, oxygen along with corticosteroids. Children who do not respond well to initial treatment require parenteral β2 agonist and magnesium. Rarely, sick children need parenteral aminophylline infusion and mechanical ventilation. Guidelines for diagnosis, treatment, ventilator management and supportive care for status asthmaticus in children are discussed in the protocol.

Conhecimento da família sobre os fatores precipitantes da crise asmática na criança / Family knowledge about precipitating factors of asthmatic crises in children / Conocimiento de la familia sobre los factores desencadenantes de la crisis asmática en el niño

Objetivou-se investigar o conhecimento da família quanto aos fatores precipitantes da crise asmática na criança; identificar as ações da família ante uma crise asmática e os recursos utilizados para controlá-la. Pesquisa transversal, descritiva, com 50 familiares de crianças asmática, mediante entrevista estruturada. Os resultados apontaram que a prevalência de asma foi maior entre as crianças de 1 a 7 anos e os conhecimentos dos seus familiares ainda são superficiais acerca dessa doença. Como medidas preventivas mais adotadas mencionaram evitar: ambiente empoeirado, andar descalço, beber água gelada, exposição a fumaças, contato com brinquedos ou animais de pelúcia. Tosse freqüente, “peito cerrado” e dificuldade de respirar foram os sintomas mais citados. Concluiu-se ser necessário criar programas destinados a desenvolver ações educativas de saúde com as famílias, no concernente ao estilo de vida, prevenção da exacerbação das crises e aderência ao tratamento.

This study aimed to investigate how much families know about precipitating factors for asthmatic crisis in children; to identify their actions when a crisis occurs and the resources used to control it. It is a Cross-sectional and descriptive research, involving 50 relatives of children with asthma, using structured interviews. The results of the study show higher prevalence of asthma in children from 1 to 7 years old and that their relatives’ knowledge on this disease remains superficial. The most mentioned prevention measures were to avoid: dusty environments, barefoot walking, drinking cold water, exposure to smoke, contact with plush toys or animals. Frequent cough, “tight chest” and breathing difficulties were the most cited symptoms. Programs need to be created to develop health education actions with these families, addressing lifestyle, prevention of crisis exacerbation and treatment adherence.

La finalidad de este estudio fue investigar el conocimiento de la familia respecto a los factores precipitantes de la crisis asmática en niños; identificar las acciones de la familia ante una crisis asmática y los recursos utilizados para controlarla. Investigación transversal,descriptiva, con 50 familiares de niños asmáticos, mediante entrevista estructurada. Los resultados indicaron que la prevalencia de asma fue mayor entre los niños de 1 a 7 años y que los conocimientos de sus familiares acerca de esa enfermedad siguen siendo superficiales. Como medidas preventivas más adoptadas mencionaron evitar: ambiente con polvo, andar descalzo, beber agua helada, exposición a fumaradas, contacto con juguetes o animales de peluche. Tos frecuente, “pecho cerrado” y dificultad de respirar fueron los síntomas máscitados. En conclusión, es necesario crear programas destinados a desarrollar acciones educativas de salud con las familias, respecto al estilo de vida, prevención de la exacerbación de las crises y adhesión al tratamiento.

A Case of Pseudoaneurysm Developed during Intensive Treatment of Status Asthmaticus: A Case Report / 대한구급학회지

Pseudoaneurysm formation in the pulmonary vasculature is a rare but fatal condition. Several etiologies have been described including trauma, complication after cardiac or other surgeries, tuberculosis, necrotizing pneumonia, congestive heart disease, atherosclerosis, cancer and vasculitis. We report a case of pseudoaneurysm found in a patient being treated with status asthmaticus, who developed complications of pneumonia and brain abscess secondary to sepsis.

A Case of Severe Acute Exacerbation of Bronchial Asthma Treated with Low Minute Ventilation: A Case Report / 대한구급학회지

We report a case of severe status asthmaticus in a 3-year-old boy who required mechanical ventilatory support. He initially presented with rapidly progressing respiratory distress and spontaneous air leaks. Although he was intubated and received mechanical ventilation, dynamic hyperinflation and air leaks were aggravated. We applied the volume control mode, providing sufficient tidal volume (10 ml/kg), a reduced respiratory rate (25/minute), and a prolonged expiratory time (1.8 seconds) to overcome dynamic hyperinflation. After allowing full expiration of trapped air, his over-expanded lung volumes were decreased and the air leaks resolved. He made a complete recovery without sequelae. Dynamic hyperinflation in asthmatic patients occurs from incomplete exhalation throughout narrowed airways. Controlled hypoventilation or permissive hypercapnia is an important lung-protective ventilator strategy and is beneficial in reducing dynamic hyperinflation. We suggest a controlled hypoventilation strategy with a prolonged expiratory time for patients in severe status asthmaticus with dynamic hyperinflation.

The study of severe asthma in Latin America and Spain (1994-2004): characteristics of patients hospitalized with acute severe asthma / Estudo sobre Asma Grave na América Latina e Espanha (1994-2004): características dos pacientes hospitalizados com asma aguda grave

Objective: Studies assessing the characteristics and management of patients hospitalized with asthma have been limited to a small number of facilities and have evaluated short time periods. The present study evaluated long-term changes among hospitalized asthma patients at a large number of facilities. Methods: This was a retrospective, hospital-based observational case series, designated the Study of Severe Asthma in Latin America and Spain, which was conducted in Spain and in eight Latin-American countries. We reviewed the hospital records of 3,038 patients (age range, 15-69 years) hospitalized with acute severe asthma at one of nineteen tertiary-care hospitals in 1994, 1999 and 2004. Results: Over time, the use of inhaled corticosteroids and long-acting β2 agonists increased significantly, whereas the use of theophylline as a controller medication decreased. The utilization of pulmonary function tests also increased. There was a significant reduction in the mean hospital stay (8.5 days, 7.4 days and 7.1 days in 1994, 1999 and 2004, respectively, p = 0.0001) and a significant increase in the mean of the lowest arterial pH at hospital admission. In contrast, there was a significant decrease in the proportion of cases in which PEF was determined in the emergency room (48.6% in 1994 vs. 43.5% in 2004, p = 0.0001). We found the quality of asthma management and care to be generally better in Spain than in Latin America. Conclusions: Although there have been certain improvements in the management of asthma between severe exacerbations and during hospitalization, asthma management remains suboptimal in Spain and, especially, in Latin America.

Objetivo: Estudos que avaliem as características e o gerenciamento de pacientes asmáticos hospitalizados têm sido limitados a um número pequeno de serviços e a curtos períodos de duração. O presente estudo avaliou alteraçõesde longo prazo de pacientes asmáticos hospitalizados em um grande número de serviços. Métodos: Estudo retrospectivo,observacional, de base hospitalar, denominado Estudo sobre Asma Grave na América Latina e Espanha, realizado na Espanha e em oito países da América Latina. Foi realizada uma revisão dos registros hospitalares de 3.038 pacientes (variação de idade, 15-69 anos) hospitalizados com asma aguda grave em um dos 19 hospitais terciários em 1994, 1999 e 2004. Resultados: Ao longo do tempo, o uso de corticosteroides inalatórios e de β2-agonistas aumentou significativamente, ao passo que o uso de teofilina, como medicação de controle, decaiu. A utilização de testes de função pulmonar também aumentou. Houve uma redução significativa da média do tempo de internação (8,5 dias, 7,4 dias e 7,1 dias em 1994, 1999 e 2004, respectivamente; p = 0,0001) e um aumento significativo da média do menor pH arterial na admissão. Em contrapartida, houve uma diminuição significativa na proporção de casos submetidos ao PFE no pronto-socorro (48,6% em 1994 vs. 43,5% em 2004; p = 0,0001). O tratamento e o gerenciamento da asma foram, de forma geral, melhores na Espanha que na América Latina. Conclusões: Embora tenha havido avanços no gerenciamento da asma entre exacerbações graves e durante a hospitalização, esse gerenciamento continua subotimizado na Espanha e, em especial, na América Latina.

Factors for poor prognosis of near-fatal asthma after recovery from a life-threatening asthma attack

BACKGROUND/AIMS: The aim of this study was to investigate poor prognostic factors associated with a near-fatal asthma attack following patient recovery. METHODS: We enrolled 68 patients who suffered near-fatal asthma attacks and were admitted to the intensive care units of five university hospitals. The patients were divided into two groups. The first group was comprised of patients who discontinued oral corticosteroids within 6 months after being discharged from the hospital and who maintained a forced expiratory volume in 1 s (FEV1) > or =60% of the maximum or estimated values of the corresponding patients. The second group included patients who continued on oral corticosteroids for > or =6 months or who maintained a FEV1 <60%. RESULTS: In patients with near-fatal asthma, factors for a poor prognosis included older age [48.47+/-3.53 vs. 64.69+/-2.59 years, p<0.05], chronic severe asthma, high values for inflammation-related laboratory markers (ESR, 8.75+/-2.05 vs. 23.88+/-4.40 mm/h, p=0.004; CRP, 1.72+/-0.46 vs. 6.68+/-9.36 mg/dL, p<0.05), asthma exacerbated by pneumonia (28.1 vs. 52.8%, p<0.05), and relatively low nutritional status (albumin, 4.00+/-0.14 vs. 3.51+/-0.10 g/dL, p<0.05). CONCLUSIONS: These prognostic factors may induce irreversible obstruction of the airways with subsequent acute exacerbation of asthma or the need for continual oral corticosteroids after being discharged from the hospital. Patients with these factors should be treated appropriately, under close surveillance.