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1.
Pediatr Crit Care Med ; 19(11): e585-e594, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30106766

RESUMO

OBJECTIVES: To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation. DESIGN: Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory University between 2004 and 2015. SETTING: Large, free-standing academic quaternary care children's hospital in Atlanta, GA. PATIENTS: Children 6-18 years old with physician-diagnosed and confirmed asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 579 children were analyzed with 170 children (29.4%) being admitted to the PICU for an asthma exacerbation in their lifetime. Of these 170 children with a history of critical asthma, 24.1% were classified as having mild-to-moderate asthma, and 83 of 170 children (48.8%) had been intubated and experienced near-fatal asthma. Multiple logistic regression was used to identify risk factors associated with increased odds of PICU admission with or without endotracheal intubation. Hospitalization within the prior 12 months of survey (odds ratio, 8.19; 95% CI, 4.83-13.89), a history of pneumonia (odds ratio, 2.56; 95% CI, 1.52-4.29), having a designation of increased chronic asthma severity on high-dose inhaled corticosteroids (odds ratio, 2.76; 95% CI, 1.62-4.70), having a father with asthma (odds ratio, 2.15; 95% CI, 1.23-3.76), living in a region with a higher burden of poverty (odds ratio, 1.28; 95% CI, 1.02-1.61), and being of black race (odds ratio, 2.01; 95% CI, 1.05-3.84) were all associated with increased odds of PICU admission with or without intubation. CONCLUSIONS: Our findings suggest that there are factors associated with critical and near-fatal asthma, distinct from the chronic asthma severity designations, that should be the focus of future investigation.


Assuntos
Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Estado Asmático/fisiopatologia , Administração por Inalação , Adolescente , Corticosteroides/administração & dosagem , Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Albuterol/administração & dosagem , Estudos de Casos e Controles , Criança , Feminino , Humanos , Modelos Logísticos , Masculino , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Estado Asmático/terapia
2.
Trials ; 19(1): 466, 2018 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-30157917

RESUMO

BACKGROUND: Despite effective treatments and long-standing management guidelines, there are approximately 1400 hospital admissions for asthma weekly in the United Kingdom (UK), many of which could be avoided. In our previous research, a secondary analysis of the intervention (ARRISA) suggested an improvement in the management of at-risk asthma patients in primary care. ARRISA involved identifying individuals at risk of adverse asthma events, flagging their electronic health records, training practice staff to develop and implement practice-wide processes of care when alerted by the flag, plus motivational reminders. We now seek to determine the effectiveness and cost-effectiveness of ARRISA in reducing asthma-related crisis events. METHODS: We are undertaking a pragmatic, two-arm, multicentre, cluster randomised controlled trial, plus health economic and process evaluation. We will randomise 270 primary care practices from throughout the UK covering over 10,000 registered patients with 'at-risk asthma' identified according to a validated algorithm. Staff in practices randomised to the intervention will complete two 45-min eLearning modules (an individually completed module giving background to ARRISA and a group-completed module to develop practice-wide pathways of care) plus a 30-min webinar with other practices. On completion of training at-risk patients' records will be coded so that a flag appears whenever their record is accessed. Practices will receive a phone call at 4 weeks and a reminder video at 6 weeks and 6 months. Control practices will continue to provide usual care. We will extract anonymised routine patient data from primary care records (with linkage to secondary care data) to determine the percentage of at-risk patients with an asthma-related crisis event (accident and emergency attendances, hospitalisations and deaths) after 12 months (primary outcome). We will also capture the time to crisis event, all-cause hospitalisations, asthma control and any changes in practice asthma management for at-risk and all patients with asthma. Cost-effectiveness analysis and mixed-methods process evaluations will also be conducted. DISCUSSION: This study is novel in terms of using a practice-wide intervention to target and engage with patients at risk from their asthma and is innovative in the use of routinely captured data with record linkage to obtain trial outcomes. TRIAL REGISTRATION: ISRCTN95472706 . Registered on 5 December 2014.


Assuntos
Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Sistemas de Apoio a Decisões Clínicas , Técnicas de Apoio para a Decisão , Prestação Integrada de Cuidados de Saúde/organização & administração , Capacitação em Serviço/métodos , Admissão do Paciente , Atenção Primária à Saúde/organização & administração , Sistema de Registros , Estado Asmático/prevenção & controle , Antiasmáticos/economia , Asma/diagnóstico , Asma/economia , Asma/fisiopatologia , Análise Custo-Benefício , Prestação Integrada de Cuidados de Saúde/economia , Custos de Medicamentos , Registros Eletrônicos de Saúde , Custos Hospitalares , Humanos , Pulmão/efeitos dos fármacos , Pulmão/fisiopatologia , Estudos Multicêntricos como Assunto , Admissão do Paciente/economia , Ensaios Clínicos Pragmáticos como Assunto , Atenção Primária à Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Estado Asmático/diagnóstico , Estado Asmático/economia , Estado Asmático/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Reino Unido , Gravação em Vídeo
3.
BMJ Case Rep ; 20172017 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-28754757

RESUMO

Status asthmaticus (SA) is a life-threatening disorder. Severe respiratory failure may require extracorporeal membrane oxygenation (ECMO). Previous reports have demonstrated utility of ECMO in SA in various patients with varying success. A 25-year-old man was admitted with status asthmatics and severe hypercapnic respiratory failure. Despite tailored ventilator therapies, such as pressure control ventilation and maximal pharmacological therapy, including general anaesthesia, the patient’s condition deteriorated rapidly. Veno-venous ECMO (VV-ECMO) was provided for respiratory support. The patient’s clinical condition improved over the following 72 hours and was discharged from the intensive care unit on day 3. This case report demonstrates the successful use of VV-ECMO in a patient with severe respiratory failure due to SA, who failed to respond to maximal therapy. This case adds support to a growing body of literature that shows that ECMO can be used with success for refractory status asthmaticus.


Assuntos
Dióxido de Carbono/metabolismo , Cuidados Críticos , Oxigenação por Membrana Extracorpórea , Hipercapnia/terapia , Insuficiência Respiratória/terapia , Estado Asmático/terapia , Adulto , Tubos Torácicos , Circulação Extracorpórea , Humanos , Hipercapnia/fisiopatologia , Masculino , Insuficiência Respiratória/metabolismo , Estado Asmático/metabolismo , Estado Asmático/fisiopatologia , Resultado do Tratamento
4.
Medisan ; 21(7)jul. 2017. tab
Artigo em Espanhol | LILACS | ID: biblio-894624

RESUMO

Se efectuó un estudio descriptivo y transversal, de casos y controles no pareado, de 120 pacientes con asma persistente, atendidos en la consulta de Alergología del Policlínico de Especialidades, perteneciente al Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde enero de 2014 hasta igual periodo de 2015, con vistas a describir las características clínicas y causas de esta enfermedad. Los pacientes fueron seleccionados mediante muestreo aleatorio simple y se distribuyeron en 2 grupos: uno de 60 integrantes con asma severa (de estudio) y el otro de igual cantidad con asma ligera (control). En la casuística predominaron los afectados con asma persistente moderada-severa del sexo femenino y el grupo etario de 40 años y más, mientras que los irritantes inespecíficos y las infecciones respiratorias resultaron ser los factores predisponentes de mayor ocurrencia. Sobresalieron la asociación con nasosinopatías y los cambios bruscos de temperatura


A descriptive and cross-sectional, cases and controls non paired study of 120 patients with persistent asthma was carried out. They were assisted in the Allergology Service of the Specialties Polyclinic, belonging to Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, from January, 2014 to the same period in 2015, aimed at describing the clinical characteristics and causes of this disease. The patients were selected by means of simple random sampling and they were distributed into 2 groups: one of 60 members with severe asthma (study group) and the other with the same number with light asthma (control group). In the case material there was a prevalence of those affected with moderate-severe persistent asthma from the female sex and the 40 years age group and over, while the unspecific irritant and the respiratory infections were the predisposing factors that occurred with more frequency. The association with nasosinopathies and the abrupt changes of temperature were notable


Assuntos
Humanos , Masculino , Feminino , Adulto , Asma/etiologia , Estado Asmático/fisiopatologia , Fatores Desencadeantes , Infecções Respiratórias , Sinais e Sintomas Respiratórios , Atenção Secundária à Saúde , Epidemiologia Descritiva , Estudos Transversais
5.
A A Case Rep ; 8(11): 286-290, 2017 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-28328592

RESUMO

A 24-year-old woman with history of asthma was intubated emergently for acute status asthmaticus triggered by acute respiratory syncytial virus infection and treated with permissive hypercapnia. Her ventilation was complicated by auto-positive end-expiratory pressure and elevated peak airway, plateau, and central venous pressures. On hospital day 2, she was noted to have anisocoria. Imaging showed diffuse cerebral edema with central herniation. Difficult ventilation and hypercapnia directly contributed to her severe cerebral edema. Comanagement between neurologic and medical/pulmonary intensivists enabled the management of the competing treatment requirements for status asthmaticus and cerebral edema. This case highlights the importance of balancing conflicting physiologic needs and collaboration between teams.


Assuntos
Edema Encefálico/terapia , Cuidados Críticos/métodos , Hérnia/terapia , Equipe de Assistência ao Paciente , Respiração Artificial , Estado Asmático/terapia , Doença Aguda , Edema Encefálico/diagnóstico , Edema Encefálico/etiologia , Edema Encefálico/fisiopatologia , Feminino , Hérnia/diagnóstico , Hérnia/etiologia , Hérnia/fisiopatologia , Humanos , Recuperação de Função Fisiológica , Respiração Artificial/efeitos adversos , Fatores de Risco , Índice de Gravidade de Doença , Estado Asmático/complicações , Estado Asmático/diagnóstico , Estado Asmático/fisiopatologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto Jovem
6.
Artigo em Inglês | MEDLINE | ID: mdl-28137226

RESUMO

BACKGROUND: Status asthmaticus is an acute exacerbation of asthma that is persistent and intractable and remains unresponsive to initial treatment with bronchodilators and systemic corticosteroids and that the condition can result in hypoxemia, hypercarbia, and secondary respiratory failure. OBJECTIVE: To review treatment and recent patents on management of status asthmaticus. METHOD: A PubMed search was completed in Clinical Queries using the key term "status asthmaticus". The search included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term status "asthmaticus" from www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com. RESULTS: Supplemental oxygen should be given to maintain an oxygen saturation of ≥ 92% in room air. Mainstay of pharmacologic treatment of status asthmaticus includes short-acting, ß2 agonists such as salbutamol (albuterol) administered by metered-dose inhaler with spacer or, preferably, by nebulizer and oral corticosteroids. There is no advantage to intravenous corticosteroids unless the child cannot tolerate oral corticosteroids (e.g., protracted vomiting), or unable to take oral corticosteroid (e.g., intubated or unconscious). Inhaled ipratropium bromide and intravenous magnesium sulfate should be considered in children with severe asthma exacerbations not responsive to conventional therapy. Subcutaneous and intramuscular ß2 agonists such as terbutaline and epinephrine may be considered for children with severe asthma exacerbation who have poor air entry, are uncooperative with nebulized therapy, or have poor response to nebulized therapy. Monoclonal anti-IgE antibody (omalizumab) and humanized monoclonal antibodies targeting interleukin pathway have shown great promise in severe refractory eosinophilic asthma. Failing therapeutic interventions necessitate non-invasive or invasive ventilation support. Severe exhaustion, deteriorating consciousness, poor air entry, worsening hypoxemia, hypercapnia, and cardiopulmonary arrest are indications for mechanical ventilation and intubation. For chronic treatment of asthma, inhaled corticosteroids, bronchodilator, and oral montelukasts are the mainstay. Some formulations of herbal medicine are efficacious but evidence of other modalities of complementary and alternative medicine are generally lacking. This review also discusses recent patents related to the management of asthma. These recent patents describe a few immunomodulating medications useful for the treatment of chronic severe asthma. There have been no recent patents for the management of status asthmaticus. CONCLUSION: Inhaled bronchodilators and systematic corticosteroids are the mainstay of therapy in the management of severe and status asthmaticus.


Assuntos
Antiasmáticos/uso terapêutico , Broncodilatadores/uso terapêutico , Estado Asmático/tratamento farmacológico , Administração por Inalação , Antiasmáticos/administração & dosagem , Broncodilatadores/administração & dosagem , Criança , Glucocorticoides/administração & dosagem , Glucocorticoides/uso terapêutico , Humanos , Oxigênio/administração & dosagem , Patentes como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/métodos , Estado Asmático/fisiopatologia
8.
Neumol. pediátr. (En línea) ; 11(4): 155-161, oct. 2016. tab
Artigo em Espanhol | LILACS | ID: biblio-835074

RESUMO

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.


Assuntos
Humanos , Criança , Estado Asmático/diagnóstico , Estado Asmático/terapia , Gasometria , Corticosteroides/uso terapêutico , Estado Asmático/fisiopatologia , Oximetria , Respiração Artificial , Índice de Gravidade de Doença
10.
Pediatr Pulmonol ; 51(11): 1122-1130, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27171324

RESUMO

BACKGROUND: The ideal dosing of albuterol via metered-dose inhalers for acute childhood asthma is not well established. We hypothesized that greater doses of albuterol would result in less time in the hospital and lower admission rates. METHODS: This was a randomized controlled double-blind multicenter study, conducted in emergency rooms (ER). We included patients with 2-17 years old with moderate to severe acute asthma (Pediatric Respiratory Assessment Measure, PRAM, score ≥5). Dosages administered during the first hour included: 6 (up to 25 kg) or 12 puffs (>25 kg) in the control group and 9 (up to 15 kg), 12 (>15-20 kg), 15 (>20-25 kg), or 18 puffs (>25 kg) in the study group. Several efficacy (changes in PRAM score, pulse oximetry, and FEV1 , length of stay, and admission rates) and safety (albuterol plasma levels, heart rate, serum potassium, glucose and bicarbonate levels, EKG, and tremor rates) outcome measures were assessed. RESULTS: We included 119 patients with similar baseline conditions, and no significant differences were observed between groups in the length of stay (P = 0.48) or admission rate (P = 0.55). No significant differences were observed in FEV1 , PRAM score, and pulse oximetry changes after 1 hr and at discharge or admission. No significant differences were observed in safety outcomes between groups. CONCLUSIONS: Higher albuterol dosage regimens did not result in lower admission rate or shorter length of stay in the ER, but showed similar safety profile for children with moderate to severe acute asthma. Pediatr Pulmonol. 2016;51:1122-1130. © 2016 Wiley Periodicals, Inc.


Assuntos
Albuterol/administração & dosagem , Asma/tratamento farmacológico , Broncodilatadores/administração & dosagem , Inaladores Dosimetrados , Estado Asmático/tratamento farmacológico , Administração por Inalação , Adolescente , Albuterol/efeitos adversos , Albuterol/uso terapêutico , Asma/fisiopatologia , Broncodilatadores/efeitos adversos , Broncodilatadores/uso terapêutico , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Método Duplo-Cego , Serviço Hospitalar de Emergência , Feminino , Frequência Cardíaca , Humanos , Masculino , Oximetria , Estado Asmático/fisiopatologia , Resultado do Tratamento
11.
J Extra Corpor Technol ; 47(2): 109-12, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26405359

RESUMO

The inability to adequately support a patient on extracorporeal membrane oxygenation (ECMO) due to impaired drainage is not an uncommon occurrence during support. Typically, the causes include hypovolemia, kinks in the circuit, cannula malposition, or inadequate cannula size. In this report we present an uncommon etiology of this problem. A 3-year-old female presented to our hospital in status asthmaticus and pulseless electrical activity (PEA). This was a result of dynamic hyperinflation of the lungs causing physical obstruction of venous return to the heart. Upon initiating venoarterial (VA) ECMO, we experienced inadequate drainage that did not improve despite multiple interventions. This resolved with the addition of an inhaled anesthetic gas to treat this patient's severe bronchospasm. This case illustrates the importance of considering a patient's physiology or disease state and how that may affect the mechanics of ECMO support.


Assuntos
Anestésicos Inalatórios/uso terapêutico , Drenagem/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Estado Asmático/fisiopatologia , Estado Asmático/terapia , Doença Aguda , Pré-Escolar , Drenagem/métodos , Feminino , Humanos , Radiografia Torácica
12.
Paediatr Anaesth ; 25(5): 460-7, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25580870

RESUMO

Status asthmaticus is an acute, intractable asthma attack refractory to standard interventions that can lead to progressive respiratory failure. Successful management requires a fundamental understanding of the disease process, its clinical presentation, and proper evaluation. Treatment must be instituted early and is aimed at reversing the airway inflammation, bronchoconstriction, and hyper-reactivity that often lead to lower airway obstruction, impaired ventilation, and oxygenation. Most patients are effectively treated with standard therapy including beta2-adrenergic agonists and corticosteroids. Others necessitate adjunctive therapies and escalation to noninvasive ventilation or intubation. We will review the pathophysiology, evaluation, and treatment options for pediatric patients presenting with status asthmaticus with a particular focus on refractory status asthmaticus treated with volatile anesthetics. In addition, we include a proven approach to the management of these patients in the critical care setting, which requires close coordination between critical care and anesthesia providers. We present a case series of three patients, two of which have the longest reported cases of continuous isoflurane use in status asthmaticus. This series was obtained from a retrospective chart review and highlights the efficacy of the volatile anesthetic, isoflurane, in three pediatric patients with refractory life-threatening status asthmaticus.


Assuntos
Anestésicos Inalatórios , Estado Asmático/tratamento farmacológico , Adolescente , Corticosteroides/uso terapêutico , Agonistas de Receptores Adrenérgicos beta 2 , Antiasmáticos/uso terapêutico , Pré-Escolar , Feminino , Humanos , Intubação Intratraqueal , Isoflurano , Masculino , Pediatria/métodos , Respiração Artificial , Estado Asmático/fisiopatologia , Estado Asmático/terapia
13.
Indian J Pediatr ; 82(4): 328-32, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24903131

RESUMO

OBJECTIVE: To compare the efficacy of nebulised budesonide with that of oral prednisone in the treatment of acute severe asthma in children. METHODS: Children aged 5-12 y with acute exacerbation of bronchial asthma were included. The study (budesonide) group received budesonide respirator solution (800 µg) at intervals of 20 min and a single dose of placebo tablets. The control (prednisolone) group received placebo solution at intervals of 20 min and a single dose of oral prednisolone (2 mg/kg). Both groups received three doses of nebulised salbutamol (0.15 mg/kg). Heart rate, respiratory rate, oxygen saturation, PEFR (Peak Expiratory Flow Rate) and fitness for discharge were assessed. RESULTS: Both groups showed a progressive decrease in tachycardia with treatment, but it was significantly greater in study group (p = 0.0002). There was significant decrease in tachypnea and improvement in oxygen saturation in both groups, but the difference between the groups (p = 0.334 and p = 0.814 respectively) was not significant. There was significant improvement in PEFR values in budesonide group (p = 0.024). Both groups showed significant improvement in clinical severity scores at the end of 2 h (p < 0.0001). Budesonide group had significantly higher proportion of patients fit for discharge at 2 h (based on clinical severity scores) (p = 0.0278). CONCLUSIONS: Nebulised budesonide significantly improves PEFR levels and fitness for discharge at 2 h when compared to oral prednisolone in children between 5 and 12 y with acute severe asthma.


Assuntos
Budesonida/administração & dosagem , Prednisolona/administração & dosagem , Estado Asmático , Broncodilatadores/administração & dosagem , Criança , Método Duplo-Cego , Monitoramento de Medicamentos/métodos , Feminino , Glucocorticoides/administração & dosagem , Humanos , Masculino , Nebulizadores e Vaporizadores , Oxigênio/análise , Gravidade do Paciente , Testes de Função Respiratória/métodos , Estado Asmático/diagnóstico , Estado Asmático/tratamento farmacológico , Estado Asmático/fisiopatologia , Resultado do Tratamento
14.
Perfusion ; 30(4): 291-4, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25070898

RESUMO

We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient's pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient's evolving needs.


Assuntos
Anafilaxia/terapia , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/terapia , Hipóxia/terapia , Insuficiência Respiratória/terapia , Estado Asmático/terapia , Anafilaxia/complicações , Anafilaxia/fisiopatologia , Criança , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipóxia/etiologia , Hipóxia/fisiopatologia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Estado Asmático/complicações , Estado Asmático/fisiopatologia
15.
Pulm Pharmacol Ther ; 27(1): 57-61, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23523660

RESUMO

INTRODUCTION: The role of aminophylline in the treatment of severe acute asthma in the pediatric critical care unit (PCCU) is not clear. We sought to examine the association of aminophylline treatment with PCCU length of stay and time to symptom improvement. MATERIAL AND METHODS: Patients with severe acute asthma who were admitted to our PCCU and received aminophylline infusion were retrospectively compared with similar patients who did not receive aminophylline. The primary outcome measure was functional length of stay (i.e. time to which patients could be transferred to a general pediatric ward bed). A secondary outcome was time to symptom improvement. RESULTS: Adjusted functional length of stay was longer for subjects who received aminophylline (n = 49) than for the patients who did not (n = 47) (hazard ratio 0.396, p < 0.001), as well as the time for symptom improvement (hazard ratio 0.359, p < 0.001). In the group of subjects receiving aminophylline, those with a serum theophylline level ≥ 10 mcg/ml (therapeutic) (n = 31) had longer functional length of stay (hazard ratio 0.457, p = 0.0225) and time to symptom improvement (hazard ratio 0.403, p = 0.0085) than those with levels < 10 mcg/ml (sub-therapeutic) (n = 18). CONCLUSIONS: The addition of aminophylline to therapy with corticosteroids and inhaled ß-agonists was associated with statistically and clinically significant increases in functional length of stay and time to symptom improvement in the PCCU. This potential morbidity supports the National Asthma Education and Prevention Program guideline proscribing aminophylline use in acute asthma.


Assuntos
Aminofilina/uso terapêutico , Broncodilatadores/uso terapêutico , Unidades de Terapia Intensiva Pediátrica , Estado Asmático/tratamento farmacológico , Adolescente , Agonistas Adrenérgicos beta/administração & dosagem , Agonistas Adrenérgicos beta/uso terapêutico , Aminofilina/administração & dosagem , Aminofilina/farmacocinética , Broncodilatadores/administração & dosagem , Broncodilatadores/farmacocinética , Criança , Pré-Escolar , Quimioterapia Combinada , Feminino , Glucocorticoides/administração & dosagem , Glucocorticoides/uso terapêutico , Humanos , Infusões Intravenosas , Tempo de Internação , Masculino , Estudos Retrospectivos , Índice de Gravidade de Doença , Estado Asmático/fisiopatologia , Teofilina/sangue , Fatores de Tempo , Resultado do Tratamento
16.
Crit Care Clin ; 29(2): 153-66, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23537669

RESUMO

Status asthmaticus is a frequent cause of admission to a pediatric intensive care unit. Prompt assessment and aggressive treatment are critical. First-line or conventional treatment includes supplemental oxygen, aerosolized albuterol, and corticosteroids. There are several second-line treatments available; however, few comparative studies have been performed and in the absence of good evidence-based treatments, the use of these therapies is highly variable and dependent on local practice and provider preference. In this article the pathophysiology and treatment of status asthmaticus is discussed, and the literature regarding second-line treatments is critically assessed to apply an evidence basis to the treatment of this severe disease.


Assuntos
Corticosteroides/uso terapêutico , Albuterol/uso terapêutico , Antiasmáticos/uso terapêutico , Oxigenoterapia , Estado Asmático/terapia , Administração por Inalação , Corticosteroides/administração & dosagem , Obstrução das Vias Respiratórias/terapia , Albuterol/administração & dosagem , Antiasmáticos/administração & dosagem , Gasometria , Broncodilatadores/administração & dosagem , Broncodilatadores/uso terapêutico , Criança , Humanos , Unidades de Terapia Intensiva Pediátrica , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Ventilação não Invasiva/métodos , Respiração com Pressão Positiva/métodos , Fatores de Risco , Índice de Gravidade de Doença , Estado Asmático/diagnóstico , Estado Asmático/fisiopatologia , Resultado do Tratamento
18.
Obstet Gynecol ; 121(2 Pt 2 Suppl 1): 422-4, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23344396

RESUMO

BACKGROUND: Asthma remains a common chronic illness in pregnancy with the potential for catastrophic complications. Most women with asthma exacerbation can be treated with medical management and continuation of pregnancy. However, refractory cases may necessitate delivery for fetal or maternal indications. CASE: We report a case of status asthmaticus at 33 weeks of gestation with significant maternal respiratory acidosis and difficulty with ventilation necessitating delivery by cesarean delivery in the medical intensive care unit. The patient was unresponsive to standard medical therapies. Delivery resulted in immediate improvement in maternal ventilation parameters. CONCLUSION: In cases of life-threatening status asthmaticus refractory to standard medical and ventilatory therapies in the third trimester, cesarean delivery should be considered as a final effort to increase tidal volumes and improve maternal gas exchange.


Assuntos
Acidose Respiratória/fisiopatologia , Cesárea , Complicações na Gravidez/fisiopatologia , Estado Asmático/fisiopatologia , Acidose Respiratória/etiologia , Adulto , Feminino , Humanos , Recém-Nascido , Masculino , Gravidez , Complicações na Gravidez/etiologia , Estado Asmático/complicações , Volume de Ventilação Pulmonar
19.
J Pediatr ; 161(2): 214-21.e3, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22494876

RESUMO

OBJECTIVE: To characterize the clinical course, therapies, and outcomes of children with fatal and near-fatal asthma admitted to pediatric intensive care units (PICUs). STUDY DESIGN: This was a retrospective chart abstraction across the 8 tertiary care PICUs of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Inclusion criteria were children (aged 1-18 years) admitted between 2005 and 2009 (inclusive) for asthma who received ventilation (near-fatal) or died (fatal). Data collected included medications, ventilator strategies, concomitant therapies, demographic information, and risk variables. RESULTS: Of the 261 eligible children, 33 (13%) had no previous history of asthma, 218 (84%) survived with no known complications, and 32 (12%) had complications. Eleven (4%) died, 10 of whom had experienced cardiac arrest before admission. Patients intubated outside the PICU had a shorter duration of ventilation (median, 25 hours vs 84 hours; P < .001). African-Americans were disproportionately represented among the intubated children and had a shorter duration of intubation. Barotrauma occurred in 15 children (6%) before admission. Pharmacologic therapy was highly variable, with similar outcomes. CONCLUSION: Of the children ventilated in the CPCCRN PICUs, 96% survived to hospital discharge. Most of the children who died experienced cardiac arrest before admission. Intubation outside the PICU was correlated with shorter duration of ventilation. Complications of barotrauma and neuromyopathy were uncommon. Practice patterns varied widely among the CPCCRN sites.


Assuntos
Asma/mortalidade , Unidades de Terapia Intensiva Pediátrica , Adolescente , Anestesia por Inalação , Asma/fisiopatologia , Asma/terapia , Gasometria , Criança , Pré-Escolar , Cuidados Críticos , Oxigenação por Membrana Extracorpórea , Feminino , Hospitalização , Humanos , Lactente , Intubação Intratraqueal , Masculino , Readmissão do Paciente , Respiração com Pressão Positiva , Respiração Artificial , Fenômenos Fisiológicos Respiratórios , Estado Asmático/mortalidade , Estado Asmático/fisiopatologia , Estado Asmático/terapia , Taxa de Sobrevida
20.
Pediatr Crit Care Med ; 13(1): 28-31, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21460758

RESUMO

OBJECTIVE: Hyperlactatemia and lactic acidosis are common in adults with acute severe asthma however only a few cases have been reported in children. Type A lactic acidosis is associated with impaired oxygen delivery; type B occurs in the presence of normal oxygen delivery and has been described to occur with excessive adrenergic stimulation. Type A and B lactic acidosis can be distinguished by the blood lactate/pyruvate ratio. Our objectives are to 1) investigate the incidence of hyperlactatemia and lactic acidosis in children with acute severe asthma, and 2) determine whether lactate elevation is type A or B. DESIGN: Prospective observational study. SETTING: University-affiliated tertiary care children's hospital. PATIENTS: All children (n = 105) with acute severe asthma admitted to the pediatric intensive care unit between May 1, 2008 and November 30, 2009 were included. INTERVENTIONS: Blood lactate concentration was measured on a blood gas analyzer for all blood gas assessments obtained for clinical care. Hyperlactatemia was defined as lactate >2.2 mmol/L and lactic acidosis as lactate >5 mmol/L and pH <7.35. If lactate concentration was >5 mmol/L, consent was requested for measuring blood lactate and pyruvate using enzymatic laboratory methods. Lactate/pyruvate ratio >25:1 indicated type A lactic acidosis. MEASUREMENTS AND MAIN RESULTS: Eighty-seven (83%) children had lactate >2.2 mmol/L and 47 (45%) had lactate >5 mmol/L. Of those with lactate >5 mmol/L, 33 (70%) had corresponding blood pH <7.35. Lactate/pyruvate ratios were obtained for 16 patients. Of these, lactate/pyruvate ratio was <10 in three patients; 10-25 in 11; >25 in one; and indeterminate in one. CONCLUSIONS: Lactic acidosis is common in children with acute severe asthma and is primarily type B occurring in the presence of normal oxygen delivery.


Assuntos
Acidose Láctica/etiologia , Unidades de Terapia Intensiva Pediátrica , Ácido Láctico/sangue , Estado Asmático/complicações , Acidose Láctica/fisiopatologia , Adolescente , Gasometria , Broncodilatadores/uso terapêutico , Criança , Pré-Escolar , Estudos de Coortes , Terapia Combinada , Feminino , Seguimentos , Hospitais Pediátricos , Humanos , Masculino , Oxigenoterapia/métodos , Estudos Prospectivos , Piruvatos/sangue , Medição de Risco , Índice de Gravidade de Doença , Estado Asmático/fisiopatologia , Estado Asmático/terapia , Resultado do Tratamento
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