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Background: To conduct a systematic review looking into the use of sevoflurane in the management of status asthmaticus (SA) in adults., Methods: We performed a systematic search on PubMed, EMBASE, and The Cochrane Library - CENTRAL through 23rd August 2023, restricting to studies reported in English. We included studies reporting use of sevoflurane in asthmatics beyond its use as an anaesthetic agent in surgeries i.e. in the emergency department (ED) and critical care setting, and focused on patient's clinical parameters, ventilation pressures and weaning of invasive ventilation., Results: A total of 13 publications fulfilled the inclusion criteria, comprising of 18 cases. All publications were of case reports/ series and conference abstracts, and no randomised trials were available. Most patients required intubation despite best medical management before sevoflurane administration, and high airway pressures and respiratory acidosis were apparent. There was significant heterogeneity regarding severity of asthma, treatment instituted, and the delivery, duration and concentration of sevoflurane administered. Many of the studies also did not quantify the changes in parameters pre- and post-sevoflurane. Sixteen patients experienced improvements in clinical status with sevoflurane administration-one required escalation to extracorporeal membrane oxygenation (ECMO), and another did not survive., Conclusion: The systematic review suggests sevoflurane can be a valuable treatment option in SA. As these cases are rare and heterogenous, further prospective case series are needed to support this., (© 2024. The Author(s).)

Background: In the state of Kentucky, many status asthmaticus (SA) patients require care in the Pediatric Intensive Care Unit (PICU) and a fraction of these patients may receive "rescue therapies" with inhaled volatile anesthetics (IVA) and/or Extracorporeal Membrane Oxygenation (ECMO). We present a series of such patients with the objective of comparing the clinical parameters of individual patients who received inhaled volatile anesthesia and subsequently the need for ECMO., Methods: Children between 2 and 18 years of age admitted to our PICU from January 2014 to July 2020 with SA were reviewed and categorized as 1) patients who received IVA alone, 2) patients who received IVA and then subsequently ECMO, and 3) patients on ECMO alone., Results: A total of 1772 children with SA episodes were identified with a mortality of 13 patients. Seven children with SA were identified who received either IVA, ECMO, or both. One patient received only IVA, 5 received both IVA and ECMO and one received only ECMO. All received standard asthma therapies of steroids, albuterol, magnesium sulphate, and aminophylline prior to escalation. Six out of seven refractory SA received IVA, and five (83%) of those were subsequently escalated to ECMO. There was an improvement in mean pH after cannulation compared to IVA. pCO 2 levels had no improvement after IVA administration but decreased by an average of 20 points after ECMO. Patients peak inspiratory pressures decreased within the 1st 24 h of ECMO cannulation from a mean of 30 to 18. There were no other complications related to ECMO placement., Conclusion: While we cannot decisively draw any conclusions from our study due to the small sample, it was noted that there was no clear advantage of using IVA prior to ECMO in our patients. Most patients who received IVA were escalated to ECMO indicating that early ECMO cannulation may be beneficial. Given the high cost and potential complications of both, there is a need for the development of well-defined guidelines for severe SA management in the PICU., (© The Author(s), published by EDP Sciences, 2024.)

Acute severe asthma describes serious asthmatic attacks, which remain a major treatment challenge and a significant source of morbidity in adults. It places the patient in danger of developing respiratory failure, a condition known as status asthmaticus. It is often fatal if not recognized and treated early. Many patients are at risk for numerous reasons; thus, the key issues are early detection, assessment and management. A multidisciplinary and collaborative approach is needed to effectively treat acute respiratory failure (ARF). Considerable research has investigated the range of opportunities available for treating asthma. Current treatment options include conventional agents, such as inhalational corticosteroids, â-agonists, leukotriene modulators, monoclonal antibodies, and oral corticosteroids (OCS). Nurses are in a perfect position to assess patients' risk of developing respiratory failure, monitor them, evaluate their care, and coordinate a multidisciplinary approach. In this review, we discuss acute asthma and the role of the nursing officer (NO) in the management of the illness. The review will also emphasize various current treatment approaches available for the NO that can effectively target and prevent respiratory failure. This review provides nurses and other healthcare workers with updated information on timely, effective and safe supportive management of patients with asthma.

Background: Standardized acute asthma management with score-based, respiratory therapist (RT)-driven pathways and protocols improves outcomes including decreased length of stay (LOS) and time on continuous albuterol therapy. Limited data are available for the safety of continuous albuterol used outside of pediatric ICU (PICU). We use a modified pediatric asthma score (PAS) for the asthma pathway at our institution. The safety and effectiveness of using PAS to initiate/stop continuous albuterol as part of a score-based, RT-driven asthma pathway were evaluated., Methods: A retrospective review of children ≥ 2 y admitted for asthma exacerbation to the PICU and step-down unit who received continuous albuterol as part of the asthma pathway during 2017-2019 was completed. Demographic and clinical data were extracted including PAS, dose and duration of continuous albuterol, LOS, and complications. Outcomes of subjects admitted to the PICU and step-down unit were compared., Results: Results are expressed as median (interquartile range). The study included 412 children (61% male, 59.9% Black, 92.7% non-Hispanic, 44.9% moderate persistent asthma) with age and weight of 6.4 (4.0-10.0) y and 24.8 (17.3-39.5) kg, respectively. Most children were admitted to step-down unit (71.1%). Initial albuterol dose, duration, and LOS were 15 (10-20) mg/h, 9.1 (5.7-16.0) h, and 1.4 (0.9-2.3) d, respectively. Respiratory support was required by 29% of subjects. Need to restart therapy (2.9%), transfer to PICU (1.7%), and intubation (0.5%) were infrequent. No pneumothoraces or deaths were reported. Emergency department visits (3.9%) or readmissions (0.7%) within 30 d of discharge were low. Subjects admitted to the PICU were sicker and required more therapies and respiratory support than those admitted to the step-down unit., Conclusions: Use of an RT-driven, score-based pathway for initiation and discontinuation of continuous albuterol for treatment of pediatric asthma exacerbation was safe and effective in the PICU and step-down unit., Competing Interests: Dr Berlinski discloses relationships with Cystic Fibrosis Foundation, Mylan, National Institutes of Health, Therapeutic Development Network, Trudell Medical International, Vertex, and the International Pharmaceutical Aerosol Consortium on Regulation and Science. Ms Willis is a section editor for Respiratory Care. The remaining authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Background: Protocol-driven therapy has been successful in managing patients with asthma on pediatric wards, but there is wide variability in ICU-level management that is often provider-dependent. This study aimed to determine if a standardized protocol for critical asthma treatment could improve clinical outcomes., Methods: A pre-intervention cohort consisting of subjects age 2-18 y, excluding patients with airway obstruction that was not felt to be due to asthma, who were admitted to the ICU for critical asthma. Demographics and data along with medication administration information were gathered using the hospital electronic medical record. A post-intervention cohort was obtained over 13 months in an identical manner. The primary end point was time on continuous albuterol. Subjects adhering to the protocol were examined as a subset., Results: 71 post-intervention subjects were compared with a historical cohort of 52 pre-intervention subjects over a similar time frame. There were no significant differences in demographic characteristics. Median time on continuous albuterol (14.4 h vs 8.1 h, P = .14) and secondary end points of median ICU length of stay (LOS), hospital LOS, and time from discontinuing continuous albuterol to transfer out of ICU were not significantly reduced in the post-intervention cohort. Overall adherence to the clinical protocol through completion was 42%. When comparing the pre-intervention cohort with the protocol-adherent subjects, significant reductions were seen in time on continuous albuterol (14.4 h vs 3.0 h, P < .001), ICU LOS (38.7 h vs 21.0 h, P < .001), and hospital LOS (2.8 d vs 1.7 d, P = .005)., Conclusions: Implementation of an asthma protocol in the pediatric ICU did not result in significant improvements in time on continuous albuterol or hospital and pediatric ICU LOS, likely due to low adherence to the protocol. However, in subjects who did adhere to the protocol there were significant reductions in the outcome measures., Competing Interests: The authors have disclosed no conflicts of interest. This work was supported by National Institutes of Health’s National Center for Advancing Translational Sciences Grant UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences., (Copyright © 2021 by Daedalus Enterprises.)

Background: Salbutamol-induced lactic acidosis is a rare presentation that could manifest in specific clinical context as acute asthmatic attack treatment. An increase of glycolysis pathway leading to pyruvate escalation is the mechanism of hyperlactatemia in β2-adrenergic agonist drug., Case Presentation: A 40-year-old man who had poor-controlled asthma, presented with progressive dyspnea with coryza symptom for 6 days. He was intubated and admitted into medical intensive care unit due to deteriorated respiratory symptom. Severe asthmatic attack was diagnosed and approximate 1.5 canisters of salbutamol inhaler was administrated within 24 h of admission. Initial severe acidosis consisted of acute respiratory acidosis from ventilation-perfusion mismatch and acute metabolic acidosis resulting from bronchospasm and hypoxia-related lactic acidosis, respectively. The lactate level was normalized in 6 h after hypoxemia and ventilation correction. Given the lactate level re-elevated into a peak of 4.6 mmol/L without signs of tissue hypoxia nor other possible etiologies, the salbutamol toxicity was suspected and the inhaler was discontinued that contributed to rapid lactate clearance. The patient was safely discharged on the 6th day of admission., Conclusion: The re-elevation of serum lactate in status asthmaticus patient who had been administrated with the vast amount of β2-adrenergic agonist should be considered for salbutamol-induced lactic acidosis and promptly discontinued especially when there were no common potentials.

Objective: To compare the efficacy of nebulised salbutamol alone and in combination with ipratropium bromide in acute severe asthma in children., Methods: The randomised controlled trial was conducted at the National Institute of Child Health, Karachi, from October 2012 to March 2013, and comprised patients with acute severe asthma who were randomised into two equal groups. Group A patients received 3 doses of nebulised salbutamol alone (0.03 ml/kg/dose) at 15-minute intervals and Group B received 3 similar doses of salbutamol along with ipratropium (250 ug/dose). Acute severe asthma was categorised as serve exacerbation (clinical score >10) and moderate (5-10 score) based on Bentur Modification. Efficacy was measured after 5minutes of the last dose by change in severity score from severe exacerbation (baseline) to low score. SPSS 10 was used for statistical analysis., Results: There were two groups of 100(50%) patients each. The mean age in Group A was 9.1±3 years and 9.3±2.8 years in Group B. Male-Female ratio in Group A was 1.5:1 and in Group B it was 1.2:1. In Group B, 93(93%) children showed improvement in clinical score (<10 score) while it was 84(84%) in Group A. There was better response in clinical score in Group A than Group B, but it was not significant (p>0.05)., Conclusions: The combination of nebulised salbutamol along with ipratropium bromide in the treatment of acute asthma exacerbation was not superior to salbutamol alone.

Background: In our institution's pediatric emergency department, adherence to evidence-based asthma guidelines was noted to be suboptimal for patients with asthma exacerbations. We hypothesized that an evidence-based asthma protocol would improve time to treatment and adherence to National Institutes of Health guidelines for patients presenting to the emergency department with status asthmaticus., Methods: Subjects at our institution were retrospectively identified through an electronic medical record search following institutional review board approval. The asthma protocol was initiated in February 2012. All pediatric subjects who received continuous albuterol in the emergency department before (February 26, 2009, to February 22, 2012, n = 193) and after (February 23, 2012, to December 31, 2012, n = 68) protocol initiation were analyzed. The post-protocol data were collected as part of routine quality assurance monitoring with a target of 60 post-protocol subjects. Subjects were identified at the end of each month, which resulted in a total of 68 subjects being included. Primary outcomes measured included time to initial treatment with inhaled bronchodilator therapy, time to treatment with systemic corticosteroids, and total number of ipratropium bromide treatments delivered., Results: Two-hundred sixty-one subjects (7.1 ± 4.6 y of age, 66% male) were included. Demographics were similar in the pre- and post-protocol groups. Compared with the pre-protocol group, more subjects in the post-protocol group received bronchodilators within 30 min (60% vs 77%, P = .02), at least one dose of ipratropium bromide (55% vs 87%, P < .001), 3 doses of ipratropium bromide (14% vs 54%, P < .001), and corticosteroids within 60 min (62% vs 77%, P = .04). There were no statistically significant differences between the pre- and post-protocol cohorts in the mean time to first bronchodilator treatment (32 ± 41 vs 26 ± 52 min, P = .34), mean time to corticosteroid administration (74 ± 68 vs 54 ± 63 min, P = .06), or mean emergency department length of stay (342 ± 143 vs 364 ± 183 min, P = .31)., Conclusions: An asthma protocol resulted in improved adherence to National Institutes of Health guidelines in children with status asthmaticus and improved efficiency in the administration of rescue bronchodilator and systemic corticosteroid therapy., (Copyright © 2015 by Daedalus Enterprises.)

This report describes the treatment of eight patients with status asthmaticus, six of whom were already maximally treated. They were consequently treated with enoximone, a selective phosphodiesterase III inhibitor, in their refractory phase. Bronchodilatation in these patients was immediate. No side-effects were observed. Enoximone appears to be a valuable addition to the treatment of status asthmaticus. I.V. administration bypasses inhalation incapability in severe asthma. It is likely to reduce or altogether prevent the need for resorting to secondary or tertiary high-tech therapy such as mechanical ventilation or anaesthetics, thus avoiding complications, as well as for transfers to specialized intensive care units. Not only do these aspects enable substantial cost savings, but they also may spare the patient a lot of anguish and a prolonged recovery., (© The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

A 7-year-old known asthmatic presented with an acute severe asthma attack to the Accident and Emergency department. Following a poor response to salbutamol and ipratropium nebulisers, he was given intravenous salbutamol and aminophylline. Over the course of the following 3 h, there was improvement in his bronchospasm with decreasing oxygen requirement, however, his respiratory rate showed an upward trend. Serial blood gas estimations showed a worsening metabolic acidosis unresponsive to two fluid boluses of 20 ml/kg of normal saline. Lactate levels were subsequently measured and found to be high, accounting for the metabolic acidosis. High lactate levels were attributed to intravenous salbutamol. His blood gases and lactate level returned to normal within 3 h after stopping intravenous salbutamol. He was recommended on salbutamol nebulisers while still continuing on intravenous aminophylline. He continued to improve and was discharged home after 4 days.

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 beta2 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.

Background: Due to changing evidence on efficacy of MDI+spacer as compared to nebuliser, two types of managements were going on in our Day unit, depending on the presence of different medical professionals. We wanted to find out the evidence of the best practice from within our unit, and then to formulate guidelines based on it for the management of paediatric acute asthma., Methods: We isolated 54 cases of children suffering from acute asthma attack from admissions during Oct 2004-March 2005 within the age range of 3-14 yrs. We categorised them into four classes of mild, moderate, severe and life threatening acute attack depending on its severity and then separated them in two groups. Group I received salbutamol Via MDI+spacer and Group II received salbutamol via nebuliser. Our outcome measure was time to clinical improvement and duration of hospital stay., Results: We didn't find any major difference between the two groups, moreover MDI+spacer was better than nebuliser for the treatment of severe acute asthma attack in children., Conclusion: Our study supported and confirmed the evidence that MDI+spacer is least as effective as nebuliser in the management of acute asthma in children.

Though intravenous (IV) Magnesium Sulphate (MgS04) has additive effect to beta-2 agonists, its additive benefit in face of combination therapy with beta-2-agonists and ipratropium (standard therapy of severe acute exacerbation of asthma) remains unaddressed. The aim of this investigation was to evaluate the role of IV MgSO4 when used as an adjunct to standard therapy of severe exacerbations of asthma. Randomized, single blinded, placebo-controlled study was carried out in Emergency Department (ED). Patients aged 18-60 years presenting with acute asthma and FEV1 < 30 % predicted (pred.) were included. All patients received IV Hydrocortisone on arrival. In group1 (controls), patients were nebulised with salbutamol and ipratropium thrice at 20 minutes interval and were given 2g IV MgSO4 at 30 minutes. In group2 patients were nebulised similarly, but were given IV normal saline at 30 minutes for blinding. FEV1 was evaluated at baseline and at 30 minutes intervals. The primary efficacy end point was FEV1%pred. at 120 mins and pooled discharge rate (derived from comparing proportion of groups attaining PEFR > or = 60%pred. and relief in dyspnea at 30, 60, 90, 120 minutes). Both groups of 30 patients each, were matched with respect to demographic and pulmonary parameters (Baseline FEV1% :22.0+/-5.1% in group2 vs.22.07+/-5.2% in group1, p=0.87).At 120 minutes, there was a higher mean FEV1 %pred (62.84+/-4.73% vs. 56.7+/-4.5%) and %improvement from baseline of (40.7+/-9.2%vs34.77+/-7.3%), in group 2 as compared to group1 (Mean Difference= 6.07%, C.I.1.87-10.62., p<0.01).The pooled discharge rate in group2 with respect to group1 was positive and significant (log rank.=6.8, p<0.05). Thus IV MgSO4 improves pulmonary function and discharge rates, when used as an adjunct to standard therapy in severe acute asthma.Magnesium sulfate as an adjunct to standard therapy in patients with severe exacerbation of asthma could cause improvement in pulmonary function and decrease in hospital admission.

Background: Patients with severe persistent asthma despite GINA 2002 step 4 treatment are at risk for asthma-related morbidity and mortality. This study constitutes the Israeli arm of the international INNOVATE study., Objectives: To determine the efficacy and safety of Xolair as an add-on treatment in patients with severe persistent asthma., Methods: Asthma patients (age 12-75 years) not controlled with high dose inhaled corticosteroids and long-active beta-2 agonists were randomized to receive either Xolair or placebo for 28 weeks in a double-blind study in two Israeli centers., Results: Thirty-three patients, 20 females and 13 males, mean age 54 +/- 11.7 years, were included in the Israeli arm of the INNOVATE study. There were neither major adverse events nor withdrawals from the study. Xolair (omalizumab) significantly reduced the rate of clinically significant asthma exacerbations (55% reduction) and all asthma-related emergency visits (53% reduction)., Conclusions: In patients with severe persistent difficult-to-treat asthma, despite regular treatment with LABA and inhaled corticosteroids (GINA 2002 step 4), Xolair is a safe and effective treatment.

Objectives: To estimate the cost and characterize the management of asthma attacks in primary care., Design: Prospective, observational study of 1 year's duration. Setting. 10 physician's offices at 9 primary care centers located in 5 provinces (Asturias, Barcelona, Cadiz, Madrid, and Valencia) of Spain., Participants: 10 family physicians who saw 133 consecutive patients with an asthma attack., Method: Prospective, observational study; no intervention was used. Direct and indirect costs arising from asthma attacks were calculated. Episodes were treated according to the physicians' habitually used procedures; the study protocol did not specify any predetermined intervention., Results: The attacks were classified as mild in 43.6% of the cases, moderately severe in 43.6%, and severe in 12.8%. Of all severe attacks, 17.2% occurred in patients with intermittent asthma. The more severe the attack, the less preventive treatment patients had received previously. The mean cost of asthma attacks was 166.7 (95% CI, 146.5-192.3); 80% (132.4) (95% CI, 122.7-143.8) were direct costs and 20% (34.3) (95% CI, 17-56.2) were indirect costs. The most economical management option was to change treatment, perform diagnostic tests and have the patient attend 2 follow-up appointments with the physician., Conclusions: Mean cost of each asthma attack treated in primary care was 166.7 (95% CI, 146.5-192.3), of which 80% were direct costs and 20% indirect costs.

This prospective study of 169 adult patients hospitalized for severe acute asthma in four pneumology wards compared the incidence and costs of patients who were managed (group A) or not managed (group P) before hospitalization, according to the guidelines and international recommendations (11 criteria judged by experts). Ambulatory costs were calculated by questioning patients. Valuation of hospital costs was based DRGs weighted by length of stay. The incidence in group P patients was estimated at 70%; A patients were 14 years younger than those in group P and had less severe asthma. Their annual ambulatory care prior to hospitalization was less costly irrespective of age category or degree of severity (euro 685 vs. euro 1,145 in group A); their length of hospital stay was shorter (6.03 vs. 10.78 days), resulting in a lower cost of hospitalization (euro 2,820 vs. euro 4,843). In group P a specific education program based on increased understanding, compliance, self-management, and smoking cessation, particularly in young patients should lead to reductions in hospitalizations.

Objectives: To evaluate the reliability, validity, and responsiveness of a new clinical asthma score, the Pediatric Asthma Severity Score (PASS), in children aged 1 through 18 years in an acute clinical setting., Methods: This was a prospective cohort study of children treated for acute asthma at two urban pediatric emergency departments (EDs). A total of 852 patients were enrolled at one site and 369 at the second site. Clinical findings were assessed at the start of the ED visit, after one hour of treatment, and at the time of disposition. Peak expiratory flow rate (PEFR) (for patients aged 6 years and older) and pulse oximetry were also measured., Results: Composite scores including three, four, or five clinical findings were evaluated, and the three-item score (wheezing, prolonged expiration, and work of breathing) was selected as the PASS. Interobserver reliability for the PASS was good to excellent (kappa = 0.72 to 0.83). There was a significant correlation between PASS and PEFR (r = 0.27 to 0.37) and pulse oximetry (r = 0.29 to 0.41) at various time points. The PASS was able to discriminate between those patients who did and did not require hospitalization, with area under the receiver operating characteristic curve of 0.82. Finally, the PASS was shown to be responsive, with a 48% relative increase in score from start to end of treatment and an overall effect size of 0.62, indicating a moderate to large effect., Conclusions: This clinical score, the PASS, based on three clinical findings, is a reliable and valid measure of asthma severity in children and shows both discriminative and responsive properties. The PASS may be a useful tool to assess acute asthma severity for clinical and research purposes.

Objective: To compare the effectiveness of salbutamol administration by metered-dose inhaler with a home-made spacer versus jet nebulizer in children with moderate wheezing attacks., Material and Methods: A randomized, single-blinded trial was performed with a convenience sample of children presenting wheezing. The children were enrolled in an emergency room and randomly assigned to one of two treatment groups: home-made spacer group or nebulizer group. Clinical scores and oxygen saturation were recorded at baseline and 15 minutes after salbutamol administration. Treatment with salbutamol (100 microg/3 kg in the spacer group, and 250 microg/3 kg in the nebulizer group) was repeated at 20-minute intervals, until the child was considered to have improved significantly, with no need of any further dose, or until three doses were delivered. Treatment cost, time spent to prepare and deliver the drug, and level of parental satisfaction with the treatment were recorded., Results: Fifty-four children with age between 22 days and 11.7 years were enrolled--27 in each group. Baseline and demographic characteristics were similar for both groups. The spacer was as effective as the nebulizer in terms of clinical score and oxygen saturation. The different doses (100 microg/3 kg with the spacer, and 250 microg/3 kg with the nebulizer) were shown to be clinically equivalent. Treatment cost was significantly lower in the spacer group, as was the time to prepare and deliver the drug. Parental satisfaction was similar for both inhaler devices., Conclusion: The home-made spacer with a metered-dose inhaler is a cost-effective alternative to a jet nebulizer in the delivery of salbutamol to children with moderate wheezing attacks.

Asthma is a common chronic disorder, with a prevalence of 8 to 10 percent in the U.S. population. From 5 to 10 percent of patients have severe disease that does not respond to typical therapeutic interventions. To prevent life-threatening sequelae, it is important to identify patients with severe asthma who will require aggressive management of exacerbations. Objective monitoring of pulmonary status using a peak flow meter is essential in patients with persistent asthma. Patients who have a history of fragmented health care, intubation, or hospitalization for asthma and those with mental illness or psychosocial stressors are at increased risk for severe asthma. Oxygen, beta2 agonists, and systemic corticosteroids are the mainstays of acute asthma therapy. Inhaled anticholinergic medications provide additional bronchodilation. In patients who deteriorate despite usual therapeutic efforts, evidence supports individualized use of parenteral beta2 agonists, magnesium sulfate, aminophylline, leukotriene inhibitors, or positive pressure mask ventilation before intubation.

Severe asthma, although difficult to define, includes all cases of difficult/therapy-resistant disease of all age groups and bears the largest part of morbidity and mortality from asthma. Acute, severe asthma, status asthmaticus, is the more or less rapid but severe asthmatic exacerbation that may not respond to the usual medical treatment. The narrowing of airways causes ventilation perfusion imbalance, lung hyperinflation, and increased work of breathing that may lead to ventilatory muscle fatigue and life-threatening respiratory failure. Treatment for acute, severe asthma includes the administration of oxygen, beta2-agonists (by continuous or repetitive nebulisation), and systemic corticosteroids. Subcutaneous administration of epinephrine or terbutaline should be considered in patients not responding adequately to continuous nebulisation, in those unable to cooperate, and in intubated patients not responding to inhaled therapy. The exact time to intubate a patient in status asthmaticus is based mainly on clinical judgment, but intubation should not be delayed once it is deemed necessary. Mechanical ventilation in status asthmaticus supports gas-exchange and unloads ventilatory muscles until aggressive medical treatment improves the functional status of the patient. Patients intubated and mechanically ventilated should be appropriately sedated, but paralytic agents should be avoided. Permissive hypercapnia, increase in expiratory time, and promotion of patient-ventilator synchronism are the mainstay in mechanical ventilation of status asthmaticus. Close monitoring of the patient's condition is necessary to obviate complications and to identify the appropriate time for weaning. Finally, after successful treatment and prior to discharge, a careful strategy for prevention of subsequent asthma attacks is imperative.

Objective: To compare the efficacy of a commercial spacer device versus an improvised spacer device in delivering aerosolized beta-2 agonist through metered dose inhaler in an acute exacerbation of bronchial asthma., Design: Randomized controlled trial., Setting: Urban tertiary care teaching hospital., Methods: 60 children between 1 to 12 years of age with acute asthma were prospectively enrolled and randomized into two groups. Detailed history, clinical evaluation and appropriate laboratory investigations were recorded on a pretested proforma. One group received inhaled salbutamol using metered dose inhaler via commercial spacer device (Group 1), while the other received it via improvised spacer device (Group II). The response was sequentially assessed after 20, 40 and 60 minutes of institution of therapy., Results: The two groups were comparable with respect to various parameters at presentation (p > 0.05). All the outcome parameters showed a significant improvement with time in both groups (p < 0.05). There was no statistical difference between the response in the two groups (p< 0.05)., Conclusion: Metered dose inhaler with improvised spacer device is equivalent in efficacy and a more cost effective alternative to metered dose inhaler with commercial spacer for administration of beta-2 agonist in acute asthma.

The aims of this study were: to assess the safety of a sputum induction method using inhaled normal saline in children with acute asthma; and to investigate changes in sputum cell counts between acute exacerbations of asthma and its resolution. Ultrasonically nebulized normal saline was used to induce sputum from children (n = 8) presenting with acute asthma within 1 h of arrival and again at least 14 days later, after resolution of the exacerbation. Children received pretreatment with bronchodilator, and peak expiratory flow (PEF) was monitored throughout the procedure. Samples were analysed for total cell count, differential cell counts, and for eosinophils and neutrophils using specific immunochemical stains. Sputum induction was performed without adverse effect in each child with acute asthma. The mean fall in PEF from baseline during sputum induction was 5.3% during the acute attack and 3.4% at resolution. A shorter nebulization time was required to induce sputum in acute asthma than at follow-up (7.8 vs 13.9 min; p = 0.04). During acute asthma, there was an intense cellular infiltrate (mean total cell count 34 x 10(6) cells.mL-1), which resolved after recovery (1.9 x 10(6) cells.mL-1) (p = 0.04). The infiltrate was heterogenous, comprising eosinophils (6.7 x 10(6) cells.mL-1), neutrophils (5.4 x 10(6) cells.mL-1) and mast cells (0.47 x 10(6) cells.mL-1). Resolution of the exacerbation was accompanied by a significant fall in eosinophils and neutrophils (p < or = 0.04). Normal saline induction of sputum can be used to assess airway inflammation in acute asthma. Children with acute asthma have intense airway inflammation that is heterogeneous and involves neutrophils, eosinophils and mast cells.

The intensity of asthma exacerbations may vary from mild to severe. Many studies have demonstrated that the speed at which severe asthma exacerbation (SAE) develops varies among patients. In some asthmatics, the exacerbation comes on very quickly, whereas in others there is a progressive deterioration of clinical, functional and blood gas parameters. Sudden SAE are characterised by their explosive presentation and quick recovery. This evolution contrasts with that of patients with a slow onset SAE, who often need prolonged hospitalization. Absence of secretions suctioned from the airways during mechanical ventilation has been reported in sudden SAE, whereas large amounts of viscid mucus are found in patients with the slow onset SAE. The lungs of patients who died during a sudden onset SAE often show empty airways and a predominant neutrophilic infiltration in the bronchial epithelium, in contrast to the presence of abundant eosinophils in patients who died during a slow onset SAE. Sudden onset SAE may occur as sporadic cases or in outbreaks. Sporadic cases may result from the ingestion of nonsteroidal anti-inflammatory drugs (NSAID) in patients with intolerance to these products, massive exposure to common allergens and ingestion of foods containing sulphites. Asthma outbreaks have been described in many cities. In contrast to sudden onset SAE, slow onset SAE is characterized by a progressive deterioration, accompanied by an increase in the use of bronchodilators. Lack of appropriate monitoring of function by peak expiratory flow (PEF) recording, failure of patients to recognize worsening symptoms and underusage of inhaled and oral steroid treatment have been repeatedly identified as factors which are likely to be associated with slow onset SAE. The contribution of psychosocial problems, depression, denial of asthma severity and nonadherence with the treatment should not be overlooked in patients with slow onset SAE. Classification of severe asthma exacerbations into two types (sudden onset and slow onset) could help to reveal the aetiology of the attack and may also be relevant to the management of the patient.

The case is reported of a 28 year old woman with status asthmaticus unresponsive to three days of maximal medical treatment. Resolution of bronchospasm was achieved with an infusion of the intravenous anaesthetic agent ketamine.

A trial was conducted of continuous nebulised salbutamol and oral once a day prednisolone in a group of 11 children with status asthmaticus (group A) and compared with a conventional protocol comprising aminophylline infusion and intravenous hydrocortisone every six hours in a matched control group (group B). Monitoring by a clinical asthma score, pulse oximetry (oxygen saturation, SaO2), and peak expiratory flow rate (PEFR) revealed earlier improvement in these parameters in group A. Significant differences in mean SaO2 values appeared after 12 and 18 hours respectively. Mean PEFR percentage values were higher in group A compared with group B. A larger number (9/11) of patients could be discharged from hospital within 24 hours in group A compared with group B where only 3/11 could be discharged. All patients recovered without any side effects. It is concluded that continuous nebulised salbutamol and oral once a day prednisolone is safe and effective in treatment of children with status asthmaticus.

The initial resuscitation and stabilization provided to a critically ill or injured child is often an important determinant of outcome. Before transfer to a tertiary care facility the initial care may be provided by physicians unaccustomed to managing critically ill children. The authors outline the unique aspects of resuscitation and stabilization of the critically ill child and give guidelines for the initial management of diseases affecting the central nervous system and respiratory tract (the most frequent indications for transfer to a tertiary care facility) and other, less frequent but important problems. In many situations it is worth while to enlist the expertise of the tertiary care centre, either by telephone consultation or by dispatch of a specially trained transport team.

A fire-fighter, who developed chronic severe asthma after exposure to decomposition products of plastics during routine fire-fighting, is described. The outcome was fatal 25 months after onset of the disease.