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Scichilone N, Barnes PJ, Battaglia S, Benfante A, Brown R, Canonica GW, Caramori G, Cazzola M, Centanni S, Cianferoni A, Corsico A, De Carlo G, Di Marco F, Gaga M, Hawrylowicz C, Heffler E, Matera MG, Matucci A, Paggiaro P, Papi A, Popov T, Rogliani P, Santus P, Solidoro P, Togias A, Boulet LP. The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians. J Clin Med 2020; 9:jcm9082397. [PMID: 32727032 PMCID: PMC7463666 DOI: 10.3390/jcm9082397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Severe asthma is an important topic in respiratory diseases, due to its high impact on morbidity and mortality as well as on health-care resources. The many challenges that still exist in the management of the most difficult-to-treat forms of the disease, and the acknowledgement of the existence of unexplored areas in the pathophysiological mechanisms and the therapeutic targets represent an opportunity to gather experts in the field with the immediate goals to summarize current understanding about the natural history of severe asthma and to identify gaps in knowledge and research opportunities, with the aim to contribute to improved medical care and health outcomes. This article is a consensus document from the “International Course on Severe Asthma” that took place in Palermo, Italy, on May 10–11, 2019. Emerging topics in severe asthma were addressed and discussed among experts, with special focus on patient’s needs and research opportunities, with the aim to highlight the unanswered questions in the diagnostic process and therapeutic approach.
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Affiliation(s)
- Nicola Scichilone
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
- Correspondence: ; Tel.: +39-091-655-2146
| | - Peter John Barnes
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK;
| | - Salvatore Battaglia
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Alida Benfante
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Robert Brown
- Department of Anesthesiology and Critical Care Medicine, Medicine, Department of Medicine, Division of Pulmonary Medicine, Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD 21287, USA;
| | - Giorgio Walter Canonica
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Gaetano Caramori
- Respiratory Medicine Unit, Department of Biomedical Sciences, Dentistry and Morphological and Functional Imaging (BIOMORF), University of Messina, 98122 Messina, Italy;
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics – University of Pavia, 27100 Pavia, Italy;
| | - Giuseppe De Carlo
- The European Federation of Allergy and Airways Diseases Patients Associations (EFA), 1000 Brussels, Belgium;
| | - Fabiano Di Marco
- Respiratory Unit, ASST - Papa Giovanni XXIII Hospital, Bergamo, University of Milan, 24127 Milan, Italy;
| | - Mina Gaga
- 7th Respiratory Medicine Dept, Asthma Cen, Athens Chest Hospital, 11527 Athens, Greece;
| | - Catherine Hawrylowicz
- Division of Asthma, Allergy and Lung Biology, King’s College London, Guy’s Hospital, London SE1 9RT, UK;
| | - Enrico Heffler
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, 50139 Florence, Italy;
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, 56126 Pisa, Italy;
| | - Alberto Papi
- Research Center on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Todor Popov
- Clinic of Occupational Diseases, University Hospital Sv. Ivan Rilski, 1431 Sofia, Bulgaria;
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Pierachille Santus
- Division of Respiratory Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy;
| | - Paolo Solidoro
- Pneumology Unit U, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy;
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, MD 20814, USA;
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Long B, Lentz S, Koyfman A, Gottlieb M. Evaluation and management of the critically ill adult asthmatic in the emergency department setting. Am J Emerg Med 2020; 44:441-451. [PMID: 32222313 DOI: 10.1016/j.ajem.2020.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management. OBJECTIVE This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma. DISCUSSION It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission. CONCLUSIONS This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, United States
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Carrié S, Anderson TA. Volatile anesthetics for status asthmaticus in pediatric patients: a comprehensive review and case series. Paediatr Anaesth 2015; 25:460-7. [PMID: 25580870 DOI: 10.1111/pan.12577] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2014] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Sabrina Carrié
- Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; McGill University Health Center, Department of Anesthesia, Montreal, QC, Canada
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Abstract
Recent literature on paediatric status asthmaticus (PSA) confirms an increasing percentage of admissions to paediatric intensive care units. PSA is a medical emergency that can be fatal and needs careful and prompt intervention. The severity of PSA is mainly determined by clinical judgement of signs and symptoms. Peak flow measurements and serial lung function measurements are not reliable in PSA. Validated clinically useful instruments are lacking. The three main factors that are involved in the pathophysiology of PSA, bronchoconstriction, mucus plugging and airway inflammation need to be addressed to optimise treatment. Initial therapies include supplementation of oxygen, repetitive administration of rapid acting β2-agonists, inhaled anticholinergics in combination with systemic glucocorticosteroids and intravenous magnesium sulphate. Additional treatment modalities may include methylxanthines, DNase, ketamine, sodium bicarbonate, heliox, epinephrine, non-invasive respiratory support, mechanical ventilation and inhalational anaesthetics.
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Affiliation(s)
- Muriel Koninckx
- Paediatric Intensive Care, Middelheim Ziekenhuis, Lindendreef 1, Antwerp, Belgium.
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Lubret M, Bervar JF, Thumerelle C, Deschildre A, Tillie-Leblond I. [Asthma: treatment of exacerbations]. Rev Mal Respir 2012; 29:245-53. [PMID: 22405117 DOI: 10.1016/j.rmr.2011.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 04/12/2011] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Exacerbations remain, in both adults and children, a common reason for emergency consultation. The management of the asthmatic patient with an acute exacerbation is well defined. BACKGROUND The initial evaluation, based on the background risk factors and the clinical examination, will determine the choice of treatment and management. Treatment is based on bronchodilators and corticosteroids in the majority of cases. VIEWPOINTS An episode of exacerbation may be the opportunity to establish contact with the patient (an educational approach) to improve the adherence to long-term treatment with inhaled corticosteroids, which remain the best way of preventing future exacerbations. CONCLUSION Early and appropriate management of exacerbations of asthma should reduce asthma morbidity and mortality. It could also reduce the socioeconomic costs of these episodes and the number and duration of hospital admissions.
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Affiliation(s)
- M Lubret
- Unité de pneumologie allergologie pédiatriques, hôpital Jeanne-de-Flandre, CHRU de Lille, Lille cedex, France
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Papiris SA, Manali ED, Kolilekas L, Triantafillidou C, Tsangaris I. Acute severe asthma: new approaches to assessment and treatment. Drugs 2010; 69:2363-91. [PMID: 19911854 DOI: 10.2165/11319930-000000000-00000] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The precise definition of a severe asthmatic exacerbation is an issue that presents difficulties. The term 'status asthmaticus' relates severity to outcome and has been used to define a severe asthmatic exacerbation that does not respond to and/or perilously delays the repetitive or continuous administration of short-acting inhaled beta(2)-adrenergic receptor agonists (SABA) in the emergency setting. However, a number of limitations exist concerning the quantification of unresponsiveness. Therefore, the term 'acute severe asthma' is widely used, relating severity mostly to a combination of the presenting signs and symptoms and the severity of the cardiorespiratory abnormalities observed, although it is well known that presentation does not foretell outcome. In an acute severe asthma episode, close observation plus aggressive administration of bronchodilators (SABAs plus ipratropium bromide via a nebulizer driven by oxygen) and oral or intravenous corticosteroids are necessary to arrest the progression to severe hypercapnic respiratory failure leading to a decrease in consciousness that requires intensive care unit (ICU) admission and, eventually, ventilatory support. Adjunctive therapies (intravenous magnesium sulfate and/or others) should be considered in order to avoid intubation. Management after admission to the hospital ward because of an incomplete response is similar. The decision to intubate is essentially based on clinical judgement. Although cardiac or respiratory arrest represents an absolute indication for intubation, the usual picture is that of a conscious patient struggling to breathe. Factors associated with the increased likelihood of intubation include exhaustion and fatigue despite maximal therapy, deteriorating mental status, refractory hypoxaemia, increasing hypercapnia, haemodynamic instability and impending coma or apnoea. To intubate, sedation is indicated in order to improve comfort, safety and patient-ventilator synchrony, while at the same time decrease oxygen consumption and carbon dioxide production. Benzodiazepines can be safely used for sedation of the asthmatic patient, but time to awakening after discontinuation is prolonged and difficult to predict. The most common alternative is propofol, which is attractive in patients with sudden-onset (near-fatal) asthma who may be eligible for extubation within a few hours, because it can be titrated rapidly to a deep sedation level and has rapid reversal after discontinuation; in addition, it possesses bronchodilatory properties. The addition of an opioid (fentanyl or remifentanil) administered by continuous infusion to benzodiazepines or propofol is often desirable in order to provide amnesia, sedation, analgesia and respiratory drive suppression. Acute severe asthma is characterized by severe pulmonary hyperinflation due to marked limitation of the expiratory flow. Therefore, the main objective of the initial ventilator management is 2-fold: to ensure adequate gas exchange and to prevent further hyperinflation and ventilator-associated lung injury. This may require hypoventilation of the patient and higher arterial carbon dioxide (PaCO(2)) levels and a more acidic pH. This does not apply to asthmatic patients intubated for cardiac or respiratory arrest. In this setting the post-anoxic brain oedema might demand more careful management of PaCO(2) levels to prevent further elevation of intracranial pressure and subsequent complications. Monitoring lung mechanics is of paramount importance for the safe ventilation of patients with status asthmaticus. The first line of specific pharmacological therapy in ventilated asthmatic patients remains bronchodilation with a SABA, typically salbutamol (albuterol). Administration techniques include nebulizers or metered-dose inhalers with spacers. Systemic corticosteroids are critical components of therapy and should be administered to all ventilated patients, although the dose of systemic corticosteroids in mechanically ventilated asthmatic patients remains controversial. Anticholinergics, inhaled corticosteroids, leukotriene receptor antagonists and methylxanthines offer little benefit, and clinical data favouring their use are lacking. In conclusion, expertise, perseverance, judicious decisions and practice of evidence-based medicine are of paramount importance for successful outcomes for patients with acute severe asthma.
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Affiliation(s)
- Spyros A Papiris
- 2nd Pulmonary Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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