Can fatal asthma be prevented?--a personal view

The critically ill asthmatic--from ICU to discharge

Status asthmaticus (SA) is defined as an acute, severe asthma exacerbation that does not respond readily to initial intensive therapy, while near-fatal asthma (NFA) refers loosely to a status asthmaticus attack that progresses to respiratory failure. The in-hospital mortality rate for all asthmatics is between 1% to 5%, but for critically ill asthmatics that require intubation the mortality rate is between 10% to 25% primarily from anoxia and cardiopulmonary arrest. Timely evaluation and treatment in the clinic, emergency room, or ultimately the intensive care unit (ICU) can prevent the morbidity and mortality associated with respiratory failure. Fatal asthma occurs from cardiopulmonary arrest, cerebral anoxia, or a complication of treatments, e.g., barotraumas, and ventilator-associated pneumonia. Mortality is highest in African-Americans, Puerto Rican-Americans, Cuban-Americans, women, and persons aged ≥ 65 years. Critical care physicians or intensivists must be skilled in managing the critically ill asthmatics with respiratory failure and knowledgeable about the few but potentially serious complications associated with mechanical ventilation. Bronchodilator and anti-inflammatory medications remain the standard therapies for managing SA and NFA patients in the ICU. NFA patients on mechanical ventilation require modes that allow for prolonged expiratory time and reverse the dynamic hyperinflation associated with the attack. Several adjuncts to mechanical ventilation, including heliox, general anesthesia, and extra-corporeal carbon dioxide removal, can be used as life-saving measures in extreme cases. Coordination of discharge and follow-up care can safely reduce the length of hospital stay and prevent future attacks of status asthmaticus.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Severe asthma

Severe asthma is a term that is commonly used to describe patients with refractory, brittle, near fatal, and difficult-to-control asthma. Patients with severe asthma typically experience persistent symptoms despite medical therapy, report decreased quality of life and suffer an accelerated loss of lung function. The role of genetics, environmental exposure, and infection in the development of more severe asthma is the focus of ongoing research. While pathologic changes in these patients are now believed to involve lung parenchyma, in addition to large and small airways, the independent contribution of each of these compartments to the severe asthma phenotype is not well defined. The clinical evaluation of severe asthma patients should include investigating conditions commonly associated with severe asthma, such as gastroesophageal reflux disease, vocal cord dysfunction, and rhinosinusitis. In addition, advanced imaging techniques, measurement of exhaled gas or sputum indices, and airway biopsy are tools that may aid in evaluating severe asthma patients in the near future. Management of patients with severe asthma requires a comprehensive approach that includes non-pharmacological and pharmacological measures. Combination antiinflammatory and long-acting bronchodilator therapy remains the mainstay of management.

Status asthmaticus

Despite improved understanding of the pathophysiology and treatment of asthma, significant morbidity and mortality exist for both the pediatric and adult patient. The critical care practitioner must understand the chronic as well as the acute nature of the condition in order to provide effective intervention. This article reviews the epidemiology and pathophysiology of asthma, clinical assessment, management principles, therapeutic modalities, and future approaches to the management of asthma.

Proposta de indicadores e padrões para a avaliação de qualidade da atenção hospitalar: o caso da asma brônquica

Este artigo tem por objetivos propor indicadores para a avaliação de qualidade da assistência hospitalar a pacientes com asma brônquica, através de critérios explícitos baseados em revisão bibliográfica. O problema central da atenção apontado pela bibliografia foi a existência de falhas na avaliação da gravidade da crise de asma, tanto por parte dos pacientes e familiares, como pelos profissionais de saúde de todos os níveis da atenção, resultando em sérias conseqüências não só para o paciente, como também para a sociedade em geral. No Brasil, de 1980 a 1990, ocorreram em média 2.000 óbitos por asma/ano, sendo cerca de 70% deles intra-hospitalares. O diagnóstico de asma foi a quarta causa de internação no Estado do Rio de Janeiro em 1993. Somente 12% dos 81 casos que foram a óbito fizeram uso de UTI. Essas informações justificam uma avaliação mais apurada da assistência hospitalar a essa doença, e, como contribuição para o processo de avaliação, propomos a realização de revisão da internação de todos os casos que resultaram em óbito e revisão esporádica de uma amostra das internações. Os critérios propostos são: avaliação da gravidade da crise, avaliação da terapia medicamentosa prescrita, educação do paciente e/ou familiares e agendamento de consulta pós-alta hospitalar.