Right heart pressures on bronchial asthma

Hidden Comorbidities in Asthma: A Perspective for a Personalized Approach

Bronchial asthma is the most frequent inflammatory non-communicable condition affecting the airways worldwide. It is commonly associated with concomitant conditions, which substantially contribute to its burden, whether they involve the lung or other districts. The present review aims at providing an overview of the recent acquisitions in terms of asthma concomitant systemic conditions, besides the commonly known respiratory comorbidities. The most recent research has highlighted a number of pathobiological interactions between asthma and other organs in the view of a shared immunological background underling different diseases. A bi-univocal relationship between asthma and common conditions, including cardiovascular, metabolic or neurodegenerative diseases, as well as rare disorders such as sickle cell disease, α1-Antitrypsin deficiency and immunologic conditions with hyper-eosinophilia, should be considered and explored, in terms of diagnostic work-up and long-term assessment of asthma patients. The relevance of that acquisition is of utmost importance in the management of asthma patients and paves the way to a new approach in the light of a personalized medicine perspective, besides targeted therapies.

Radiographic inversion of pulmonary blood flow in acute asthma

Chest radiographs are obtained routinely in children hospitalized with asthma but are considered to be of low utility. We describe a previously unreported radiographic inversion of pulmonary artery flow patterns in the chest films of a majority of children and young adults hospitalized for asthma. Seventy-five hospital records of 65 patients aged 2 to 25 years (mean 9.2) admitted for asthma during the calendar year 1991 were reviewed. As compared with the normal pattern, patients with inverted vascularity were younger (mean age 6.75 years), tended to be admitted through the emergency department, and had significantly more signs of labored breathing, such as tachypnea, retractions, nasal flaring, and tachycardia. We propose that the exaggerated respiratory effort in these children raises the transmural pulmonary artery pressure, impeding pulmonary blood flow. This results in distension of the right ventricle, which then compresses the left ventricle in the confines of the pericardium by posterior displacement of the interventricular septum. The resultant loss of left-sided compliance raises the left atrial and pulmonary venous pressures, leading to inversion of vascular markings through the same mechanism as seen in left-heart failure. We conclude that attention to this easily recognized sign will detect presence of the hemodynamically significant respiratory obstruction in asthmatic patients.

Reversible T-wave abnormality in severe acute asthma: an electrocardiographic sign of severity

Reversible electrocardiographic (ECG) abnormalities are well recognized in severe acute asthma. Inferior lead T-wave abnormalities have only rarely been reported, and their frequency and significance have not been well documented. We studied 70 consecutive patients with severe acute asthma on admission to hospital and during recovery, in order to examine the frequency and natural history of such changes and to document their relationship to the severity of the attack. Twenty-two patients (34%) had inferior lead T-wave inversion on ECGs performed within 1 h of admission (group 1), whereas the rest did not (group 2). Apart from sinus tachycardia this was the most common ECG abnormality. Patients with inferior T-wave inversion were found to have more severe asthma in terms of degree of pulsus paradoxus, peak expiratory flow rate, forced expiratory volume in 1 s and arterial blood oxygen tension. Ten group 1 and ten group 2 patients underwent two-dimensional echocardiography during the acute phase of their illness and during recovery. Six (60%) group 1 patients showed echocardiographic evidence of right ventricular pressure overload compared with only one (10%) patient in group 2 (P less than 0.02). Following recovery, voluntary hyperventilation and exercise testing in ten group 1 patients failed to reproduce the ECG changes seen on admission. Reversible inferior lead T-wave abnormalities may occur in the severe acute asthma and appear to be related to the severity of the attack.

Comparison of serial electrocardiographic and vectorcardiographic changes during recovery from status asthmaticus

Serial electrocardiographs (ECG) and vectorcardiographs (VCG) have been performed on 10 patients admitted to hospital in status asthmaticus on 12 separate occasions. The VCG was more efficient than the ECG in the detection of right atrial and ventricular enlargement. Both investigations were equally reliable in recording changes in frontal plane P wave axis. The mean frontal plane P wave axis fell from +60 degrees (range +35 degrees to +90 degrees) on the day of admission to +43 degrees (range +30 degrees to +60 degrees) at the time of discharge. The mean FEV1 expressed as a percentage of predicted values increased from 48% (range 25% to 81%) to 87% (range 44% to 123%). In direct contrast to previous studies the presence of an abnormally vertical frontal plane P wave axis (> 60 degrees) was related to the severity of airway obstruction (p < 0.01).

Severe bronchial asthma requiring ventilation. A review of 20 cases and advice on management

The natural history and outcome of 20 asthmatics who required mechanical ventilation is reviewed. Seven of these patients died. The majority of the deaths could have been prevented if: (1) The patient had been followed-up in an asthma clinic and had been fully informed of the danger of an asthmatic attack. (2) The medical staff had been trained more fully in the evaluation and management of a severe asthma attack. Careful sequential assessment will enable timely transfer of patients with severe bronchial asthma to a unit experienced in their management.

Reversible electrocardiographic changes in severe acute asthma

Previous reports have documented the occurrence of reversible electrocardiographic changes including right axis deviation, P pulmonale, right bundle-branch block, and ST-segment and T-wave abnormalities in patients with acute attacks of asthma. In a further systematic study, the electrocardiographs of 63 patients admitted with severe acute asthma have been evaluated. The most consistent change was an abnormally vertical P-wave axis in 78% of the patients. P pulmonale was present in 22% and right ventricular enlargement in only one patient. Right axis deviation, right bundle-branch block, and rhythm abnormality were not present in any patient. In 11%, ST-segment or T-wave abnormalities suggesting myocardial ischaemia were noted. These abnormalities persisted for up to nine days and were unexplained. Other ECG abnormalities in acute asthma may reflec positional changes of the heart due to overdistension of the lungs. All ECG changes resolved after clinical improvement.