[Comparative efficiency of nebulized adrenaline and salbutamol in severe acute asthma. A randomized, controlled prospective study]

OBJECTIVE

To compare nebulized salbutamol and nebulized adrenaline in acute severe asthma (ASA).

STUDY DESIGN

Prospective controlled study.

PATIENTS AND METHODS

October 1998 at May 99, 44 patients (31 women and 13 men, 35 +/- 11 yrs) with ASA (defined as peak expiratory flow rate (PEF) < 150 l min-1 and normo- or hypercapnia) were randomized to receive either nebulized salbutamol (n = 22), 10 mg/h-1 during 2 h then 5 mg every 4 h or nebulized adrenaline (n = 22), 6 mg/h-1 during 2 h then 3 mg every 4 h. The efficacy was assessed by PEF, forced expiratory volume in one second (FEV1) and Fischl's score during eight hours and by arterial blood gases during the first hour. Side-effects were evaluated by heart rate, systolic blood pressure, serum potassium and blood glucose. Statistical tests: Wilcoxon, Fischer exact, ANOVA and Scheffe's test.

RESULTS

Both groups were similar with respect to age, sex, severity, duration of asthma and length of crisis. With the two treatments, PEF increased significantly but no statistical difference were observed between the two groups during the eight hours: 117.7 +/- 41.6 l min-1 to 203.3 +/- 56.9 l min-1 in the salbutamol group; 116.4 +/- 36.8 l min-1 to 217.3 +/- 188.8 l min-1 in the adrenaline group; p = 0.77. FEV1, Fischl's score and arterial blood gases did not differ significantly between treatments at every time interval. There were no significant difference between the two groups in terms of side-effects. The intravenous way was necessary at 3 cases of the salbutamol group and 4 cases of adrenaline group (NS).

CONCLUSION

The results suggest that nebulized adrenaline is as effective as nebulized salbutamol in the ASA without significant side-effects. The nebulization could reduce systemic effects of adrenaline.

Grading asthma severity: using the APS component of the Apache II system

OBJECTIVE

Measurement of severity is fundamental to the description and comparison of case series, treatment regimens and disease outcomes. This study examines the Acute Physiology Score (APS) as a severity measure of an acute "life-threatening" asthma attack.

DESIGN

The APS in the emergency department (ED) and ICU, demographic, treatment and outcome variables were prospectively studied. Relationships between severity, treatment and progress were investigated. In addition, patients were stratified according to ED APS and differences between the participating hospitals were examined.

SETTING

Emergency Departments and Intensive Care Units of two New Zealand hospitals.

PATIENTS

64 admissions to the ICUs following an acute episode of asthma.

INTERVENTIONS

Standard management of acute asthma as practised at the two participating hospitals.

MEASUREMENTS AND RESULTS

Both the treatment delivered (intravenous salbutamol, sodium bicarbonate and IPPV) and the rate of improvement as defined by change in APS between the ED and the ICU were found to be strongly related to ED APS. Similarly, the length of stay in the ICU correlated with the ICU APS. Stratification on the basis of ED APS allowed small but significant differences in patient physiologic derangement, dose of salbutamol, use of IPPV and incidence of complications to be detected between patients at the two hospitals.

CONCLUSION

This prospective study involving two hospitals validates the APS as a method for measuring the severity of an acute asthma attack. It demonstrates how correction for severity can be used to compare treatment and outcome variables in different case series.

Predicting outcome in critical care: the current status of the APACHE prognostic scoring system

The APACHE (Acute Physiology and Chronic Health Evaluation) prognostic scoring system was developed in 1981 at the George Washington University Medical Center as a way to measure disease severity. APACHE II, introduced in 1985, was a simplified modification of the original APACHE. The APACHE II score consisted of three parts: 12 acute physiological variables, age and chronic health status. Probability of death can be derived by using the disease category and the APACHE II score. The uses of APACHE II include risk stratification to account for case mix in clinical studies, comparison of the quality of care among ICUs, and assessment of group and individual prognoses. APACHE III, a refinement of APACHE II, will be introduced in late 1990. The APACHE III data base includes 17,457 patients from a representative sample of 40 American hospitals. Additional potential uses of APACHE III include the identification of factors in the ICU which contribute to outcome and assistance in individual patient decision-making. This article reviews the development, current uses and potential applications of the APACHE system.