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Abramo T, Williams A, Mushtaq S, Meredith M, Sepaule R, Crossman K, Burney Jones C, Godbold S, Hu Z, Nick T. Paediatric ED BiPAP continuous quality improvement programme with patient analysis: 2005-2013. BMJ Open 2017; 7:e011845. [PMID: 28093429 PMCID: PMC5253518 DOI: 10.1136/bmjopen-2016-011845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE In paediatric moderate-to-severe asthmatics, there is significant bronchospasm, airway obstruction, air trapping causing severe hyperinflation with more positive intraplural pressure preventing passive air movement. These effects cause an increased respiratory rate (RR), less airflow and shortened inspiratory breath time. In certain asthmatics, aerosols are ineffective due to their inadequate ventilation. Bilevel positive airway pressure (BiPAP) in acute paediatric asthmatics can be an effective treatment. BiPAP works by unloading fatigued inspiratory muscles, a direct bronchodilation effect, offsetting intrinsic PEEP and recruiting collapsed alveoli that reduces the patient's work of breathing and achieves their total lung capacity quicker. Unfortunately, paediatric emergency department (PED) BiPAP is underused and quality analysis is non-existent. A PED BiPAP Continuous Quality Improvement Program (CQIP) from 2005 to 2013 was evaluated using descriptive analytics for the primary outcomes of usage, safety, BiPAP settings, therapeutics and patient disposition. INTERVENTIONS PED BiPAP CQIP descriptive analytics. SETTING Academic PED. PARTICIPANTS 1157 patients. INTERVENTIONS A PED BiPAP CQIP from 2005 to 2013 for the usage, safety, BiPAP settings, therapeutic response parameters and patient disposition was evaluated using descriptive analytics. PRIMARY AND SECONDARY OUTCOMES Safety, usage, compliance, therapeutic response parameters, BiPAP settings and patient disposition. RESULTS 1157 patients had excellent compliance without complications. Only 6 (0.5%) BiPAP patients were intubated. BiPAP median settings: IPAP 18 (16,20) cm H2O range 12-28; EPAP 8 cmH2O (8,8) range 6-10; inspiratory-to-expiratory time (I:E) ratio 1.75 (1.5,1.75). Pediatric Asthma Severity score and RR decreased (p<0.001) while tidal volume increased (p<0.001). Patient disposition: 325 paediatric intensive care units (PICU), 832 wards, with 52 of these PED ward patients were discharged home with only 2 hours of PED BiPAP with no returning to the PED within 72 hours. CONCLUSIONS BiPAP is a safe and effective therapeutic option for paediatric patients with asthma presenting to a PED or emergency department. This BiPAP CQIP showed significant patient compliance, no complications, improved therapeutics times, very low intubations and decreased PICU admissions. CQIP analysis demonstrated that using a higher IPAP, low EPAP with longer I:E optimises the patient's BiPAP settings and showed a significant improvement in PAS, RR and tidal volume. BiPAP should be considered as an early treatment in the PED severe or non-responsive moderate asthmatics.
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Affiliation(s)
- Thomas Abramo
- Division of Pediatric Emergency, Department of Pediatrics, Vanderbilt School of Medicine
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Arkansas School of Medicine Arkansas Children's Hospital Little Rock, Little Rock, Arkansas, USA
| | - Abby Williams
- Vanderbilt School of Medicine, Nashville, Tennessee, USA
- Pediatric Emergency Medicine Associates of Atlanta, Atlanta, Georgia, USA
| | - Samaiya Mushtaq
- Vanderbilt School of Medicine, Nashville, Tennessee, USA
- University of Texas Southwestern Medical Center
| | - Mark Meredith
- Division of Pediatric Emergency, Department of Pediatrics, Vanderbilt School of Medicine
- University of Tennessee LeBonheur Children's Hospital Memphis Tennessee
| | - Rawle Sepaule
- Department of Respiratory Care, Vanderbilt Medical University, Vanderbilt Children's Hospital
| | - Kristen Crossman
- Division of Pediatric Emergency, Department of Pediatrics, Vanderbilt School of Medicine
| | | | - Suzanne Godbold
- Department of Pediatric Emergency Medicine, Respiratory Care, Arkansas Children's Hospital
| | - Zhuopei Hu
- Department of Pediatrics, University of Arkansas School of Medicine
| | - Todd Nick
- Department of Pediatrics, University of Arkansas School of Medicine
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Hirashima J, Yamana H, Matsui H, Fushimi K, Yasunaga H. Effect of intravenous magnesium sulfate on mortality in patients with severe acute asthma. Respirology 2016; 21:668-73. [PMID: 26781339 DOI: 10.1111/resp.12733] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/08/2015] [Accepted: 10/08/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Intravenous magnesium sulfate is used as adjunctive therapy for severe asthma exacerbations. However, previous randomized controlled trials of the administration of intravenous magnesium sulfate for asthma exacerbations have shown mixed results, and no study has evaluated its effect on mortality in patients with life-threatening asthma. The objective of this study was to investigate the association between intravenous magnesium sulfate administration and mortality in patients with severe asthma. METHODS Patients with severe asthma requiring intravenous corticosteroids and oxygenation were selected using the Japanese Diagnosis Procedure Combination inpatient database. One-to-one propensity score matching was performed between patients having received or not intravenous magnesium sulfate. Primary outcomes were 7-, 14- and 28-day mortalities. Secondary outcomes were total dose of intravenous corticosteroids during hospitalization, duration of mechanical ventilation and length of stay. RESULTS Among 14,122 eligible patients, 619 received intravenous magnesium sulfate. Propensity score matching created a matched cohort of 599 pairs with and without intravenous magnesium sulfate. There were no significant differences between patients with and without intravenous magnesium sulfate in terms of 28-day mortality (1.3% vs 1.8%, P = 0.488), median total dose of intravenous corticosteroids (2400 mg vs 2400 mg, P = 0.580), median duration of mechanical ventilation (1 day vs 1 day, P = 0.118) and median length of stay (16 days vs 13 days, P = 0.640). CONCLUSION This study found no significant benefit of intravenous magnesium sulfate use in terms of mortality in patients with severe acute asthma.
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Affiliation(s)
- Junko Hirashima
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hayato Yamana
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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Albertson TE, Sutter ME, Chan AL. The acute management of asthma. Clin Rev Allergy Immunol 2015; 48:114-25. [PMID: 25213370 DOI: 10.1007/s12016-014-8448-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, PSSB 3400, 4150 V Street, Sacramento, CA, 95817, USA,
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Wang Y, Miwa T, Ducka-Kokalari B, Redai IG, Sato S, Gullipalli D, Zangrilli JG, Haczku A, Song WC. Properdin Contributes to Allergic Airway Inflammation through Local C3a Generation. THE JOURNAL OF IMMUNOLOGY 2015; 195:1171-81. [PMID: 26116506 DOI: 10.4049/jimmunol.1401819] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 05/23/2015] [Indexed: 01/04/2023]
Abstract
Complement is implicated in asthma pathogenesis, but its mechanism of action in this disease remains incompletely understood. In this study, we investigated the role of properdin (P), a positive alternative pathway complement regulator, in allergen-induced airway inflammation. Allergen challenge stimulated P release into the airways of asthmatic patients, and P levels positively correlated with proinflammatory cytokines in human bronchoalveolar lavage (BAL). High levels of P were also detected in the BAL of OVA-sensitized and challenged but not naive mice. Compared with wild-type (WT) mice, P-deficient (P(-/-)) mice had markedly reduced total and eosinophil cell counts in BAL and significantly attenuated airway hyperresponsiveness to methacholine. Ab blocking of P at both sensitization and challenge phases or at challenge phase alone, but not at sensitization phase alone, reduced airway inflammation. Conversely, intranasal reconstitution of P to P(-/-) mice at the challenge phase restored airway inflammation to wild-type levels. Notably, C3a levels in the BAL of OVA-challenged P(-/-) mice were significantly lower than in wild-type mice, and intranasal coadministration of an anti-C3a mAb with P to P(-/-) mice prevented restoration of airway inflammation. These results show that P plays a key role in allergen-induced airway inflammation and represents a potential therapeutic target for human asthma.
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Affiliation(s)
- Yuan Wang
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Takashi Miwa
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Blerina Ducka-Kokalari
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104; and
| | - Imre G Redai
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104; and
| | - Sayaka Sato
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Damodar Gullipalli
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | | | - Angela Haczku
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104; and
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104;
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Singhi S, Grover S, Bansal A, Chopra K. Randomised comparison of intravenous magnesium sulphate, terbutaline and aminophylline for children with acute severe asthma. Acta Paediatr 2014; 103:1301-6. [PMID: 25164315 DOI: 10.1111/apa.12780] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 07/16/2014] [Accepted: 08/18/2014] [Indexed: 01/31/2023]
Abstract
AIM This study compared the efficacy of intravenous magnesium sulphate, terbutaline and aminophylline for children with acute, severe asthma poorly responsive to standard initial treatment. METHODS We enrolled 100 children, aged one to 12 years, who had failed to respond to initial standard treatment for acute, severe asthma, in this randomised controlled trial. They received either intravenous magnesium sulphate, terbutaline or aminophylline. Responses were monitored using a modified Clinical Asthma Severity (CAS) score. The primary outcome was treatment success, defined as a reduction in the CAS of four points or more 1 h after starting the intervention. RESULTS The magnesium sulphate group had higher treatment success (33/34, 97%) than the terbutaline and aminophylline groups (both 23/33, 70%) (p = 0.006) and faster resolution of retractions, wheeze and dyspnoea (p < 0.001). No adverse events occurred among patients receiving magnesium sulphate, but two patients receiving terbutaline had hypokalemia and nine patients receiving aminophylline had nausea and, or, vomiting. CONCLUSION Adding a single dose of Intravenous magnesium sulphate to inhaled beta2-agonists and corticosteroids was more effective, and safer, than using terbutaline or aminophylline when treating a child with acute severe asthma poorly responsive to initial treatment.
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Affiliation(s)
- Sunit Singhi
- Department of Pediatrics; Advanced Pediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Sudhanshu Grover
- Department of Pediatrics; Advanced Pediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Arun Bansal
- Department of Pediatrics; Advanced Pediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Kapil Chopra
- Department of Pediatrics; Advanced Pediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
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