IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial

Inhaled magnesium versus inhaled salbutamol in rescue treatment for moderate and severe asthma exacerbations in pediatric patients

OBJECTIVE

To compare the effectiveness of inhaled Magnesium Sulfate associated with Salbutamol versus Inhaled Salbutamol alone in patients with moderate and severe asthma exacerbations.

METHOD

Clinical, prospective and randomized study with patients between 3 and 14 years of age divided into two groups: one to receive inhaled salbutamol associated with magnesium sulfate (GSM), the other to receive inhaled salbutamol alone (GS). The sample consisted of 40 patients, 20 patients in each group. Severity was classified using the modified Wood-Downes score, with values between 4 and 7 classified as moderate and 8 or more classified as severe.

RESULTS

Post-inhalation scores decreased both in patients who received salbutamol and magnesium and in those who received salbutamol alone, with no statistically significant difference between the groups.

CONCLUSIONS

Despite the benefits when administered intravenously, inhalation of the drug alone or in combination did not reduce the severity of the exacerbation.

Magnesium alginate as a low-viscosity (intramolecularly cross-linked) system for the sustained and neuroprotective release of magnesium

The administration of Mg ions is advantageous in pathological scenarios such as pre-enclampsia and forms of neuroinflammation (e.g. stroke or injury); yet, few systems exist for their sustained delivery. Here, we present the (static light scattering and diffusing-wave spectroscopy) characterization of magnesium alginate (MgAlg) as a potentially injectable vehicle ifor the delivery of Mg. Differently from other divalent cations, Mg does not readily induce gelation: it acts within MgAlg coils, making them more rigid and less prone to entangle. As a result, below a threshold concentration (notionally below 0.5 % wt.) MgAlg are inherently less viscous than those of sodium alginate (NaAlg), which is a major advantage for injectables; at higher concentrations, however, (stable, Mg-based) aggregation starts occurring. Importantly, Mg can then be released e.g. in artificial cerebrospinal fluid, via a slow (hours) process of ion exchange. Finally, we here show that MgAlg protects rat neural stem cells from the consequence of an oxidative insult (100 μM H2O2), an effect that we can only ascribe to the sustained liberation of Mg ions, since it was not shown by NaAlg, MgSO4 or the NaAlg/MgSO4 combination. Our results therefore indicate that MgAlg is a promising vehicle for Mg delivery under pathological (inflammatory) conditions.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Magnesium sulfate treatment for acute severe asthma in adults-a systematic review and meta-analysis

Introduction

Add-on magnesium sulfate (MgSO4) for refractory asthma exacerbation has been much debated. The aim of this review and meta-analysis is, therefore, to provide an update on the current evidence for the efficacy of MgSO4 in exacerbations of asthma in adults refractory to standard of care treatment.

Methods

A systematic review was performed in accordance with the PRISMA guidelines. The search was performed in the PubMed database (updated April 2023). For the meta-analysis, a random-effects model was applied using the metaphor package for RStudio (RStudio, Inc.).

Results

A total of 17 randomized controlled trials were included. Three of the nine studies addressing treatment with intravenous (IV) MgSO4 found a significant effect on lung function compared to placebo. Of the eight studies investigating hospital admission rate, only two found a significant effect of MgSO4. Six of the nine studies investigating treatment with nebulized MgSO4 compared to placebo found a favorable effect on forced expiratory volume in 1. second (FEV1) and peak expiratory flow rate (PEF). Only two of the five studies investigating the effect on hospital admission rate found an effect of MgSO4. Comparing effect sizes in a meta-analysis revealed a greater effect on PEF in asthma patients treated with nebulized MgSO4 (MD, 23.57; 95% CI, -2.48 to 49.62, p < 0.01) compared to placebo. The analysis of patients treated with i.v. MgSO4 compared to placebo showed no statistically significant difference (MD, 5.49; 95% CI, -18.67 to 29.65, p = 0.10).

Conclusion

Up to two out of three studies revealed an effect of MgSO4 treatment for asthma exacerbation when assessed by FEV1/PEF, but fewer studies were positive for the outcome of hospital admissions.

Enhanced Antiviral Function of Magnesium Chloride-Modified Heparin on a Broad Spectrum of Viruses

Previous studies reported on the broad-spectrum antiviral function of heparin. Here we investigated the antiviral function of magnesium-modified heparin and found that modified heparin displayed a significantly enhanced antiviral function against human adenovirus (HAdV) in immortalized and primary cells. Nuclear magnetic resonance analyses revealed a conformational change of heparin when complexed with magnesium. To broadly explore this discovery, we tested the antiviral function of modified heparin against herpes simplex virus type 1 (HSV-1) and found that the replication of HSV-1 was even further decreased compared to aciclovir. Moreover, we investigated the antiviral effect against the new severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and measured a 55-fold decreased viral load in the supernatant of infected cells associated with a 38-fold decrease in virus growth. The advantage of our modified heparin is an increased antiviral effect compared to regular heparin.

Diet Modifications in Primary Prevention of Asthma. Where Do We Stand?

The steep increase in asthma prevalence, observed worldwide in recent decades, has created an urgent need to search for effective methods of its prevention. Among other environmental factors, changes in diet habits and the potential influence of individual food components on immunological processes have been extensively studied as a potential method of intervention in primary prevention of asthma. The preventive role of some nutrients has been confirmed: unpasteurized milk reduced the risk of asthma in epidemiological studies, vitamin D supplementation was effective in preventing the transient forms of wheezing in small children and high maternal intake of fish oil reduced the risk of persistent wheeze and asthma in children. However, not all studies provided consistent results, and many food ingredients are still pending for defining their role in asthma development. Moreover, a novel approach looking not only at single food ingredients, but the whole dietary patterns and diversity has recently been proposed. In this paper, we discuss the current role of nutrients in asthma primary prevention and the reasons for inconsistencies in the study results. We look at single diet components, but also the whole dietary patterns. We describe the proposed mechanisms of action at different stages of life, identify the role of modifiers and delineate future perspectives on the application of nutrients in targeting strategies for asthma primary prevention.

Management of Asthma Exacerbations in the Emergency Department

Asthma exacerbations occur across a wide spectrum of chronic severity; they contribute to millions of emergency department (ED) visits in both children and adults every year. Management of asthma exacerbations is an important part of the continuum of asthma care. The best strategy for ED management of an asthma exacerbation is early recognition and intervention, continuous monitoring, appropriate disposition, and, once improved, multifaceted transitional care that optimizes subacute and chronic asthma management after ED discharge. This article concisely reviews ED evaluation, treatment, disposition, and postdischarge care for patients with asthma exacerbations, based on high-quality evidence (eg, systematic reviews from the Cochrane Collaboration) and current international guidelines (eg, the National Asthma Education and Prevention Program Expert Panel Report 3, Global Initiative for Asthma, and Australian guidelines). Special populations (young children, pregnant women, and the elderly) also are addressed. Despite advances in asthma science, there remain many important evidence gaps in managing ED patients with asthma exacerbation. This article summarizes several of these controversial areas and challenges that merit further investigation.

Pharmacotherapeutic strategies for critical asthma syndrome: a look at the state of the art

INTRODUCTION

'Critical Asthma Syndrome' (CAS) is an umbrella term proposed to include several forms of asthma, responsible for acute and life-threatening exacerbations. CAS requires urgent and adequate supportive and pharmacological treatments to prevent serious outcomes.

AREAS COVERED

The purpose of this review is to discuss current knowledge on the pharmacotherapeutic strategies for treatment of CAS.

EXPERT OPINION

Airflow limitation, airway wall edema, and mucus plugs are the pathophysiological targets of pharmacological therapies. Strategies to achieve these goals are based on the use of various classes of drugs. Inhaled beta2-agonists are the mainstay of the initial therapy of CAS. Inhaled anticholinergic agents may be considered in the treatment of CAS in addition to beta 2 agonists. Systemic corticosteroids should be administered as soon as possible in order to counteract airway inflammation and restore normal airway sensitivity. The effectiveness of pharmacological therapies in CAS is linked not only to the timely use of drugsbut also to the dosage and route of administration. Early recognition and aggressive treatment are essential for the management of CAS; however, prevention is the best cure. Although significant progress has been made, further efforts are needed to implement an optimal exacerbation prevention strategy.

Efficacy of Magnesium Sulfate Treatment in Children with Acute Asthma

OBJECTIVE

Systemic administration of magnesium sulfate (MgSO4) has been proposed as a treatment for pediatric patients with acute asthma. However, previous trials show mixed results and uncertain evidence of benefit. The aim of the study was to ascertain whether intravenous (IV) MgSO4 improves lung function parameters in children with acute asthma.

METHODS

This was a prospective clinical trial. All patients with acute asthma received 40-50 mg/kg or maximum 1,500 mg (>30 kg) of single dose IV MgSO4, administered over 60 min. Spirometry was conducted before and 15 min after MgSO4 infusion.

RESULTS

One hundred and fifteen children aged 6 to 17 years presenting with acute asthma and FEV1 between 40% and 75% of predicted were included. Then, the patients were classified into 2 groups; mild asthma attack (FEV1 ranged from 60% to 75%; n = 50) or moderate asthma attack (FEV1 ranged from 40% to 59%; n = 65). The baseline characteristics were similar in both groups. The mean percent predicted pre and post values for FEV1/FVC ratio (mild group: 82.59 ± 9.46 vs. 85.06 ± 8.95; moderate group: 77.31 ± 11.17 vs. 79.99 ± 11.77), FEV1 (mild group: 67.14 ± 4.99 vs. 72.29 ± 8.05; moderate group: 48.50 ± 6.81 vs. 53.78 ± 9.81), PEF (mild group: 65.49 ± 12.32 vs. 71.37 ± 12.96; moderate group: 47.56 ± 11.78 vs. 51.97 ± 13.98), and FEF25-75 (mild group: 58.20 ± 12.24 vs. 66.57 ± 16.95; moderate group: 37.77 ± 11.37 vs. 43.41 ± 14.19) showed a statistically significant (p < 0.05 for all) bronchodilator effect after MgSO4 infusion in both groups with few side effects.

CONCLUSION

Administration of IV MgSO4 was associated with improved pulmonary function in children with acute asthma.

The role of magnesium in different inflammatory diseases

Magnesium deficiency (MgD) can cause inflammation in human body. The known mechanisms of inflammation caused by MgD include activation of phagocytic cells, opening of calcium channels, activation of the N-methyl-D-aspartate (NMDA) receptor, and activation of nuclear factor (NF)-κB. In addition, MgD causes systemic stress response through neuroendocrinological pathways. The inflammation caused by MgD can result in pro-atherogenic changes in the metabolism of lipoproteins, endothelial dysfunction, and high blood pressure. Studies suggest that magnesium may play an important role in the pathophysiology of some inflammatory diseases. Several clinical trials and laboratory studies have been done on the functional role of magnesium. In this study, we review some inflammatory diseases, in which the magnesium has a role in their pathophysiology. Among these diseases, diabetes, asthma, preeclampsia, atherosclerosis, heart damage, and rheumatoid arthritis have been highlighted.

The role of oral magnesium supplements for the management of stable bronchial asthma: a systematic review and meta-analysis

Asthma is a chronic lung disease characterized by airway inflammation and hyper-responsiveness of airway smooth muscles. There is growing evidence that magnesium may have a role in managing asthma through its dual effect as an anti-inflammatory and bronchodilating agent. To assess the efficacy of oral magnesium supplements in chronic asthmatic patients. In addition to searching through Clinicaltrials.gov/ and references for oral magnesium supplement studies, we performed a database search in Medline, CINAHL, CENTRAL, and Embase. We contacted the authors of the included trials to ask for additional information. We included randomized controlled trials that compared oral magnesium supplements versus placebo, in addition to standard asthma treatment in mild-moderate asthmatic adults and children (older than 6 years). Two reviewers independently performed the study selection, data abstraction, and the assessment of the risk of bias. Eight trials at moderate risk of bias enrolling a total of 917 patients were included. Oral magnesium improved FEV1 at week 8 (5.69 (L/min); 95% CI: 1.92, 9.46; I2: 45%). There was no significant improvement in FEV1 at other follow up periods. There was no significant change in FVC, Methacholine challenge test, the frequency of bronchodilator use, or symptoms score. There were no data on mortality or quality of life. Oral magnesium supplements may lead to improvement in FEV1 that was only demonstrated at eight weeks; but no effect on any other outcome. Until future evidence emerges, oral magnesium cannot be recommended as adjuvants to standard treatment for mild to moderate asthmatic individuals.

Limitations of the results from randomized clinical trials involving intravenous and nebulised magnesium sulphate in adults with severe acute asthma

The role of intravenous (IV) or nebulised magnesium sulphate (MgSO₄) in the treatment of severe acute asthma in adults is unclear. A controversy exists regarding its efficacy. In children MgSO₄ has a more evident clinical effect, but the child population has not been considered in this work. The applicability of the results from randomized clinical trials (RCTs) involving MgSO₄ in adult population is questioned in the optimal treatment of asthma exacerbations. According to the newest guidelines from the Global Initiative for Asthma (GINA), optimal treatment in the emergency department (ED) is based on short-acting beta₂-agonists (SABA), oral or IV corticosteroids (CS), short acting muscarinic antagonists (SAMA) and the controlled oxygen therapy. Further improvements with IV or nebulised MgSO₄ were assessed in a recent large multicentre, double-blind, placebo-controlled randomized 3 Mg trial, which failed to demonstrate clinical benefit. Several other RCTs found some benefit with MgSO₄, although the majority lacked some treatment options that are used in the optimal treatment of asthma exacerbations. Therefore, we reviewed the limitations of RCTs of IV or nebulised MgSO₄ in adults with acute asthma, with the aim to answer in which subpopulation MgSO₄ could be beneficial.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Effects of magnesium sulfate infusion on clinical signs and lung function of horses with severe asthma

OBJECTIVE To evaluate whether MgSO₄ solution administered IV would improve the clinical signs and lung function of horses with severe asthma and potentiate the effects of salbutamol inhalation in those horses. ANIMALS 6 adult horses with severe asthma. PROCEDURES Asthmatic horses were used in 3 crossover design experiments (6 treatments/horse). Clinical scores for nasal flaring and the abdominal component associated with breathing and lung function were determined before and after administration of salbutamol (800 μg, by inhalation), MgSO₄ solution (2.2 mg/kg/min, IV, over 20 minutes), and combined MgSO₄-salbutamol treatment. The data were collected during experimental procedures to assess salbutamol inhalation versus mock inhalation, MgSO₄ infusion versus infusion of saline (NaCl) solution (adjusted to the same osmolarity as the MgSO₄ solution), and the combined MgSO₄-salbutamol treatment versus salbutamol inhalation alone. RESULTS Infusion of MgSO₄ significantly improved clinical scores when administered alone or in combination with salbutamol inhalation. With the combination treatment, lung function improved, albeit not significantly. Tidal volume also increased following combined MgSO₄-salbutamol treatment. Salbutamol alone significantly improved lung function, whereas saline solution administration and a mock inhalation procedure had no effect on the studied variables. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that MgSO₄ infusion alone or in combination with salbutamol inhalation improved the clinical signs of severely asthmatic horses. The effects of MgSO₄ were not associated with significant lung function improvement, which suggested that the changes observed were attributable to alterations in the horses' breathing patterns. Infusion of MgSO₄ solution at the studied dose offers little advantage over currently used medications for the treatment of severe equine asthma.

Intravenous and Nebulized Magnesium Sulfate for Treating Acute Asthma in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aimed to evaluate the efficacy of intravenous (IV) and nebulized magnesium sulfate in acute asthma in children.

METHODS

The PubMed, Cochrane Library, and EMBASE databases were searched. Randomized controlled trials and quasi-randomized controlled trials of IV and nebulized magnesium sulfate in pediatric acute asthma were included. The outcomes subject to meta-analysis were pulmonary function, hospitalization, and further treatment. If statistical heterogeneity was significant, random-effects models were used for meta-analysis, otherwise, fixed-effects models were applied.

RESULTS

Ten randomized and quasi-randomized trials (6 IV, 4 nebulized) were identified. Intravenous magnesium sulfate treatment is associated with significant effects on respiratory function (standardized mean difference, 1.94; 95% confidence interval [CI], 0.80-3.08; P = 0.0008) and hospital admission (risk ratio, 0.55; 95% CI, 0.31-0.95; P = 0.03). But nebulized magnesium sulfate treatment shows no significant effect on respiratory function (standardized mean difference, 0.19; 95% CI, -0.01-0.40; P = 0.07) or hospital admission (risk ratio, 1.11; 95% CI, 0.86-1.44; P = 0.42).

CONCLUSIONS

The meta-analysis revealed that IV magnesium sulfate is an effective treatment in children, with the pulmonary function significantly improved and hospitalization and further treatment decreased. But nebulized magnesium sulfate treatment showed no significant effect on respiratory function or hospital admission and further treatment.

The role of magnesium sulfate in the intensive care unit

Magnesium (Mg) has been developed as a drug with various clinical uses. Mg is a key cation in physiological processes, and the homeostasis of this cation is crucial for the normal function of body organs. Magnesium sulfate (MgSO4) is a mineral pharmaceutical preparation of magnesium that is used as a neuroprotective agent. One rationale for the frequent use of MgSO4 in critical care is the high incidence of hypomagnesaemia in intensive care unit (ICU) patients. Correction of hypomagnesaemia along with the neuroprotective properties of MgSO4 has generated a wide application for MgSO4 in ICU.

Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care

OBJECTIVE

In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost.

METHODS

Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods.

RESULTS

A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital.

CONCLUSIONS

Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.

Lack of efficacy of nebulized magnesium sulfate in treating adult asthma: A meta-analysis of randomized controlled trials

BACKGROUND

Nebulized magnesium sulfate (MgSO₄) has been used to treat asthma, but the efficacy remains controversial. We aimed to comprehensively review the efficacy of nebulized MgSO₄ in treating adult patients with asthma.

METHODS

PubMed, Embase, and Cochrane Library were searched for relevant studies published up to July 18, 2016. Randomized controlled trials (RCTs) were included if adult patients with acute or stable asthma had been treated with nebulized MgSO₄ compared with placebo or another bronchodilator. Standardized mean differences (SMDs), relative risks (RRs) and 95% confidence intervals (CIs) were calculated. Outcomes included pulmonary function, hospital admission and adverse events.

RESULTS

A total of 1386 patients from sixteen trials (1240 acute asthma patients and 146 stable asthma patients) were subjected to meta-analysis. Compared to placebo as normal saline, whether using in acute or stable adult asthma, nebulized MgSO₄ did not significantly improve the respiratory function: SMD 0.39 (95% CI -0.03-0.82, P = 0.07), and 1.48 (95% CI -0.14-3.11, P = 0.07), respectively. Furthermore, nebulized MgSO₄ did not reduce hospital admission in adult patients with acute asthma (RR, 0.72; 95% CI, 0.52-1.00; P = 0.05), although it was not associated with increased adverse events (RR 1.15; 95% CI, 0.88-1.52; P = 0.31).

CONCLUSIONS

Evidence to date suggests that nebulized MgSO₄ has no role in the management of adult patients with acute or stable asthma.

High-Dose Magnesium Sulfate Infusion for Severe Asthma in the Emergency Department: Efficacy Study

OBJECTIVE

To assess the efficacy of a high-dose prolonged magnesium sulfate infusion in patients with severe, noninfectious-mediated asthma.

DESIGN

Prospective, randomized, open-label study.

SETTING

Twenty-nine-bed pediatric emergency department located in a children's hospital in Asuncion, Paraguay.

PATIENTS

All patients of 6-16 years old who failed to improve after 2 hours of standard therapy for asthma.

INTERVENTIONS

Subjects were randomized to receive magnesium sulfate, 50 mg/kg over 1 hour (bolus) or high-dose prolonged magnesium sulfate infusion of 50 mg/kg/hr for 4 hours (max, 8.000 mg/4 hr). Patients were monitored for cardiorespiratory complications.

MEASUREMENTS AND MAIN RESULTS

Asthma severity was assessed via asthma scores and peak expiratory flow rates at 0-2-6 hours. The primary outcome was discharge to home at 24 hours. An analysis of the hospital length of stay and costs was a secondary outcome. Thirty-eight patients were enrolled, 19 in each group. The groups were of similar ages, past medical history of asthma, asthma score, and peak expiratory flow rate. There was a significant difference in the patients discharged at 24 hours: 47% in high-dose prolonged magnesium sulfate infusion (9/19) versus 10% (2/21) in the bolus group (p = 0.032) with an absolute risk reduction 37% (95% CI, 10-63) and a number needed to treat of 2.7 (95% CI, 1.6-9.5) to facilitate a discharge at or before 24 hours. The length of stay was shorter in the high-dose prolonged magnesium sulfate infusion group (mean ± SD in hr: high-dose prolonged magnesium sulfate infusion, 34.13 ± 19.54; bolus, 48.05 ± 18.72; p = 0.013; 95% CI, 1.3-26.5). The cost per patient in the high-dose prolonged magnesium sulfate infusion group was one third lower than the bolus group (mean ± SD: high-dose prolonged magnesium sulfate infusion, $603.16 ± 338.47; bolus, $834.37 ± 306.73; p < 0.016). There were no interventions or discontinuations of magnesium sulfate due to adverse events.

CONCLUSIONS

The early utilization of high-dose prolonged magnesium sulfate infusion (50 mg/kg/hr/4 hr), for non-infectious mediated asthma, expedites discharges from the emergency department with significant reduction in healthcare cost.

Effect of intravenous magnesium sulfate on mortality in patients with severe acute asthma

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.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Magnesium should be given to all children presenting to hospital with acute severe asthma

Asthma is one of the most prevalent chronic condition affecting children worldwide and acute exacerbations requiring emergency medical management are common. In addition to corticosteroids, a number of drugs may be used in the management of acute severe asthma aiming to reverse bronchoconstriction. Magnesium sulphate - either inhaled or intravenous - may be added to conventional therapy of children with acute severe asthma. Despite its safety profile and effectiveness, the use of magnesium sulphate has been inconsistent due to lack of consensus. The authors believe that the accumulating evidence of a favorable 'cost benefit' profile justifies the use of magnesium for all children presenting with acute severe asthma.

Point of care blood gases with electrolytes and lactates in adult emergencies

Point-of-care testing (POCT) is one of the formidable concept introduce in the field of critical care settings to deliver decentralized, patient-centric health care to the patients. Rapid provision of blood measurements, particularly blood gases and electrolytes, may translate into improved clinical outcomes. Studies shows that POCT carries advantages of providing reduced therapeutic turnaround time (TTAT), shorter door-to-clinical-decision time, rapid data availability, reduced preanalytic and postanalytic testing errors, self-contained user-friendly instruments, small sample volume requirements, and frequent serial whole-blood testing. However, still there is a noticeable debate that exists among the laboratorians, clinicians, and administrators over concerns regarding analyzer inaccuracy, imprecision and performance (interfering substances), poorly trained non-laboratorians, high cost of tests, operator-dependent quality of testing, and difficulty in integrating test results with hospital information system (HIS). On search of literature using Medline/Pubmed and Embase using the key phrases "ppoint-of-care test," "central laboratory testing," "electrolytes," "blood gas analysis," "lactate," "emergency department," "intensive care unit," we found that POCT of blood gases and selected electrolytes may not entirely replace centralized laboratory testing but may transfigure the clinical practice paradigm of emergency and critical care physicians. We infer that further comprehensive, meaningful and rigorous evaluations are required to determine outcomes which are more quantifiable, closely related to testing events and are associated with effective cost benefits.

The role of magnesium sulfate in acute asthma: does route of administration make a difference?

PURPOSE OF REVIEW

The role of magnesium sulfate (MgSO4) in the treatment of acute asthma is not clear. Four recent systematic reviews suggest a limited role of intravenous (i.v.) and inhaled nebulized treatment. The purpose of this review is to summarize the current literature, focus on two recent large multicenter randomized controlled trials, and discuss future research directions.

RECENT FINDINGS

The Magnesium Nebulized Trial In Children (MAGNETIC) trial has shown little benefit to routine use of nebulized MgSO4 in children with acute asthma, but there may be a benefit in those with severe exacerbations and a shorter duration of symptoms. The 3Mg trial has shown no role for nebulized MgSO4 in adults and, at best a limited role for i.v. MgSO4 in only the most severe exacerbations. This is the only study with direct comparison of nebulized and i.v. MgSO4.

SUMMARY

MgSO4 has a role in severe exacerbations of acute asthma and there is no evidence of benefit outside this clinical situation. Both nebulized and i.v. treatments are well tolerated and inexpensive. In adults, the most effective route of administration is i.v. There are no direct comparison studies in children. Further research should focus on more severe exacerbations.

Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department

BACKGROUND

Asthma is a chronic respiratory condition characterised by airways inflammation, constriction of airway smooth muscle and structural alteration of the airways that is at least partially reversible. Exacerbations of asthma can be life threatening and place a significant burden on healthcare services. Various guidelines have been published to inform management personnel in the acute setting; several include the use of a single bolus of intravenous magnesium sulfate (IV MgSO4) in cases that do not respond to first-line treatment. However, the effectiveness of this approach remains unclear, particularly in less severe cases.

OBJECTIVES

To assess the safety and efficacy of IV MgSO4 in adults treated for acute asthma in the emergency department.

SEARCH METHODS

We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to 2 May 2014. We also searched www.ClinicalTrials.gov and reference lists of other reviews, and we contacted trial authors to ask for additional information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults treated in the emergency department (ED) for exacerbations of asthma if they compared any dose of IV MgSO4 with placebo.

DATA COLLECTION AND ANALYSIS

All review authors screened titles and abstracts for inclusion, and at least two review authors independently extracted study characteristics, risk of bias and numerical data. Disagreements were resolved by consensus, and we contacted trial investigators to obtain missing information.We analysed dichotomous data as odds ratios using study participants as the unit of analysis, and we analysed continuous data as mean differences or standardised mean differences using fixed-effect models. We rated all outcomes using GRADE and presented results in Summary of findings table 1.We carried out subgroup analyses on the primary outcome for baseline severity of exacerbations and whether or not ipratropium bromide was given as a co-medication. Unpublished data and studies at high risk of bias for blinding were removed from the main analysis in sensitivity analyses.

MAIN RESULTS

Fourteen studies met the inclusion criteria, randomly assigning 2313 people with acute asthma to the comparisons of interest in this review.Most studies were double-blinded trials comparing a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes versus a matching placebo. Eleven were conducted at a single centre, and three were multi-centre trials. Participants in almost all of the studies had already been given at least oxygen, nebulised short-acting beta2-agonists and IV corticosteroids in the ED; in some studies, investigators also administered ipratropium bromide. Ten studies included only adults, and four included both adults and children; these were included because the mean age of participants was over 18 years.Intravenous MgSO4 reduced hospital admissions compared with placebo (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.60 to 0.92; I(2) = 28%, P value 0.18; n = 972; high-quality evidence). In absolute terms, this odds ratio translates into a reduction of seven hospital admissions for every 100 adults treated with IV MgSO4 (95% CI two to 13 fewer). The test for subgroup differences revealed no statistical heterogeneity between the three severity subgroups (I(2) = 0%, P value 0.73) or between the four studies that administered nebulised ipratropium bromide as a co-medication and those that did not (I(2) = 0%, P value 0.82). Sensitivity analyses in which unpublished data and studies at high risk for blinding were removed from the primary analysis did not change conclusions.Within the secondary outcomes, high- and moderate-quality evidence across three spirometric indices suggests some improvement in lung function with IV MgSO4. No difference was found between IV MgSO4and placebo for most of the non-spirometric secondary outcomes, all of which were rated as low or moderate quality (intensive care admissions, ED treatment duration, length of hospital stay, readmission, respiration rate, systolic blood pressure).Adverse events were inconsistently reported and were not meta-analysed. The most commonly cited adverse events in the IV MgSO4 groups were flushing, fatigue, nausea and headache and hypotension (low blood pressure).

AUTHORS' CONCLUSIONS

This review provides evidence that a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulised short-acting beta2-agonists and IV corticosteroids. Differences in the ways the trials were conducted made it difficult for the review authors to assess whether severity of the exacerbation or additional co-medications altered the treatment effect of IV MgSO4. Limited evidence was found for other measures of benefit and safety.Studies conducted in these populations should clearly define baseline severity parameters and systematically record adverse events. Studies recruiting participants with exacerbations of varying severity should consider subgrouping results on the basis of accepted severity classifications.

The use of intravenous and inhaled magnesium sulphate in management of children with bronchial asthma

BACKGROUND

Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity. When uncontrolled, asthma can place significant limits on daily life, and is sometimes fatal. The use of magnesium sulphate (MgSO4) is one of numerous treatment options available during acute severe asthma in children. The efficacy of intravenous, or inhaled MgSO4 has been demonstrated, while little is known about the actual clinical use of either intravenous (IV) or inhaled MgSO4.

OBJECTIVE

To assess the effectiveness of intravenous (IV) and/or inhaled MgSO4 on hospital admissions and pulmonary function in children with asthma. This systematic review assessed the best available evidence for the use of either intravenous or inhaled MgSO4 in children with acute asthma. Magnesium deficiency is a common electrolyte disorder in children with acute severe asthma. Several authors reported that IV magnesium was effective in the treatment of moderate to acute asthma in children but evidence for nebulised magnesium was insufficient. In addition, it is used in severe, progressed cases to prevent respiratory failure and/or admission to the intensive care unit. It has bronchodilating and anti-inflammatory effects and modulates ion transport and influences intracellular calcium concentration. Intravenous MgSO4 therapy helps in achieving earlier improvement in clinical signs and symptoms of asthma, e.g. respiratory function and significantly reduced hospital admission, in children with acute severe asthma. The role of nebulised MgSO4 in asthmatic children requires further investigation.

CONCLUSION

According to the previous studies, the author recommends the use of intravenous MgSO4 as a safe and effective adjunct to conventional bronchodilator therapy in acute severe asthma in children.

Childhood asthma: a guide for pediatric emergency medicine providers

Pediatric asthma is a disease that is managed across outpatient physicians, hospitalists, critical care physicians, and emergency department (ED) physicians. Scoring systems may facilitate a rapid assessment of the child with asthma in the ED. Short-acting beta agonists are still the mainstay of therapy for acute exacerbations along with corticosteroids and ipratropium bromide. ED providers must also know the indications for noninvasive ventilation and intubation. Most patients can be treated and discharged from the ED after acute exacerbation, and should be given a plan for going home that provides educational material and emergency scenarios to help prevent future acute incidents.

Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit

OBJECTIVES

An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients.

METHODS

Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980-2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital.

RESULTS

Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status.

CONCLUSIONS

Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.

Medical emergencies: pulmonary embolism and acute severe asthma

In this, the second of two articles covering specific medical emergencies, we discuss the definitions, epidemiology, pathophysiology, acute and chronic management of pulmonary embolus and acute severe asthma.

Intravenous and nebulized magnesium sulfate for treating acute asthma in adults and children: a systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis was conducted to estimate the effects of intravenous and nebulized magnesium sulfate on treating adults and children with acute asthma.

METHODS

Electronic literature search and the manual search of key respiratory journals were performed up to October 18, 2011. Randomized controlled trials were included if patients had been treated with intravenous or nebulized magnesium sulfate in combination with β2-agonists and were compared with the use of β2-agonists. Standardized mean differences (SMDs) and the relative risks (RRs) were calculated for pulmonary functions and hospital admission respectively.

RESULTS

25 trials (16 intravenous, 9 nebulized) involving 1754 patients were included. In adults intravenous treatment was associated with a significant effect upon respiratory function (SMD, 0.30; 95% confidence interval (CI), 0.05 to 0.55; p = 0.02) but weak evidence of effect upon hospital admission (RR 0.86,95% CI 0.73 to 1.01; p = 0.06) in adults, and in children with significant effects upon both respiratory function (SMD, 1.94; 95% CI, 0.80 to 3.08; p = 0.0008) and hospital admission (RR, 0.70; 95% CI, 0.54 to 0.91; p = 0.008). Nebulized treatment was associated with significant effects upon respiratory function (SMD, 0.23; 95% CI, 0.06 to 0.41; p = 0.009) and hospital admission (RR, 0.63; 95% CI, 0.43 to 0.92; p = 0.02) in adults.

CONCLUSION

The use of intravenous magnesium sulfate, in addition to β2-agonists and systemic steroids, in the treatment of acute asthma appears to produce benefits with respect to improve pulmonary function and reduce the number of hospital admissions for children, and only improve pulmonary function for adults. However, the use of nebulized magnesium sulfate just appears to produce benefits for adults.

Feasibility of short-term infusion of magnesium sulfate in pediatric patients with status asthmaticus

OBJECTIVE

This report describes the feasibility of high-dose magnesium sulfate infusion in pediatric patients with status asthmaticus.

METHODS

Retrospective chart review over a 3-year period of all patients younger than 18 years of age with status asthmaticus who underwent a high-dose magnesium sulfate infusion for 4 hours. All patients were breathing spontaneously but were refractory to conventional therapy. The magnesium sulfate infusion regimen was 50 mg/kg (for patients weighing >30 kg) or 75 mg/kg (for those weighing ≤30 kg) over a period of 30 to 45 minutes, followed by a continuous infusion of 40 mg/kg/hr for 4 hours. Information regarding vital and clinical respiratory signs, serum magnesium (SrMg), ionized magnesium (iMg), electrocardiograms, and cardiac troponin levels were retrieved. We analyzed the relationship between SrMg and iMg by using linear regression analysis.

RESULTS

Nineteen patients were included. At the end of the infusion, SrMg levels were 4.4 ± 0.8 mg/dL, and iMg levels were 0.95 ± 0.2 mmol/L. SrMg levels only moderately predicted iMg (r(2) = 0.541). There were no reports of hypotension, respiratory failure, neurological problems, or nausea. Discomfort at the site of infusion was reported in three cases. Troponin levels (n = 12) and electrocardiograms (n = 12), when available, were noted at the end of the infusion and were normal in all patients p=0.01.

CONCLUSIONS

In this case series, short-term high-dose administration of magnesium sulfate in the context of status asthmaticus was feasible, and we did not observe clinical complications with its use. Total SrMg was inadequate to reflect the active form of magnesium, iMg. The dose used achieved theoretical therapeutic levels of iMg.

Management of asthma during pregnancy

Asthma is an inflammatory lung condition that is the most common chronic disease affecting pregnancy. The changes in pulmonary physiology during pregnancy include increased minute ventilation, decreased functional residual capacity, increased mucus production, and airway mucosa hyperemia and edema. Pregnancy is also associated with a physiological suppression of the immune system. Many studies have described the heterogeneous immune system response in women with asthma during pregnancy, which partly explains why asthma has been shown to worsen, improve, or remain stable in equal proportions of women during pregnancy. Asthma may be associated with poor maternal and fetal outcomes. However, better maternal and fetal outcomes are observed with better asthma control. Asthma controller medications are generally thought to be safe during pregnancy, but limited data are available for some of the medicines. Newer medications like omalizumab open avenues for the treatment of asthma, but also pose a challenge, as there is limited experience with their use. Therefore, a multidisciplinary approach, including obstetricians, asthma specialists, and pediatricians should collaborate with the patient to carefully weigh the risks and benefits to determine an optimal management plan for each individual patient. The aim of this review article is to summarize the most recent literature about the immunological changes that occur during pregnancy, physiological and clinical implications of asthma on pregnancy, and asthma management and medication use in pregnant women.

Magnesium sulfate for acute asthma in adults: a systematic literature review

Magnesium sulfate (MgSO(4)) has been considered as an adjunct therapy for severe and life-threatening asthma exacerbation. The literature search was performed using MEDLINE, EMBASE, Cochrane Library and Google Scholar to summarize the current state of knowledge regarding magnesium therapy in acute exacerbation of adult asthma. A total of 16 trials and 4 meta-analyses were identified. As results, intravenous MgSO(4) was beneficial in severe exacerbation, but evidence for nebulized magnesium was insufficient. However, larger trials are required to draw confirmative conclusions on the efficacy. Regarding the safety concern, the risk of major toxicity appears to be very low at usual doses described in the literature. Additionally, results from 4 surveys were examined on the gaps between knowledge and practice, and on the barrier to the use of MgSO(4) at emergency departments. This literature review summarized the up-to-date evidence on the issues regarding the use of MgSO(4) for acute asthma. We expect more studies to be conducted for evidence making in the Asian-Pacific regions.

Best Treatment Guidelines For Bronchial Asthma

Asthma is a common disease worldwide with significant ethnic and regional variations. An increasing morbidity and mortality, as well as health care burden from asthma have been recognized lately. Several evidence based guidelines have been developed with an aim to standardize and improve the quality of management. These guidelines seek to translate the advances in the understanding of pathogenesis of asthma and in the development of new agents and strategies into practical application at all levels of healthcare. These advocate an assessment of the patients to classify the severity of diseases followed by a step-wise approach to treatment. With the current management we hope to achieve minimum or nil day time and night time symptoms, prevent acute exacerbations and attain normal or near normal lung function, thus improving the overall quality of life.

Unusual asthma syndromes and their management

Asthma usually presents with symptoms of wheeze, dyspnoea and cough. However, clinicians should be aware of atypical presentation of this disorder when cough is the main or only symptom in conditions such as cough-variant asthma, nonasthmatic eosinophilic bronchitis and atopic cough. Early diagnosis and treatment of these conditions with inhaled corticosteroids improves symptoms in the majority of patients. Up to 10% of patients with asthma remain poorly controlled in spite of optimal standard therapy. These patients have been encompassed under the term 'treatment-refractory asthma' (TRA), have the greatest morbidity and are responsible for more than 50% of healthcare costs. In this review we discuss investigations, management and pathophysiology of the various phenotypes of atypical presentations of asthma as well as novel biological agents licensed and those that have been reported in clinical trials in terms of their efficacy and safety in TRA.