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 importance of bacterial and viral infections associated with adult asthma exacerbations in clinical practice

BACKGROUND

Viral infection is one of the risk factors for asthma exacerbation. However, which pathogens are related to asthma exacerbation in adults remains unclear.

OBJECTIVE

The relation between various infections and adult asthma exacerbations was investigated in clinical practice.

METHODS

The study subjects included 50 adult inpatients due to asthma exacerbations and 20 stable outpatients for comparison. The pathogens from a nasopharyngeal swab were measured by multiplex PCR analysis.

RESULTS

Asthma exacerbations occurred after a common cold in 48 inpatients. The numbers of patients with viral, bacterial, or both infections were 16, 9, and 9, respectively. The dominant viruses were rhinoviruses, respiratory syncytial virus, influenza virus, and metapneumovirus. The major bacteria were S. pneumoniae and H. influenzae. Compared to pathogen-free patients, the patients with pathogens were older and non-atopic and had later onset of disease, lower FeNO levels, lower IgE titers, and a higher incidence of comorbid sinusitis, COPD, or pneumonia. Compared to stable outpatients, asthma exacerbation inpatients had a higher incidence of smoking and comorbid sinusitis, COPD, or pneumonia. Viruses were detected in 50% of stable outpatients, but a higher incidence of rhinovirus, respiratory syncytial virus, and metapneumovirus infections was observed in asthma exacerbation inpatients. H. influenzae was observed in stable asthmatic patients. Other bacteria, especially S. pneumoniae, were important in asthma exacerbation inpatients.

CONCLUSION

Viral or bacterial infections were observed in 70% of inpatients with an asthma exacerbation in clinical practice. Infection with S. pneumoniae was related to adult asthma exacerbation.

Clinical usefulness of a guideline-based screening tool for the diagnosis of allergic rhinitis in asthmatics: the Self Assessment of Allergic Rhinitis and Asthma questionnaire

BACKGROUND AND OBJECTIVE

Allergic rhinitis (AR) is common in asthmatic patients and may impair asthma control. However, this comorbidity is frequently missed. A simple test is needed to enable physicians to diagnose and evaluate the severity of both diseases. The Self Assessment of Allergic Rhinitis and Asthma (SACRA) questionnaire, which GINA and ARIA Japan committees developed in 2011, consist of questionnaires based on GINA and ARIA guidelines for the diagnosis and severity of AR and asthma, and a visual analogue scale (VAS) to evaluate the severity of both diseases. Our objective was to investigate the clinical usefulness of SACRA as a patient-based screening tool for identifying asthmatic patients with AR.

METHODS

SACRA, ACT (Asthma Control Test) and serum IgE RAST were performed in asthmatic patients. The correlation between SACRA and other parameters were analyzed.

RESULTS

Four hundred twenty asthmatic patients were enrolled. Among 168 subjects who self-reported no concomitant AR, 76 asthmatics scored one or more symptoms on SACRA. Eventually, 32 of these 76 subjects were diagnosed with AR by physicians based on laboratory data or physical examinations by ear, nose and throat specialists. The sensitivity and specificity of SACRA for the diagnosis of AR were 92% and 66%, respectively. The estimated prevalence of AR among asthmatics was 66%, almost identical to that of the previous nationwide study in Japan. The level of asthma control assessed by the VAS on SACRA and the ACT score showed a strong correlation (r = -0.700, P < 0.001).

CONCLUSIONS

SACRA may be a clinically useful tool for identifying bronchial asthma patients with AR.

A comparison of long-term anti-inflammatory effect of two ICS/LABA combination inhalers; fix-dosed maintenance therapy with budesonide/formoterol and salmeterol/fluticasone

BACKGROUND

The clinical usefulness of fixed-dose maintenance therapy with salmeterol/fluticasone (SFC) and budesonide/formoterol combination inhaler (BUD/FM) has been established, though evidence of the long-term anti-inflammatory effects of these 2 inhalers are limited.

METHODS

Patients with moderate persistent adult asthma who had received SFC 50/250μg bid with well-control status were recruited. After switching to 8-week therapy with fixed-dose BUD/FM 4 puffs (640/18μg) (phase-1), patients chose either SFC or BUD/FM. FeNO and ACT score were evaluated every 8 weeks until the end of the 52-week treatment period for both treatment groups (phase-2).

RESULTS

In total, 103 patients were examined: BUD/FM was chosen by 34 patients (BUD/FM group), while SFC was chosen by 23 (SFC group). Thirty-six received SFC consistently from the beginning of the study (control). Patients in the BUD/FM and SFC groups showed significant improvements in ACT scores and FeNO levels in phase-1; these beneficial effects persisted for 52 weeks in the BUD/FM group. On the other hand, in the SFC group, although the FeNO level decreased from 54.3 ± 26.4 ppb to 41.9 ± 18.3 ppb in phase-1, it increased to 54.5 ± 26.2 ppb, a level similar to the baseline prior to the beginning of BUD/FM therapy, at 8 weeks in phase-2, and remained at 50-odd ppb thereafter.

CONCLUSIONS

These results suggest that maintenance therapy with fixed-dose BUD/FM is a useful treatment option exerting an airway anti-inflammatory effect for a period as long as 1 year, even for asthmatics who could not accomplish total control with SFC.

Two tracheal BALT lymphoma patients successfully treated with chemotherapy including rituximab

Bronchus-associated lymphoid tissue (BALT) lymphoma of the trachea, an important differential diagnosis for tracheal tumors, is a rare disease with characteristic bronchoscopic findings. In this study, we reviewed 2 cases of patients who were symptomatic at the time of diagnosis, with tumors in the trachea and left main bronchus, putting them at high risk for asphyxia. Chemotherapies including rituximab were administered, and complete remission was confirmed in both cases. Because tracheal tumors often have a pernicious course, it might be beneficial to initiate a chemotherapeutic treatment regimen instead of adopting the "wait-and-see" approach in patients with symptomatic tracheal BALT lymphoma.

[A case of an asthma patient receiving omalizumab during pregnancy]

We describe the first report in Japan of a woman who received omalizumab during pregnancy and delivery. Her asthma was so severe that she had been taking systemic corticosteroids since 22 years old, but asthma was poorly controlled. She had been pregnant seven times before, but almost every time asthma control had worsened and spontaneous abortion resulted, so she had only one child. She confirmed that she was not intending to become pregnant, and initiated use of omalizumab in August 2009. However, pregnancy was identified after she had taken the drug 3 times. We explained the risks in detail, but the patient wanted to keep taking omalizumab, as her asthma control was improved and she thought she could continue the pregnancy. We therefore decided to continue with omalizumab therapy. In October, she caught a cold and experienced asthma exacerbation. Despite the risk, she decided to suspend omalizumab therapy after taking the drug 7 times, as she was not feeling any benefit from therapy. Threat of abortion was identified in February 2010, so a 544-g female baby was delivered at 26 weeks gestation by Cesarean section. The baby had to be hospitalized in the neonatal intensive care unit because of low birth weight, but she has been developing and growing without handicap. We report this case as the first known case of pregnancy and delivery for a woman receiving omalizumab in Japan. Omalizumab may be safe to use in pregnant women with difficult-to-control asthma.

Low-dose succinylcholine facilitates laryngeal mask airway insertion during thiopental anaesthesia

We have assessed the optimal dose of succinylcholine to provide satisfactory conditions for insertion of a laryngeal mask airway (LMA) without causing myalgia during induction of anaesthesia with thiopental. We studied 60 adult patients, allocated randomly to one of three groups: group 1 (n = 20) received normal saline, group 2 (n = 20) received succinylcholine 0.25 mg kg-1 and group 3 (n = 20) received succinylcholine 0.5 mg kg-1. Insertion of the LMA was performed 1 min after administration of succinylcholine or saline. Insertion conditions were significantly better in group 3 compared with groups 1 and 2. The incidence of adverse responses on insertion was significantly higher in groups 1 and 2 than in group 3. Four of 20 patients (20%) in group 3 complained of myalgia, which was higher than that in group 1 (0%) and group 2 (10%), but there were no significant differences between groups on the day of operation. On day 3 after operation, seven patients (35%) in group 3 complained of myalgia, which was significantly higher than that in group 1 (5%) and group 2 (20%). Time from administration of succinylcholine to resumption of spontaneous respiration was significantly longer in groups 2 (194.9 (SD 50.4) s) and 3 (234.2 (34.3) s) than in group 1 (84.7 (32.4) s). There was also a significant difference between groups 3 and 2 for duration of apnoea.

[Effect of continuous infusion of flumazenil on unexpected postoperative resedation by midazolam]

Resedation after general anesthesia induced by midazolam is thought to be not an unusual problem for the anesthetists. We investigated the effect of continuous infusion of flumazenil on the patients who had general anesthesia using midazolam as an induction agent and had flumazenil for prolonged recovery after procedure. Fourteen of 54 patients were judged as prolonged recovery and were given 0.25 mg of flumazenil. Then, they were randomly divided into the following two groups. In the first group, another 0.25 mg of flumazenil was given 2 hours after the first flumazenil. In the second group, 0.25 mg of flumazenil in 250 ml of lactated Ringer's solution was given continuously for 2 hours after the first flumazenil. All the patients were fully awake after the first flumazenil but one case of resedation occurred in the first group and in none of the patients in the second group. We conclude that continuous infusion of 0.25 mg of flumazenil for 2 hours is effective and makes anesthetist free from anxiety of postoperative resedation by midazolam.