Posted by James
Case 1
A 20-vear-old woman with a seven-year history of asthma was admitted to the hospital with a history of worsening bronchospasm for one week following a flu-like illness. She had l>een using albuterol, ipratropium, and l>eclomethasone inhalers without improvement. She was transferred to our Intensive Care Unit (ICU) owing to increasing respiratory distress. On admission to the ICU, her heart rate (HR) was 120 lieats per minute, respiratory rate (RR) was 18 breaths per minute, and Mood pressure (BP) was 150/80 mm Hg. Initial arterial blood gas (ABC) determinations were a pH of 7.30, Pco, of 35 mm Hg, and P<>2 of 45 mm Hg. Complete blood cell count (CBC), electrolytes, and liver function test results were normal.
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Posted by James
Tnhalational anesthetic agents have been sporadically used for status asthmaticus unresponsive to maximal standard therapy. Unfortunately, many agents have serious side effects and the delivery systems have been difficult to use outside the operating room, particularly in patients with high airway pressures.
Isoflurane, a halogenated ether, is an anesthetic agent that produces bronchodilation through a number of mechanisms. Recent technologic developments allow isoflurane to be easily and safely administered for prolonged periods of time to patients with severe bronchospasm.
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Posted by James
These considerations have prompted others to investigate simpler techniques of aerosol delivery in acute asthma. Recently, it has been suggested that p- agonist delivered by metered dose inhaler with a spacer device is simpler and as effective as В N in this setting. However, some acutely ill patients are unable to use these devices properly while others are psychologically not prepared to accept a form of therapy that they perceive as already having failed at home. Continuous nebulization may achieve the goal of simplifying treatment while introducing a new mode of bronchodilator delivery in patients with acute airway obstruction.
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Posted by James
This study compared CN of P-agonists with the standard method of BN in the initial emergency department management of asthma. Both methods were demonstrated to be effective with no significant differences in their bronchodilator activity or toxicity. Bolus nebulization was associated with a more rapid initial response, whereas FEV, improved progressively with CN. The change in FEV, was greater with CN than BN and had not yet reached a plateau after 2 hours with the former. However, the initial FEV, was lower in the CN group and this may have contributed to the aparently greater response in these patients. At the end of 2 hours, FEV, was virtually identical in both arms and we believe that the treat¬ments were equally efficacious.
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Posted by James
Forty-two patients equally divided between the two groups completed the study. Two other patients initially randomized to CN were immediately withdrawn because of technical difficulties resulting in inadequate volume delivered by the nebulizer delivery system. One patient initially in the BN group was withdrawn after a vasovagal episode, considered unlikely to be related to albuterol, while another in the same group refused further therapy and discharged himself from the emergency department.
The demographic characteristics of patients studied are seen in Table 1. Most had been taking inhaled (3- agonists, theophylline, or both.
The baseline FEV1 in the group receiving CN was lower than that in the BN group (1.13 ±0.51 L vs 1.48 ±0.64 L), (p = 0.06).
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Posted by James
Spirometry was performed prior to commencing nebulizer therapy and at 30-minute intervals for 2 hours thereafter. Tests were done using a Vitalograph model S with PFT printer (Lenexa, Kan). FEV„ FVC, and FEF25-75% were determined from the best of three expiratory maneuvers (sum of FEV, and FVC). Pulse, respiratory rate, and blood pressure were measured every 30 minutes for 2 hours. Hand tremor was assessed subjectively by the investigators as absent, mild, moderate, or severe.
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Posted by James
Subjects
We studied 46 consecutive eligible patients who presented to the Emergency Department of the Sir Mortimer B. Davis-Jewish General Hospital, Montreal, because of an exacerbation of asthma. Entry requirements dictated that subjects be at least 18 years of age and have a previous diagnosis of asthma as defined by the American Thoracic Society (ATS) criteria. Patients with complicating medical illnesses such as pneumonia, ischemic heart disease (acute or chronic), frequent ventricular premature beats, or diabetes mellitus were excluded from the study. Pregnant women and nursing mothers were also ineligible for this protocol. This study was approved by the ethics committee of the Sir Mortimer B. Davis- Jewish General Hospital. Signed informed consent was obtained from each patient.
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