Halothane, an Effective Infrequently Used Drug, in the Treatment of Pediatric Status Asthmaticus: A Case Report

Asthma is the most common chronic disease of childhood. Despite a better understanding of the disease process and its management, status asthmaticus continues to be a life-threatening event. The use of volatile inhaled anesthetics is infrequently reported as adjunctive therapy to conventional treatment of this condition. We report the use of halothane in a mechanically ventilated pediatric patient with life-threatening status asthmaticus who was admitted to the pediatric intensive care unit (PICU) after failing to respond to standard medical therapy and noninvasive positive pressure ventilation. A 12-year-old African American male was seen in the emergency department and treated with intravenous corticosteroids, beta-agonist therapy. He deteriorated rapidly and required endotracheal intubation and mechanical ventilation. Two hours later, the patient developed an acute, severe respiratory acidosis (pH = 6.97, PaCO₂ = 171, PaO₂ = 162, BE = 1.7). Halothane was started at 2% by using the Siemens Servo 900C anesthesia ventilator. Improvement in both arterial blood gases and exhaled tidal volume were noted 30 minutes after initiation of the anesthetic gas. The patient remained on halothane for a total of 36 hours. No adverse effects associated with the use of halothane were noted. The patient was extubated to BiPAP 16/6, FiO₂ = 0.30 at 68 hours and was discharged home 5 days later.     

Demographics,Clinical Course,and Outcomes of Children with Status Asthmaticus Treated in a Pediatric Intensive Care Unit: 8-Year Review

Objective. This study was done to understand the demographics, clinical course, and outcomes of children with status asthmaticus treated in a tertiary care pediatric intensive care unit (PICU). Methods. The medical charts of all patients above 5 years of age admitted to the PICU at Nationwide Children’s Hospital, Columbus, OH, USA, with status asthmaticus from 2000 to 2007 were reviewed retrospectively. Data from 222 encounters by 183 children were analyzed. Results. The mean age at admission in years was 11 ± 3.8. The median PICU stay was 1 day (range, 1–12 days) and median hospital stay was 3 days. The ventilated group (n = 17) stayed a median of 2 days longer in the PICU and hospital. Nearly half of the children (n = 91; 50%) did not receive daily controller asthma medications. Adherence to asthma medications was reported in 125 patient charts of whom 43 (34%) were compliant. Exposure to smoking was reported in 167 of whom 70 (42%) were exposed. Among patients receiving metered dose inhaler (MDI), only 39 (18%) were using it with a spacer. Among 105 patient charts asthma severity data were available, of them 21 (20%) were labeled as mild intermittent, 29 (28%) were mild persistent, 26 (25%) were moderate persistent, and 29 (28%) were severe persistent. Compared to children with only one PICU admission during the study period (n = 161), children who had multiple PICU admissions (n = 22) experienced more prior emergency department visits and hospitalizations for asthma symptoms. There were no fatalities. Conclusion. Asthmatics with any disease severity are at risk for life-threatening asthma exacerbations requiring PICU stay, especially those who are not adherent with their daily medications.     

Ventilator Strategy for Status Asthmaticus in Pregnancy: A Case-Based Review

Asthma is a common and potentially serious condition complicating pregnancy. However, the literature available on the management of severe asthma in pregnancy is limited. We describe two episodes of respiratory failure due to asthma in pregnant women and discuss their management in the context of a review of the literature. In both patients, adequate oxygenation was maintained by using controlled hypoventilation with a permissive hypercapnia strategy. Both patients received aggressive steroid therapy, aerosolized bronchodilators, sedation, and paralysis. Aggressive asthma treatment as in a nongravid female is recommended.     

Flurbiprofen Axetil,Nasal Polyps,and Status Asthmaticus: An Unusual Case Report

Introduction. Herein, we report a case of life-threatening status asthmaticus in a young male presented with nasal polyps but without any history of anaphylaxis or asthma. Discussion. The patient had normal results from preoperative respiratory systemic examinations. The postoperative asthma, which started after an infusion of nonsteroidal anti-inflammatory drugs (NSAIDs), was severe and difficult to manage. A relationship between the NSAID infusion and the asthma attack was indicated. Flurbiprofen axetil, a nonselective COX2 inhibitor, is most likely the causative agent in this case, although there are no prior reports of asthma caused by this agent. Conclusion. We concluded that flurbiprofen axetil evoked severe bronchospasm in this case. Patients who are sensitive to flurbiprofen axetil will usually react to other NSAIDs; therefore, other ordinary NSAIDs should be used with caution in hypersensitive patients. An intranasal ketorolac challenge in individuals with nasal polyps, which is a novel and safe alternative to aspirin challenge, may be recommended to rule out aspirin-exacerbated respiratory disease, prior to the systemic administration of NSAIDs.     

Ventilator Strategy for Status Asthmaticus in Pregnancy: A Case-Based Review

Asthma is a common and potentially serious condition complicating pregnancy. However, the literature available on the management of severe asthma in pregnancy is limited. We describe two episodes of respiratory failure due to asthma in pregnant women and discuss their management in the context of a review of the literature. In both patients, adequate oxygenation was maintained by using controlled hypoventilation with a permissive hypercapnia strategy. Both patients received aggressive steroid therapy, aerosolized bronchodilators, sedation, and paralysis. Aggressive asthma treatment as in a nongravid female is recommended.     

Mechanical Ventilation for Asthma: A 10-Year Experience

Background. Asthmatics requiring admission to the intensive care unit and/or mechanical ventilation have increased morbidity and mortality. The purpose of this study is to examine morbidity and mortality in patients requiring intubation and mechanical ventilation for asthma over a 10-year period. This study also reviews the clinical features and management of these patients. Methods. We performed a retrospective review of medical records over a 10-year period of adult patients who required mechanical ventilation for a primary diagnosis of asthma. The study was conducted at a university-affiliated, county hospital. Results. One hundred twenty-seven patients with 162 episodes of asthma requiring mechanical ventilation were identified. The majority of the patients (64%) were women. The predominant ethnicity was African-American (65%). These patients had multiple risk factors for asthma mortality, including recent hospital admissions, prior episodes of near-fatal asthma, medication non-compliance, and poor outpatient follow-up. Over the 10 years of the study, outpatient management of these patients changed, with the percentage of admissions in which patients had been given inhaled corticosteroids increasing from 18 percent in 1990 to 80 percent in 1998. Management of mechanical ventilation also changed. The average tidal volume settings significantly decreased after 1995. The most common complication was atelectasis, which was seen in 33 cases. Evidence of barotrauma, including pneumothorax, pneumomediastinum, and subcutaneous emphysema, was present in 10 cases. There were four deaths. All four of the patients suffered cardiopulmonary arrest in the field with subsequent anoxic brain injury and withdrawal of care. Conclusions. Although these patients had multiple risk factors for mortality from asthma, no deaths in this study were related to complications of mechanical ventilation. This low mortality may be related to changes in management of mechanical ventilation as well as changes in chronic outpatient asthma therapy.     

Pumpless Extracorporeal Lung Assist for the Treatment of Severe,Refractory Status Asthmaticus

Background. Until recently, the only available lung-protective treatment option for carbon dioxide removal due to severe, refractory status asthmaticus has been extracorporeal pump-driven membrane oxygenation (ECMO). Pumpless extracorporeal lung assist (pECLA) may serve as an alternative therapy for these patients. Case Report. A 42-year-old woman presented with an acute exacerbation of asthma to our Emergency Department. Despite optimal pharmacological therapy, the patient developed respiratory failure requiring mechanical ventilation with elevated airway pressures. For severe ventilation-refractory hypercapnia and respiratory acidosis, ECMO was used initially and was later replaced by a pECLA device. The clinical condition continuously improved with sufficient pulmonary gas exchange. The pECLA was removed after 8 days, and the patient was successfully weaned from mechanical ventilation. Conclusions. This report suggests that pECLA is an alternative extracorporeal lung assist in patients with ventilation-refractory hypercapnia and respiratory acidosis due to severe, refractory status asthmaticus.     

Effectiveness of budesonide aerosol in ventilator-dependent preterm babies: A preliminary report

The aim of this randomized, double-blind, placebo-controlled trial was to assess the short-term effect of a topical glucocorticoid (budesonide 600 μg twice daily) vs. placebo administered by metered dose inhaler (MDI) and spacer (Aerochamber MV15) directly into the endotracheal tube of intubated infants for 7 days. Twenty preterm infants (mean birthweight, 1,030 g; mean gestational age, 27.3 weeks) who still needed assisted ventilation at 14 days of age were randomly assigned to receive budesonide (n = 9) or placebo (n = 11) and completed the study. The primary outcome was the need for mechanical ventilation after 7 days of treatment. Other outcome variables included ventilator settings, blood gases, serum cortisol levels, and bronchoalveolar lavage inflammatory cell counts. No ventilated infant was extubated during the study period. The treatment group showed significant improvements in mean peak inspiratory pressure, ventilator efficiency index, and (A-a) oxygen difference. There were no changes in the placebo group. Serum cortisol levels and bronchoalveolar lavage cell counts did not change significantly during the study period. There was no difference in side effects between the groups. This trial demonstrates that topical budesonide administered by MDI and Aerochamber produces clinical improvement in ventilated preterm infants, without glucocorticoid side effects. Pediatr Pulmonol. 1996; 21:231–235. © 1996 Wiley-Liss, Inc.     

The use of non‐invasive ventilation for life‐threatening asthma attacks: Changes in the need for intubation

Background and objective: Although non‐invasive ventilation (NIV) has been shown to be effective in a wide variety of respiratory diseases, its role in severe asthma attacks remains uncertain. The aim of this study was to clarify the effectiveness of NIV in patients experiencing severe attacks of asthma. Methods: A retrospective cohort study was performed, comparing the periods November 1999–October 2003 (pre‐introduction of NIV) and November 2004–October 2008 (post‐introduction of NIV). The data and clinical outcomes for patients who experienced severe attacks of asthma, and who fulfilled the inclusion criteria, were retrieved and compared. Results: Fifty events (48 patients) from the pre‐NIV period and 57 events (54 patients) from the post‐NIV period, which required hospitalization, were included in the analysis. Nine of the 50 pre‐NIV events (mean PaO₂/fraction of inspired O₂ (FiO₂) 241 ± 161; PaCO₂ 79 ± 40) were treated primarily by endotracheal intubation (ETI), while 17 of the 57 post‐NIV events (PaO₂/FiO₂ 197 ± 132, P = 0.39; PaCO₂ 77 ± 30, P = 0.95) were treated primarily by NIV. The rate of ETI decreased in the post‐NIV period (2/57 (3.5%) vs 9/50 (18%), P = 0.01). NIV was started earlier than mechanical ventilation (MV) with ETI (mean time interval between arrival and start of MV 171.7 ± 217.9 min vs 38.5 ± 113.8 min for NIV, P < 0.05). In the post‐NIV cohort, there was a trend towards a reduction in the duration of MV with ETI or NIV (36.9 ± 38.4 h vs 20.3 ± 35.8 h, P = 0.09), and hospital stay was shortened (12.6 ± 4.2 vs 8.4 ± 2.8 days, P < 0.01). No deaths occurred during this period as a consequence of asthma attacks. Conclusions: The need for ETI in patients with severe attacks of asthma was decreased after introduction of NIV. The ready availability of NIV enabled the rapid commencement of MV and may decrease the need for ETI. NIV is an acceptable and useful method of stabilizing patients experiencing severe attacks of asthma.     

Case Report: Surgical Treatment of Multiple Hydatid Cysts in the Liver of a Pediatric Patient

Multiple hydatid cysts in the liver rarely occur in the pediatric population. Here, we present the case of a 16-year-old girl who presented with six hydatid cysts in the liver. The cysts were surgically removed and all found to be infertile. Interestingly, the patient had post-operative eosinophilia. From this experience, we conclude that individualized treatment is necessary for patients with multiple hydatid cysts.     

The Emergency Department as an Asthma Surveillance Tool at the Community Level: A Decline in the Burden of Pediatric Asthma in Halifax,Canada

We report pediatric emergency department (PED) asthma visit and inpatient asthma (AS) admission data in our area over a 5-year period. AS visits decreased by 33.9%, AS admissions by 24.6%, both significant compared with the decline in elementary school enrollment. The decrease in asthma visits was due to a decrease in the number of asthmatic patients, not a decline in repeat visits, or use of alternate venues of care. Explanations include a decrease in the burden of disease or an improvement in ambulatory care, but not alternate treatment venues or improvement in acute (PED) care. Readily available, emergency department data are useful in the community surveillance of asthma.     

The Emergency Department as an Asthma Surveillance Tool at the Community Level: A Decline in the Burden of Pediatric Asthma in Halifax, Canada

We report pediatric emergency department (PED) asthma visit and inpatient asthma (AS) admission data in our area over a 5-year period. AS visits decreased by 33.9%, AS admissions by 24.6%, both significant compared with the decline in elementary school enrollment. The decrease in asthma visits was due to a decrease in the number of asthmatic patients, not a decline in repeat visits, or use of alternate venues of care. Explanations include a decrease in the burden of disease or an improvement in ambulatory care, but not alternate treatment venues or improvement in acute (PED) care. Readily available, emergency department data are useful in the community surveillance of asthma.     

无创双水平正压通气治疗重症支气管哮喘96例临床分析

目的探讨无创双水平正压通气(BiPAP)在重症支气管哮喘治疗中的应用价值。方法观察96例重症支气管哮喘患者(无创通气组)在传统内科治疗基础上运用BiPAP治疗2h后的显效率,并与单用传统内科方法治疗的61例患者(对照组)进行比较。结果治疗后,两组患者的显效率间差异有统计学意义(P<0.05)。结论Bi-PAP是治疗重症支气管哮喘的有效方法,可有效缓解患者的症状,改善通气功能。     

Efficacy of Racemic Albuterol versus Levalbuterol Used as a Continuous Nebulization for the Treatment of Acute Asthma Exacerbations: A Randomized,Double-Blind,Clinical Trial

Objective. To compare racemic albuterol (RAC) with levalbuterol (LEV) in continuous form for the treatment of acute pediatric asthma exacerbations in the emergency department. Study design. Children between the ages of 6 and 17 inclusive were enrolled if they had a history of asthma, presented to the emergency department with an acute asthma exacerbation, and had an initial forced expiratory volume in 1 second (FEV1) <70% predicted. Patients were then randomized to receive either 7.5 mg of RAC or 3.75 mg of LEV over 1 hour, in addition to standard asthma therapies. Spirometry and asthma scoring were performed at the end of the first hour, and a second hour-long nebulization with the same drug was administered if deemed necessary. Spirometry and asthma scoring were again performed and the final disposition was recorded. As a second, optional part of the study, baseline serum albuterol levels were collected on some patients before treatment. Results. A total of 99 patients completed the study (44 RAC and 55 LEV). Baseline characteristics were similar except that the RAC group had a higher baseline asthma score. Children in the RAC group had a greater improvement in their FEV1 (p = .043) as well as in their asthma scores (p = .01) after 1 hour of continuous treatment compared to the LEV group. The greater improvement in asthma scores was maintained after the second hour of continuous therapy in the RAC group (p = .008) but not for FEV1 measurements (p = .57). There were no differences between groups for changes in heart rate, respiratory rate, oxygen saturation, or rates of admission. Conclusions. At the doses used, RAC appears to be superior to LEV with respect to changes in FEV1 and asthma score. There was no significant difference between the drugs with respect to admission rates or side-effect profile.     

A Mechanically Powered Negative Pressure Device Used in Conjunction with a Bioengineered Cell-based Product for the Treatment of Pyoderma Gangrenosum: A Case Report

Pyoderma gangrenosum (PG), an uncommon inflammatory and ulcerative skin disease, typically is treated medically with a combination of immunosuppression and local wound care, but evidence to guide care is limited. PG wounds can be difficult to heal. A 76-year-old male patient presented with a history of rheumatoid arthritis and recalcitrant PG. After 9 months of treatment with local wound care, steroids, and topical tacrolimus, the wound had increased in size from 1.8 cm x 1.5 cm to 7.2 cm x 5.6 cm. At that time, he was started on a regimen of five applications of a bioengineered cell- based product (one application every 2 weeks for a total of five applications) with twice-weekly mechanically powered negative pressure device changes. The latter was started at 75 mm Hg and changed to 125 mm Hg after 4 weeks. Oral corticosteroid therapy was initially started at 40 mg of prednisone, then slowly tapered to 20 mg, but could not be com- pletely discontinued due to a flare in the patient's rheumatoid symptoms. The wound was completely healed after 16 weeks. Research to ascertain the effectiveness of protocols of PG care, including the combination treatment described, is needed to help clinicians provide evidence-based care for these challenging wounds.     

A subgroup analysis of the MONICA study: A 12-month,open-label study of add-on montelukast treatment in asthma patients

Objective. We evaluated montelukast, a leukotriene receptor antagonist (LTRA), added to inhaled corticosteroids (ICS) or ICS+long-acting β₂ agonist (LABA) regimens over a period of 1 year to explore the therapeutic effects on asthma patients in patient subgroups. Methods. The majority of patients enrolled in this 12-month, open-label study were ≥18 years of age (n = 1681) with mild to moderate asthma insufficiently controlled by ICS or ICS+LABA. Patients received montelukast 10 mg qd as add-on therapy and were evaluated at Months 3, 6, 9, and 12. Asthma Control Test (ACT) score in the overall population was the primary endpoint; ACT score categories range from <16 (uncontrolled) to 25 (completely controlled). A post hoc secondary analysis of the following subgroups was conducted. age (< 30 years, 30–50 years, >50 years), gender, presence of allergic rhinitis, duration of asthma (< 5 years, ≥5 years), and the use of ICS or ICS+LABA. Results. Over 12 months of therapy, mean ACT scores improved by 5.7 units (p < .0001); at baseline, the mean (SD) ACT score for all patients was 14.6 (4.6) and at Month 12, the mean (SD) ACT score was 20.3 (4.2). The subgroups of patients who had allergic rhinitis and those who were <30 years of age demonstrated numerically better ACT scores compared with those who did not have allergic rhinitis or who were >30 years of age. Additional evaluation of the ACT score categories also demonstrated better control among patients who had duration of asthma <5 years and were treated with ICS without LABA. Conclusion. Add-on montelukast demonstrated significant improvement in asthma symptoms over 12 months in all patients in the study. Asthma control was improved in all patient subgroups, but comorbid allergic rhinitis, younger age, shorter duration of asthma, and treatment with only ICS and not ICS+LABA were indicators of better control with add-on montelukast. These observations may likely be shared with other antiasthmatic medications and should be further explored.     

Treatment of Aregeneratoric Anemia Following an ABO-Incompatible Allogeneic Peripheral Blood Stem Cell Transplantation: A Case Report

Aregeneratoric anemia (AA) occurs rarely after ABO-incompatible allogeneic peripheral blood stem cell transplantation (alloPBSCT), and its management is generally difficult. Here, we present a 31-year-old white man with myelodysplastic syndrome who developed AA after receiving stem cells from his human leukocyte antigen (HLA) identical, but ABO-incompatible sibling. Because his anti-A antibody titers were high, therapy with conventional doses of erythropoietin and prednisolone failed to treat the AA. Following 8 cycles of plasma exchange and higher doses of erythropoetin and prednisolone as well as danazol administration, anti-A titers decreased, and his anemia improved significantly. In conclusion, to treat and obtain a low titer of antibodies in a patient with AA following an ABO-incompatible alloPBSCT, higher doses of erythopoietin and corticosteroids associated with plasma exchange have to be used.