Spontaneous pneumomediastinum complicating severe acute asthma exacerbation in adult patients

Objectives: The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods: The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO₂) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results: Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17–21) vs 49.5 (20–73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4–12) vs 7 (3–15) days; p = 0.6939]. Conclusions: PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.     

Evaluation of an educational programme for socially deprived asthma patients.

The aim of this study was to evaluate the effectiveness of an asthma education programme in moderate and severe asthma patients in a longitudinal, prospective and randomized study with a control group. Fifty-three asthmatic patients were studied, 26 of whom were assigned to the educational group and 27 to the control group. The educational group attended the programme regularly for a period of 6 months. The programme included information about asthma, instruction on the appropriate use of medication and training in the metered dose inhaler (MDI) technique, and information about the identification and control of asthma attacks and the recognition of early signs of exacerbation. The control group was submitted to the routine care provided at the Asthma Clinic, with no formal instruction regarding asthma control. The groups were identical with regard to severity parameters, skills, lung function and quality of life at the beginning of the trial. At the end of the study, the education group showed significant differences when compared with the control group (education/control (mean values)) with respect to: visits to the asthma emergency room over the previous 6 months, 0.7/2 (p=0.03); nocturnal symptoms, 0.3/0.7 (p=0.04); score of symptoms, 1.3/2 (p=0.04). Improvements were also observed in skills and quality of life, knowledge of how to deal with attacks and how to control the environmental triggering factors, 73/35 (<0.05); correct use of the MDI, 8/4 (0.001); understanding of the difference between relief and anti-inflammatory medication, 86/20 (<0.05); and in the global limitation quality of life score, 28/50 (0.02). It is concluded that the educational programme led to a significant improvement in asthma morbidity and that the implantation of educational programmes is possible for special populations when these programmes are adapted to the socioeconomic profile of the patients, with a significant gain in terms of the reduction of symptoms and improved pulmonary function and quality of life of asthmatics.     

Expired nitric oxide and airway obstruction in asthma patients with an acute exacerbation

Expired nitric oxide (eNO) is a marker of airway inflammation that is increased in asthma. The present study was undertaken to examine the clinical utility of eNO as an aid in the assessment of asthma in the emergency department (ED). Fifty-two adult patients with acute asthma, 53 age- and sex-matched controls, and eight patients with stable asthma were enrolled. Subjects performed spirometry, their eosinophil counts and serum total IgE were measured, and a sample of mixed VC expirate was collected for measurement of NO. Mixed expired NO was 8.2 +/- 0.5 ppb in controls, 8.8 +/- 1.5 ppb in patients with stable asthma, and 15.0 +/- 1.0 ppb in patients with acute asthma. A significant difference in eNO was observed in patients with acute asthma and controls (p < 0.001). Twenty-three of the 52 patients with acute asthma versus two of 53 controls had an eNO >/= 15 ppb (p < 0.001). Expired NO concentration correlated with FEV1% (r = -0.42, p < 0.001) and with the peripheral blood eosinophil count (r = 0.34, p < 0.001) in the group of 60 patients with acute and stable asthma. The sensitivity of eNO > 10 ppb and eosinophilia (> 200 cells/microliter) was 90% in predicting airway obstruction (FEV1/FVC < 0. 8). No relationship of eNO was found to serum IgE, self- reported smoking, or glucocorticoid use. Measurement of eNO is a promising clinical tool for assessing acute asthma.     

An uncommon mimic of an acute asthma exacerbation

Foreign body aspiration in adults has a variety of clinical presentations and often goes unrecognized. We describe the case of a patient who experienced crack cocaine aspiration and presented with symptoms of an acute asthma exacerbation requiring mechanical ventilation until the eventual diagnosis and bronchoscopic removal of the foreign body.     

Evaluation of a program aimed at increasing referrals for asthma education of patients consulting at the emergency department for acute asthma

BACKGROUND: Emergency department (ED) visits for asthma may reflect poor asthma control, often due to insufficient asthma education and medical follow-up. However, few patients consulting an ED for asthma are referred for education.Aims: To describe a model for automatic referral to educational interventions targeting patients consulting at the ED for acute asthma, to demonstrate how this model can be integrated into current care, and to increase referrals for asthma education. METHODS: The program combines a short ED-based educational intervention with the goal of motivating patients and their families to pursue an educational program with an automatic referral to an asthma education center (AEC) after agreement with ED physicians. The program was implemented in nine acute care centers with a high number of ED visits for asthma. The main study parameter was the number of patients referred to an AEC after 4 months of program implementation, as compared with 4 months before. In addition, we assessed potential barriers to successfully establishing the program. RESULTS: In the first 4 months of the program, 1,104 patients were referred to an AEC, compared with 110 for the same period the year before; 106 patients (15%) patients could not be contacted, 114 patients (16.1%) refused the intervention, 488 patients (68.9%) made appointments, and 346 patients (48.9%, or 72.8% of scheduled patients) honored their appointments. CONCLUSION: We describe a model of educational intervention for asthmatic patients consulting at the ED. We found that ED professionals can motivate patients to attend an asthma education program and that an automatic referral process is well accepted by ED staff. Such intervention can help to reduce asthma-related morbidity, but local barriers to implementation of such program should be addressed.     

Elevated soluble ST2 protein levels in sera of patients with asthma with an acute exacerbation.

Previous studies have reported that ST2 is preferentially expressed on Th2 cells and plays a critical part in controlling airway inflammation in murine models of asthma. However, the clinical role of ST2 in patients with bronchial asthma remains unclear. In our study, we examined 56 patients with atopic asthma in a nonattack phase and 200 nonatopic normal volunteers for healthy control, and analyzed the relationship of their serum ST2 levels to asthma severity, pulmonary function, and laboratory data. Of the 56 patients with atopic asthma, 30 exhibited asthmatic exacerbation, and their serum ST2 levels were also analyzed. The serum ST2 levels were low, but a statistical difference was found between patients with nonattack asthma and the healthy control group (p < 0.05). We also found a differential rise of serum ST2 level that correlates well with the severity of asthma exacerbation. Furthermore, the serum ST2 levels during asthma exacerbation statistically correlated with the percentage of predicted peak expiratory flow (r = -0.634, p = 0.004) and Pa(CO(2)) (r = 0.516, p = 0.003). These results suggest that soluble human ST2 protein in sera may be related to Th2-mediated allergic inflammation inducing acute exacerbation in patients with atopic asthma.     

血小板平均体积在支气管哮喘急性发作期的变化

目的观察血小板平均体积(MPV)在支气管哮喘急性发作期患者血清中的变化,探讨血小板平均体积与支气管哮喘急性发作期的关系。方法支气管哮喘急性发作期患者40例,支气管哮喘慢性持续期患者40例,健康对照组40例,分别检测三组血清中血小板平均体积,采用单因素方差分析,比较三组之间血小板平均体积的变化。结果支气管哮喘急性发作期患者血小板平均体积为(10.69±0.96)fl,支气管哮喘慢性持续期为(10.59±0.75)fl,健康对照组为(10.46±0.66)fl,三组两两比较均P0.05,差别有统计学意义。结论支气管哮喘急性发作期患者血清中血小板平均体积较慢性持续期和健康对照组明显升高,可能与支气管哮喘急性发作期的发病及严重程度有关。     

Recent educational interventions for improvement of asthma medication adherence

Poor adherence to asthma medication treatment is a dilemma as it decreases the chance of achieving and maintaining a proper asthma control. Another dilemma is that there seems to be a small range of functional interventions that enhance adherence to long-term medication treatments. The aim was to review the last five years of published educational interventions for improving adherence to asthma medication. Through systematic database searches 20 articles were identified, which matched the inclusion criteria and described educational interventions to improve asthma self-management including adherence. The current review showed that addressing unintentional non-adherence in terms of incorrect inhaler technique by recurrent education improved the technique among many patients, but not among all. Phoning patients, as a means to remove medication beliefs as adherence barriers, seemed to be an effective educational strategy, shown as increased adherence. Involving patients in treatment decisions and individualising or tailoring educational support also seemed to have favourable effect on adherence. To conclude, addressing specific adherence barriers such as poor inhaler technique or medication beliefs could favour adherence. To change adherence behavior, the current review proposes that educational adherence support should be a collaborative effort between the patient and the health-care professional based on each individual patient's needs and patient factors, including elements such as personality traits.     

Characterisation of patients with frequent exacerbation of asthma

BACKGROUND: Exacerbation is one of the most significant problems in patients with asthma. Although subpopulation of patients is more susceptible to exacerbations than others, which clinical features characterise susceptibility to exacerbation are not well understood. METHODS: Consecutive non-smoking adult patients with asthma who had multiple exacerbations (ME) despite regular maintenance treatment were compared with those who had at most single exacerbation as control during the previous 1 year. Exacerbation of asthma is defined initiations or escalations of systemic corticosteroid as part of the management for aggravated asthma condition. RESULTS: Patients with ME (n=32, male: 6, mean age: 46.7 years) were characterised by intensive current maintenance treatment (dose of inhaled corticosteroid; 1037.5+/-452.8 vs 621.6+/-257.3 microg, P=0.0005, proportion of oral corticosteroid users; 28.1% vs 2.7%, P=0.008), severe episodes of exacerbation (asthma-related hospitalisations; 71.9% vs 23.4%, P=0.0002, arrival on ambulance; 37.5% vs 8.1%, P=0.008), concomitant chronic sinusitis (34.4% vs 10.8%, P=0.038) and intolerance to non-steroidal anti-inflammatory drugs (NSAIDs) (34.4% vs 5.4%, P=0.006) in comparison with controls (n=37, male:11, mean age:44.4). Pulmonary function in patients with ME was characterised by persistent airflow limitation and reduced reversibility. CONCLUSION: Patients with ME are at increased risk for severe exacerbation despite more intensive maintenance anti-inflammatory treatment. Persistent irreversible airflow limitation and complications of chronic sinusitis and/or NSAIDs intolerance are characteristics to this subpopulation.     

吸入呋塞米对急性发作期支气管哮喘患者肺通气功能的影响

目的 探讨吸入呋塞米对急性发作期支气管哮喘（哮喘）患者肺通气功能的影响。方法 将６例经、中度发作期哮喘患者随机分为Ａ、Ｂ、Ｃ三组,每组各２０例。Ａ组吸入生理盐水５ｍｌ,Ｂ组吸入呋塞米５０ｍｇ（５ｍｌ,１０ｍｇ／ｍｌ）,Ｃ组吸入０．１％沙丁胺醇溶液５ｍｌ。观察三组患者吸药后１５ｍｉｎ肺通气功能的变化。结果 吸药后１５ｍｉｎＢ、Ｃ组用力肺活量（ＦＶＣ）、第１ｓ用力呼气容积（ＦＥＶ１）、最在呼气流量（Ｐ     

支气管哮喘急性发作期患者血清干细胞因子水平测定及意义

目的探讨哮喘急性发作期患者血清干细胞因子（SCF）水平变化及意义。方法将40例支气管哮喘急性发作患者按病情严重程度分为轻、中、重、危重组,采用ELISA法检测各组治疗前后血清SCF水平,同时与10例正常人血清SCF水平作对照。结果中度、重度及危重组治疗前血清SCF水平明显高于对照组（P均〈0．001）,治疗后均有明显下降;重度及危重组治疗后血清SCF明显高于中度及轻度组（P均〈0．01）。结论血清SCF的水平可能与哮喘急性发作的严重程度有关;其在哮喘发病及病情判断中可能起重要作用。     

Measuring health-related quality of life in adults during an acute asthma exacerbation

BACKGROUND: Acute severe asthma can be distressing for patients. It is important to be able to identify the causes of the distress so that these can receive attention in conjunction with the conventional treatment of the airways. STUDY OBJECTIVE: To modify the Asthma Quality of Life Questionnaire (AQLQ) for evaluating patients with acute severe asthma and to test the measurement properties of the Acute Asthma Quality of Life Questionnaire (Acute AQLQ). METHODS: The Acute AQLQ contains the symptom and emotional function items of the AQLQ (n = 11), which are capable of changing over short periods of time. The measurement properties were tested during a clinical trial to compare formoterol and salbutamol in the treatment of acute severe asthma in hospital emergency departments. RESULTS: The 88 patients in the clinical trial provided evidence that the Acute AQLQ has high internal consistency (Cronbach alpha = 0.90) and is very responsive to change in status (p < 0.00001) with a responsiveness index of 2.5. Correlations between the Acute AQLQ and other measures of clinical status provided evidence of the validity of the instrument. CONCLUSION: The Acute AQLQ has strong measurement properties and can be used with confidence to identify the problems that are distressing to patients during an acute asthma exacerbation and to evaluate the effectiveness of interventions.     

急性发作期老年晚发哮喘患者气道炎症特征分析

目的检测急性发作期老年晚发哮喘(LOA)诱导痰细胞学、嗜酸细胞阳离子蛋白(ECP)和白介素-5(IL-5)、白介素-8(IL-8)水平,观察LOA气道炎症特征。方法检测86例急性发作期LOA患者诱导痰中细胞学分类计数、ECP和IL-5、IL-8水平;选择30例健康老年人作为对照。结果以诱导痰中EOS数量≥3%作为临界值,86例急性发作期LOA患者中,79例(81%)诱导痰中嗜酸细胞(EOS)数量增高,为痰EOS增高组;17例(19%)痰中性细胞数量增高,为痰非EOS增高组。痰非EOS增高组诱导痰中性细胞和IL-8水平显著高于痰EOS增高组和健康老年组(P0.01);而痰中EOS数量、ECP和IL-5水平显著低于痰EOS增高组(P0.01),但与健康老年组比较差异无统计学意义(P0.05)。结论急性发作期LOA患者存在气道嗜酸细胞和中性细胞两种炎症类型,测定患者气道炎症类型有助于指导治疗。     

替罗非班在不同入径经皮冠状动脉介入术治疗急性冠状动脉综合征中的出血风险评价

目的探讨替罗非班在不同入径经皮冠状动脉介入术(PCI)治疗急性冠状动脉综合征(ACS)中的出血风险。方法回顾性分析我院ACS患者403例,按照是否应用替罗非班分为替罗非班组和非替罗非班组,评估两组中不同入径PCI的出血事件发生率。结果桡动脉入径中,替罗非班组与非替罗非班组不明显出血事件发生率的比较差异无统计学意义(6.87%比5.10%,χ~2=0.075,P=0.784)。股动脉入径中,替罗非班组不明显出血事件发生率明显高于非替罗非班组(23.15%比9.09%,χ~2=4.610,P=0.031)。桡动脉入径中,替罗非班组与非替罗非班组穿刺部位出血发生率的比较差异无统计学意义(1.53%比1.02%,χ~2=0.064,P=0.799)。股动脉入径中,替罗非班组穿刺部位出血发生率明显高于非替罗非班组(15.74%比4.55%,χ~2=4.006,P=0.045)。股动脉入径中替罗非班组不明显出血事件及穿刺部位出血发生率均明显高于桡动脉入径中替罗非班组(χ~2=11.555,P=0.0006;χ~2=14.459,P=0.0001)。结论替罗非班在经桡动脉入径PCI治疗ACS中出血事件发生率较低,且明显低于经股动脉入径,可遵循指南进行个体化合理应用。     

Development of a web-based,work-related asthma educational tool for patients with asthma

BACKGROUND:

Asthma is a common chronic condition. Work-related asthma (WRA) has a large socioeconomic impact and is increasing in prevalence but remains under-recognized. Although international guidelines recommend patient education, no widely available educational tool exists.

OBJECTIVE:

To develop a WRA educational website for adults with asthma.

METHODS:

An evidence-based database for website content was developed, which applied evidence-based website design principles to create a website prototype. This was subsequently tested and serially revised according to patient feedback in three moderated phases (one focus group and two interview phases), followed by face validation by asthma educators.

RESULTS:

Patients (n=10) were 20 to 28 years of age; seven (70%) were female, three (30%) were in university, two (20%) were in college and five (50%) were currently employed. Key format preferences included: well-spaced, bulleted text; movies (as opposed to animations); photos (as opposed to cartoons); an explicit listing of website aims on the home page; and an exploding tab structure. Participants disliked integrated games and knowledge quizzes. Desired informational content included a list of triggers, prevention/control methods, currently available tools and resources, a self-test for WRA, real-life scenario presentations, compensation information, information for colleagues on how to react during an asthma attack and a WRA discussion forum.

CONCLUSIONS:

The website met the perceived needs of young asthmatic patients. This resource could be disseminated widely and should be tested for its effects on patient behaviour, including job choice, workplace irritant/allergen avoidance and/or protective equipment, asthma medication use and physician prompting for management of WRA symptoms.     

Efficacy of nebulized fluticasone propionate compared with oral prednisolone in children with an acute exacerbation of asthma

The aim of the present study was to investigate the efficacy and safety of nebulized fluticasone propionate (FP Nebules) compared with oral soluble prednisolone in children with an acute exacerbation of asthma. The study used an international, multi-centre, randomized, double-blind, parallel group design. Three hundred and twenty-one patients, aged 4-16 years old, who presented with an acute exacerbation of asthma, were randomly allocated to either nebulized FP (1 mg b.d.) or oral prednisolone (2 mg kg(-1) day(-1) for 4 days then 1 mg kg(-1) day(-1) for 3 days) for 7 days. Patients in the FP group showed a significantly greater increase in diary card morning peak expiratory flow (PEF) over 7 days compared with patients in the prednisolone group (difference = 9.51 min(-1), CI = 2.1, 16.8, P = 0.034). Similar increases for both treatments were shown for evening PEF. Clinic PEF improved with both treatments, but was significantly greater in patients taking FP after 7 days (difference = 11.41 min(-1), CI = 2.8, 20.0, P = 0.029). Both treatments reduced symptom scores to a similar extent. The two treatments were well tolerated, and there was no difference in the incidence of adverse events. The present study demonstrated that nebulized FP is at least as effective as oral prednisolone in the treatment of children presenting with an acute exacerbation of asthma.