Early discharge of patients hospitalized with acute asthma: a controlled study

There is no consensus on the optimal length of stay and timing of release from hospital in patients admitted with acute asthma. We hypothesize that it might be safe to discharge patients from hospital once they have responded clinically to intensive anti-asthma treatment. In a non-randomized prospective controlled study, we compared two discharge protocols in consecutive patients admitted for acute severe exacerbations of bronchial asthma. Patients in group A were discharged after remission of signs and symptoms and those in group B after improvement but before complete remission of signs and symptoms. Peak expiratory flow rates (PEFR) were monitored but were not used as discharge criteria for either group. Patients with complicating disease and who were likely to be non-compliant were excluded. The length of hospital stay (LOS) and best PEFR at discharge were significantly lower in group B (87 admissions) than group A (80 admissions). The mean (+/-SD) LOS was 1.8(+/- 1) days vs. 3.5(+/- 1.4) days and best PEFR was 58(+/- 17)% predicted versus 71(+/- 15)% predicted respectively (P < 0.001 for both variables). No patient in either group relapsed within 4 weeks of discharge from hospital. We concluded that the release of asthmatics who respond promptly to intensive treatment and are compliant with medication despite incomplete resolution of symptoms, signs and PEFR at the time of discharge from hospital may not be associated with increased risk of early relapse.     

Relationship between changes in diurnal variation of expiratory flows, lung volumes and respiratory symptoms after acute asthma

We looked at the comparative recovery of asthma symptoms and changes in airflow obstruction after an acute exacerbation of asthma in 26 asthmatics, aged 18-69 years (mean = 43). In the 4 weeks following the acute episode, they recorded their respiratory symptoms and twice-daily peak expiratory flow rates (PEFR). In 14 subjects, lung volumes were also measured on days 1, 7 and 30. Mean initial FVC and FEV1 [+/- SEM (% predicted)] were 2.30 +/- 0.16 (61%) and 1.18 +/- 0.08 (39%). The rate of improvement of airflow obstruction initially paralleled that of asthma symptoms in subjects with mild or with a recent onset of asthma. On the first study day, diurnal variation of PEFR was minimal, increased rapidly during the first week of treatment and stabilized thereafter. Mean daily delta PEFR was significantly higher in the first than at the fourth week (P = 0.005). Recovery of asthma symptoms was associated with an overall reduction in FRC and RV but there was no significant correlation between FRC or RV and dyspnea score or PEFR. Perception of airflow obstruction was generally lower, improvement of symptoms slower and of smaller amplitude in those with long-standing asthma. In conclusion, during recovery from acute asthma: (1) diurnal variation of PEFR is initially minimal, increases rapidly after beginning steroids and stabilize in the two following weeks; (2) in patients with more than mild or long-standing asthma, and magnitude and range of perception of asthma symptoms is reduced and correlates less with PEFR; and (3) no significant correlation could be found between FRC or RV and dyspnea score or PEFR.     

Menstrual-Linked Asthma

This study was conducted to determine the occurrence of menstrual-linked asthma (MLA) in India in 100 consecutive female asthmatics in the reproductive age group. The patients were required to respond to a questionnaire concerning the relationship between their asthma and the menstrual cycle. Twenty-three patients had subjective perception of deterioration in symptoms of asthma in relation to the menstrual cycle. Ten patients from both groups were also required to maintain a daily peak expiratory flow rate (PEFR) diary for 2 consecutive menstrual cycles. The mean total duration of illness in patients with MLA was significantly longer than in patients without cyclic exacerbation. Cough and breathlessness were also significantly more severe as was the disease. This was evidenced by the more frequent emergency room visits and hospitalizations in these patients. Menstrual-linked worsening of asthma was most common in the premenstrual week (17 patients). In 8 of these 17 patients, this phenomenon continued to occur during the menstrual week also. Interestingly, 1 patient complained of deterioration of asthma 2 days after menstruation was over. Such an observation is yet to be recorded. Fourteen patients reported an increase in symptoms with almost every cycle while 3 had worsening related to specific season only. Sixteen patients often required extra medication during the premenstrual and/or menstrual weeks. A significant association was also observed between severity of premenstrual syndrome and MLA. The mean PEFR values over 2 cycles revealed a significant fall in the morning as well as evening values in the premenstrual and menstrual weeks as compared to the midcycle week in patients with MLA. This fall was maximal in the premenstrual week. Such a fall was not observed in asthmatics without menstrual exacerbation of symptoms. MLA was detected in about a fourth of the female asthmatics in India and it appears to represent a more severe form of the disease. This study also documented that MLA was associated with an increase in airway resistance and was not simply due to an increased perception of symptoms during the premenstrual or menstrual weeks.     

Differences between men and women in reporting of symptoms during an asthma exacerbation

STUDY OBJECTIVE: Compared with men, women presenting to the emergency department with acute asthma are more likely to be admitted and to have a longer hospital stay. This study compares peak expiratory flow rate (PEFR) with reported symptom severity between men and women with acute asthma. The null hypothesis was that men and women report similar severity symptoms for similar levels of airway obstruction. METHODS: This study combined data from 4 prospective cohort studies performed from 1996 to 1998 as part of the Multicenter Airway Research Collaboration. Using a standardized protocol, investigators at 64 EDs in 21 US states and 4 Canadian provinces provided 24-hour per day coverage for a median of 2 weeks. RESULTS: Of the 1,291 patients with moderate to severe exacerbations (initial percentage of predicted PEFR <80%), 62% were women. Women were more likely than men to report "severe" complaints in terms of symptom frequency, symptom intensity, and resulting activity limitations (all P <.05). Women with moderate exacerbations were especially likely to describe their exacerbation as causing "severe" activity limitations (sex-PEFR interaction, P =.05). CONCLUSION: Men are less likely than women to report severe asthma symptoms and activity limitations in the presence of airway obstruction. This finding supports use of objective measures of airway obstruction when managing patients with asthma so that those whose symptoms do not reflect the severity of their obstruction can be recognized and properly treated. It also reconfirms the need for increased research on differences between men and women in acute asthma.     

Takotsubo cardiomyopathy: A known unknown foe of asthma

Introduction: Patients with uncontrolled asthma are at a greater risk of asthma attacks requiring emergency room visits or hospital admissions. Takotsubo cardiomyopathy is potentially a significant complication in a course of status asthmaticus. Case study: We describe a 43-year-old female patient who presented with status asthmaticus that was further complicated with takotsubo cardiomyopathy. Results: Recognizing apical ballooning syndrome is challenging in patients with a history of respiratory disease because the symptoms of the last entity may complicate the diagnostic approach. It is difficult to distinguish clinically apical ballooning syndrome from the acute airway exacerbation itself. Both asthma and takotsubo cardiomyopathy share the same clinical presentation with dyspnea and chest tightness. In our patient, the electrocardiographic abnormalities, the rapidly reversible distinctive characteristics of echocardiography, and the modest elevation of serum cardiac biomarkers levels, in combination with the presence of a stress trigger (severe asthma attack), strongly supported the diagnosis of broken heart syndrome. Conclusions: Clinicians should re-evaluate asthma management and be aware of the complications associated with asthma attacks such as stress-induced cardiomyopathy.     

Mechanical ventilation in children with severe asthma

Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades.     

Prehospital management of exacerbations of asthma: relation to patient and disease characteristics

OBJECTIVE: Admission to hospital due to an exacerbation of asthma may represent a failure of prehospital management to prevent an attack or bring about its remission. We aim to describe the steps taken prior to hospital attendance in patients with asthma and to identify patient or disease characteristics that were associated with failure to take appropriate actions. METHODOLOGY: Patients aged over 15 years who were discharged from hospital or the Emergency Department with a primary diagnosis of asthma completed a questionnaire about the impact of asthma and its management prior to the onset of the recent exacerbation. The impact of asthma on quality of life was measured using our Asthma Quality of Life Questionnaire (AQLQ). RESULTS: Seventy-eight subjects completed the questionnaire including 49 who had been inpatients and 29 who had been discharged from the Emergency Department. They included many subjects with severe asthma: 41% had nocturnal symptoms three or more times per week and 41% had been admitted to hospital with asthma in the 12 months prior to this episode. Their AQLQ scores were high (severe) (mean 4.5+/-2.2). Most subjects described their presenting exacerbation as slow in onset and moderate or severe in intensity. During this exacerbation and prior to hospital attendance, only 27% of subjects had measured their peak expiratory flow rate, 19% had commenced or increased the dose of inhaled steroids, and 22% had commenced oral steroids. These actions were not related to the self-perceived speed of onset of the attack. Patients with lower levels of asthma-related concerns for health and more severe mood disturbance associated with asthma were less likely to take these appropriate self-management steps. CONCLUSIONS: This study shows that the failure of prehospital management to prevent the necessity of hospital attendance in most cases stems from a failure to implement currently recommended actions or treatments for exacerbations. Addressing this problem should result in a reduction in rates of hospitalization for asthma.     

Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease

Although exacerbations of chronic obstructive pulmonary disease (COPD) are associated with symptomatic and physiological deterioration, little is known of the time course and duration of these changes. We have studied symptoms and lung function changes associated with COPD exacerbations to determine factors affecting recovery from exacerbation. A cohort of 101 patients with moderate to severe COPD (mean FEV(1) 41.9% predicted) were studied over a period of 2.5 yr and regularly followed when stable and during 504 exacerbations. Patients recorded daily morning peak expiratory flow rate (PEFR) and changes in respiratory symptoms on diary cards. A subgroup of 34 patients also recorded daily spirometry. Exacerbations were defined by major symptoms (increased dyspnea, increased sputum purulence, increased sputum volume) and minor symptoms. Before onset of exacerbation there was deterioration in the symptoms of dyspnea, sore throat, cough, and symptoms of a common cold (all p < 0.05), but not lung function. Larger falls in PEFR were associated with symptoms of increased dyspnea (p = 0.014), colds (p = 0.047), or increased wheeze (p = 0.009) at exacerbation. Median recovery times were 6 (interquartile range [IQR] 1 to 14) d for PEFR and 7 (IQR 4 to 14) d for daily total symptom score. Recovery of PEFR to baseline values was complete in only 75.2% of exacerbations at 35 d, whereas in 7.1% of exacerbations at 91 d PEFR recovery had not occurred. In the 404 exacerbations where recovery of PEFR to baseline values was complete at 91 d, increased dyspnea and colds at onset of exacerbation were associated with prolonged recovery times (p < 0.001 in both cases). Symptom changes during exacerbation do not closely reflect those of lung function, but their increase may predict exacerbation, with dyspnea or colds characterizing the more severe. Recovery is incomplete in a significant proportion of COPD exacerbations.     

Effect of exposure to domestic cooking fuels on bronchial asthma

The effect of indoor air pollution due to domestic cooking with biomass fuel and liquefied petroleum gas (LPG) on the course of bronchial asthma was examined in one hundred non-smoking female asthmatics. The parameters for evaluation were symptoms, emergency visits, and drug requirements. The patients also measured peak expiratory flow rate (PEFR) at home five times daily over a period of one week and the levels of carboxyhaemoglobin (COHb) were estimated randomly during clinic visits. The COHb levels (%) were 4.1 +/- 0.9 and 3.5 +/- 0.6 in the two groups with 22-30% of the subjects reporting increased symptoms during cooking. The number of emergency admissions and the daily requirement of steroids were comparable in both the groups. The PEFR values were lower than the predicted values in both the groups at all times. Further, the readings after exposure to cooking fuels were lower than those before cooking in both the groups (p < 0.01) and these values were similar to those observed during early morning records at 6 AM, which were the lowest. It was concluded that exposure to biomass fuel and LPG affect pulmonary function (PEFR) in asthmatics and both types of fuels affect the airway function and symptoms of bronchial asthma in a similar manner.     

Role of intravenous immunoglobulin in severe steroid-dependent asthma

Abstract
Background :  Subgroups of asthma patients have extremely severe respiratory symptoms that require chronic use of steroids for disease control. These patients are at risk of significant side-effects from chronic exposure to high doses of oral steroids. Intra­venous immunoglobulin (IVIG) has immunomodulatory properties as shown by its use in some immune disorders. A few trials have suggested a possible benefit in individuals with severe asthma.
Aims :  To evaluate the role of IVIG as an adjunctive therapy in steroid-dependent asthma, monitoring the outcomes of lung function and measured reduction in oral steroid requirement
Method :  Seven patients with severe steroid-dependent asthma were given IVIG at a dose of 1 g/kg each month for 6 months. Baseline pulmonary function tests and immunoglobulin levels were obtained. At the end of 6 months, the end-points observed were lung function and the degree of reduction in the dose of oral steroids. The number of hospital admissions during the 12 months following commencement of IVIG was compared with the preceding 12 months.
Results :  There was a significant reduction in daily prednisolone dose from 56 ± 31 mg to 39 ± 35 mg ( P  = 0.04, Wilcoxon rank sum test) and a decrease in the number of hospital admissions from 5.9 ± 2.9 to 3.6 ± 3.5 ( P  = 0.04). No significant improvement occurred in lung function.
Conclusion :  IVIG provides a potentially important adjunctive therapy in severe steroid-dependent asthma, reducing steroid requirement and decreasing hospital admissions, but not improving lung function. (Intern Med J 2003; 33: 341−344)     

Thirty cases of bronchial asthma associated with exposure to pet hamsters.

BACKGROUND: The identification, isolation, and elimination of allergen(s) causing bronchial asthma are the most efficient form of treatment. The pet industry has diversified recently, increasing the risk of exposure of pet owners to many unknown antigens. We clinically studied the characteristics of asthma associated with exposure to pet hamsters. METHODS: The study group comprised 30 adults in whom the onset, recurrence, or exacerbation of asthma was triggered by contact with pet hamsters. Clinical characteristics such as sex, age, period required for symptom onset, species of hamster, treatment and disease course, smoking status, and hamster-specific IgE antibodies in serum were studied. RESULTS: The male: female ratio of the study group was 1:1.3, and mean age was 37.7 years. Patients with no previous history of asthma initially presented with cough, progressing to episodes of asthma. Asthmatic symptoms were associated with hamster contact and ranged in severity from mild to severe. Three patients required hospital admission for treatment. The mean period from the start of hamster exposure to the onset of asthmatic episodes was 15.7 months. Dwarf hamsters were responsible for most cases. The CAP-RAST score for hamster-specific IgE antibodies was 1 to 4 in 22 patients and 0 in 8 patients. Eight patients with a score of 1 or higher for hamster-specific IgE antibodies had a CAP-RAST score of 0 for mite antigen. In these patients, terminating hamster contact resulted in a rapid improvement in symptoms, with no need for further treatment. Twenty-three of the 30 subjects (76.7%) were smokers. CONCLUSION: Exposure to pet hamsters is an important risk factor for the onset, recurrence, or exacerbation of asthma. Smoking may also increase the risk of asthmatic symptoms in patients exposed to hamsters.     

Comparison of high-dose inhaled flunisolide to systemic corticosteroids in severe adult asthma

OBJECTIVE: To investigate whether, after 48 h of IV treatment with corticosteroids, the use of high-dose inhaled flunisolide is as effective as systemic corticosteroids in adults hospitalized for a severe asthma exacerbation. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Inpatient, an urban teaching hospital medical ward; outpatient, asthma clinic affiliated with the hospital. PARTICIPANTS: Forty patients aged 18 to 55 years with asthma exacerbation requiring hospitalization. INTERVENTIONS: Inhaled flunisolide via metered-dose inhaler (250 micro g per activation) eight puffs bid compared to systemic corticosteroids alone, following eight doses of IV corticosteroids. Measurements and results: Peak expiratory flow rate (PEFR), FEV(1), and symptom scores were recorded on day 1 (at presentation to the emergency department) and day 7, at an outpatient follow-up visit. From day 1 to day 7, mean PEFR increased from 190 to 379 L/min in the flunisolide group, and from 207 to 347 L/min in the systemic corticosteroids group (p = 0.95; 95% confidence interval [CI], - 66.3, infinity ). Mean FEV(1) increased from 1.6 to 2.3 L in the flunisolide group, and from 1.4 to 2.1 L in the systemic corticosteroids group (p = 0.33; 95% CI, - 21.7, infinity ). Changes in symptom scores were - 0.7 in the flunisolide group and - 0.9 in the systemic corticosteroids group (p = 0.39; 95% CI, - 0.4, infinity ). Hospital readmission rates on day 7 were zero for both groups. CONCLUSIONS: High-dose inhaled corticosteroids are as effective as systemic corticosteroids during a 7-day period following admission to the hospital for severe asthma.     

Regular vs ad-lib albuterol for patients hospitalized with acute asthma

STUDY OBJECTIVES: Inhaled, short-acting beta-agonists and systemic corticosteroids form the mainstay of therapy in acute asthma exacerbation. Asthma, however, is an inflammatory disease of the airways, and its underlying pathology is not impacted by short-acting beta-agonists. While the efficacy of ad-lib beta-agonist administration in outpatient management of asthma symptoms is well established, little data exist to support this strategy in patients with acute, severe asthma. We postulate that as long as patients hospitalized with severe asthma exacerbation receive systemic corticosteroids, regular, scheduled administration of short-acting beta-agonists is unnecessary. Similar therapeutic outcomes can be achieved with the ad-lib administration of the short-acting beta-agonists. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Pulmonary floor of a 600-bed municipal hospital.Patients or participants: Sixty-two patients hospitalized for acute asthma. INTERVENTIONS: Patients were randomized to receive either albuterol nebulizations (regular albuterol group) or saline solution nebulizations (ad-lib group) every 4 h with management of breakthrough symptoms with albuterol metered-dose inhaler or nebulizations for both groups. All patients received systemic corticosteroids. Peak expiratory flows, asthma symptoms, and need for rescue bronchodilator were followed up on each patient until discharge. RESULTS: There was no significant difference in the length of hospitalization (median length, 48 h for ad-lib group vs 57.5 h for regular albuterol group, p = 0.82), rate of improvement in peak flow, or symptoms between the two groups. Ad-lib beta-agonist use compared to regular albuterol scheduled use resulted in a significant reduction in the total number of albuterol treatments administered (median, 7 treatments vs 19 treatments, p = 0.001) during hospitalization. CONCLUSIONS: In the management of asthma exacerbation, ad-lib administration of albuterol is therapeutically as effective as regular, scheduled administration. This method of drug administration also reduces the total dose of beta-agonists received by the hospitalized patient.     

Time Required to Achieve Asthma Control in Not Previously Inhaled Corticosteroid Treated Adult Patients

Background. To achieve the best health possible, asthma patients require targeted education to understand the disease and how it may affect them, and what they need to do to keep it controlled. Aim. To measure the length of time needed in a structured educational training program to achieve well-controlled asthma status. Methods. This 5-month clinical trial enrolled previously untreated adult asthma patients at the Asthma Center of the President Dutra Public Hospital/Federal University of Maranhão–Brazil. At the first visit, patients were stratified according to their pre-bronchodilator peak expiratory flow rate (PEFR) measurements: Class I was defined as PEFR > 80% of the predicted value; Class II as PEFR 50–80% of predicted value, and Class III as PEFR < 50% of predicted value. At enrollment and each follow-up visit patients were assessed for asthma symptoms and health care utilization. In the educational program, sessions covered signs and symptoms of asthma exacerbation, triggering factors, environmental control, and asthma drug effects. The time required to achieve well-controlled status and the total time free of asthma symptoms were evaluated by Kaplan-Meier curves. The log-rank test was used to compare PEFR classes, with significance being measured as p-values ≤ 0.05. Results. A total of 121 patients met the eligibility criteria and underwent the 6-month follow-up. The first six-month Kaplan-Meier curve demonstrated that Class I patients had a significantly better probability of achieving well-controlled asthma than the other classes (log rang = 6.78, p = 0.03), The second 6-month Kaplan-Meier curve analyzed the total time free of asthma symptoms according to PEFR class (log rank = 11, 22 p = 0.003). The time required to reach a well-controlled status was 2 or 3 months, depending on the baseline level of airway obstruction: patients in PEFR classes I and II achieved good control earlier than patients in PEFR Class III. Education and targeted training remain a key element of doctor-patient interactions and success of asthma control efforts.     

Leukotriene Receptor Antagonists: A Good Choice in the Treatment of Premenstrual Asthma?

The aim of this study was to investigate the effects of leukotriene receptor antagonists (LTRAs) on the premenstrual exacerbation of asthma (PMA). Twenty-four female patients with mild asthma were enrolled in the study. Patients were followed for three menstrual cycles and separated into two groups based on whether they exibit premenstrual worsening of asthma symptoms (n = 11) or not (n = 13). During the first month all were treated with only inhaled steroids (IS) (run-in period); during the second month they received IS plus placebo; and during the third month they were given IS plus montelukast. Furthermore, they were advised to use beta ₂ -agonists as needed. Peak expiratory flow rate (PEFR) and symptom scores were recorded during the 3 months. Pulmonary function tests (PFT) and the levels of oestrogen, progesterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were measured a week before the begining of the menstrual period. At the end of the 3-month period, it was observed that following therapy with montelukast, the patients with PMA showed significant improvement in PEFR variability and symptom scores when compared with the placebo group. Baseline FSH levels were higher, but FSH and other hormone levels and PFTs did not change in these groups. However, in the group without PMA there was no difference between the montelukast or placebo groups in PEFR variability, symptom scores, PFTs, and hormone levels. Based on the data in hand, it could be stated that LTRAs have ensured the control of symptoms and improved PEFR variability in patients with PMA by supressing inflammation. We are of the view that LTRAs would be a right choice in the treatment of patients with PMA.     

The bronchodilator effect of intravenous glucagon in asthma exacerbation: a randomized, controlled trial

STUDY OBJECTIVE: Glucagon is a rapid-acting smooth muscle relaxant with a short half-life. Previous studies suggested glucagon may have bronchodilator effects. We sought to determine whether intravenous glucagon produces clinically important immediate bronchodilation in emergency department patients with asthma exacerbation. METHODS: We conducted a randomized, double-blind, placebo-controlled study at 2 university-affiliated community teaching hospital EDs (annual census 90,000). ED patients 18 to 50 years old with asthma exacerbation and peak expiratory flow rate (PEFR) less than 350 L/min were eligible. Exclusion criteria were need for intubation, chronic obstructive pulmonary disease, diabetes mellitus, insulinoma, pheochromocytoma, pregnancy, lactation, or current oral steroid treatment. Patients were randomly assigned to receive glucagon 0.03 mg/kg or an equivalent volume of saline solution intravenously. At 10 minutes, PEFR was measured and all patients began standardized albuterol therapy. Successful bronchodilation was a PEFR increase of 60 L/min at 10 minutes. RESULTS: Success occurred in 2 (9.5%) of 21 glucagon-treated patients and 3 (12%) of 25 placebo-treated patients (95% confidence interval [CI] for difference of -2.5% [-20.4% to 15. 4%]). Mean PEFR improvement for glucagon was 2 L/min versus 9 L/min for placebo (95% CI for difference of -7 L/min [-36 L/min to 23 L/min]). CONCLUSION: Glucagon alone provided no clinically important immediate bronchodilation in ED patients with asthma exacerbation.     

Clinical evaluation of leukotriene receptor antagonists in preventing common cold-like symptoms in bronchial asthma patients.

BACKGROUND: We investigated the possibility of preventing common cold-like symptoms as a previously unknown benefit of leukotriene receptor antagonists (LTRAs). METHODS: A total of 279 adult patients with bronchial asthma referred to our hospital between June and December 2004 were retrospectively analyzed. Patients were divided into LTRA treated and untreated groups. Frequency of acute exacerbations and number of visits to emergency rooms and of hospital admissions were analyzed as indicators of frequency of infections and asthma exacerbation over the previous 12 months. RESULTS: Irrespective of inhaled corticosteroid (ICS) use, frequency of infections was significantly lower in the LTRA treated group (0.3 +/- 0.7 times/year) than in the LTRA untreated group (1.6 +/- 4.2 times/year) (P < 0.05), suggesting that LTRA therapy prevents common cold-like symptoms. Frequency of acute exacerbations and number of hospital admissions were significantly lower in the LTRA treated versus LTRA untreated group (0.4 +/- 0.8 versus 2.7 +/- 4.3 times/year and 0.0 +/- 0.2 versus 0.4 +/- 0.7 times/year, respectively; both P < 0.01). When the patients were divided into ICS treated and untreated groups, none of the parameters analyzed differed significantly between the two groups, although all parameters tended to be lower in the ICS treated group. CONCLUSIONS: Adult asthma patients undergoing treatment with LTRAs exhibit lower incidence rates of common cold-like symptoms than those not receiving LTRAs. LTRAs play an important role in reducing the incidence of common cold-like symptoms among asthma patients and in suppressing exacerbation of asthma symptoms possibly associated with these symptoms.     

Relationship between asthma and gastro-oesophageal reflux: Significance of endoscopic grade of reflux oesophagitis in adult asthmatics

BACKGROUND: The association between asthma and gastro-oesophageal reflux disease (GERD) is well known. The aim of this study was to elucidate the causal relationship between reflux oesophagitis (RE) and asthma. METHODS: Seventy-two adult asthmatics were examined regarding their GERD symptoms, and each underwent an endoscopic examination. According to the Los Angeles classification, we divided the patients into three groups: group 1 (n= 52), no mucosal break; group 2 (n= 15), RE corresponding to grades A or B; group 3 (n = 5), RE corresponding to grades C or D. The asthmatics in groups 2 and 3 received anti-reflux treatment for their GERD for 8 weeks. Their morning and evening peak expiratory flow rates (PEFR), daily variability of the PEFR and daily use of an inhalation bronchodilator were compared before and after this treatment. RESULTS: The percentage of severe asthma and postprandial exacerbation of asthma in group 3 were significantly higher than those in the other two groups. In contrast, the number of eosinophiles and the serum level of immunoglobulin E in group 3 were significantly lower than those in the other two groups. After the antireflux treatment, significant improvements of both PEFR and daily use of the inhalation bronchodilator were observed only in group 3. CONCLUSIONS: The endoscopic severity of RE is associated with the characteristics of adult asthmatics and the treatment of severe RE improved the asthmatics' condition.     

Spontaneous Pneumomediastinum: A Rare Complication of Bronchial Asthma

Pneumomediastinum is a rare complication of an acute exacerbation of asthma. We describe a 28-year-old female who was admitted to hospital with acute severe exacerbation of asthma and developed a spontaneous pneumomediastinum (SPM) with associated subcutaneous emphysema. She was successfully managed conservatively. On follow up there was resolution of the subcutaneous emphysema and the pneumomediastinum, clinically and radiologically. SPM although usually a self-limiting condition, can occasionally be life threatening. Therefore, it is important to raise the awareness of this potential complication of asthma.     

A Case of Histamine Fish Poisoning in a Young Atopic Woman

Histamine fish poisoning, also known as scombroid poisoning, is a histamine toxicity syndrome that results from eating specific types of spoiled fish. Although typically a benign syndrome, characterized by self-limited flushing, headache, and gastrointestinal symptoms, we describe a case unique in its severity and as a precipitant of an asthma exacerbation. A 25-year-old woman presented to the emergency department (ED) with one hour of tongue and face swelling, an erythematous pruritic rash, and dyspnea with wheezing after consuming a tuna sandwich. She developed abdominal pain, diarrhea and hypotension in the ED requiring admission to the hospital. A diagnosis of histamine fish poisoning was made and the patient was treated supportively and discharged within 24 hours, but was readmitted within 3 hours due to an asthma exacerbation. Her course was complicated by recurrent admissions for asthma exacerbations.