Status asthmaticus

Intrinsic asthma, also called idiopathic asthma, usually develops in adulthood. In intrinsic asthma allergic factors are not demonstrable. Episodes of intrinsic asthma may be triggered by a variety of stimuli, eg, emotional state, exposure to cold air, or inert dusts. Both intrinsic and extrinsic asthmatics can be prone to exercise-induced attacks. Individuals who experience a combination of extrinsic and intrinsic asthmatic reactions have mixed asthma. Status asthmaticus refers to an especially acute life-threatening asthma attack which is resistant to normal treatments and which may require hospitalization in order to stabilize the patient. 

Aerosolized steroids clearly play an important role in the present-day management of asthma (87). They are reasonably safe and work best when taken prophylacticaHy. Patient compliance, however, remains a significant problem. In part this problem is typical of any aerosolized agent. But in the case of steroids, the problem is exacerbated because a patient needs to take the steroids (especially prednisone) are the antiasthmatic agents of last resort and are widely used to treat status asthmaticus. An agent that could mimic the actions of steroids but which would work faster and/or without side effects might be the ideal antiasthmatic agent. 

Asthma is a chronic inflammatory disease. Therefore steroids represent the most important and most frequently used medication. Already after the fust treatment, steroids reduce cellular infiltration, inflammation, and the LAR, whereas changes in the EAR require prolonged treatment to lower the existent IgE levels. The mechanisms of steroid actions are complex and only incompletely understood. Besides their general antiinflammatory properties (see chapter glucocorticoids), the reduction of IL-4 and IL-5 production from T-lymphocytes is particularly important for asthma therapy. The introduction of inhaled steroids, which have dramatically limited side effects of steroids, is considered one of the most important advancements in asthma therapy. Inhaled steroids (beclomethasone, budesonide, fluticasone, triamcinolone, momethasone) are used in mild, moderate, and partially also in severe asthma oral steroids are used only in severe asthma and the treatment of status asthmaticus. Minor side effects of most inhaled steroids are hoarseness and candidasis, which are avoided by the prodrug steroid ciclesonide. 

The corticosteroids are contraindicated in patients with hypersensitivity to the corticosteroids, acute bron-chospasm, status asthmaticus, or other acute episodes of... 

Control of severe or incapacitating allergic conditions not controlled by other methods, bronchial asthma (including status asthmaticus), contact dermatitis, atopic dermatitis, serum sickness, drug hypersensitivity reactions... 

Tillie-Leblond I, Pugin J, Marquette CH, Lamblin C, Saulnier F, Brichet A, et al Balance between proinflamma-tory cytokines and their inhibitors in bronchial lavage from patients with status asthmaticus. Am J Respir Crit Care Med 1999 159 487-494. 

A failure to detect these classes of ADE may have serious consequences, as the ADE itself may be disabling or even life threatening, but even when it is relatively trivial it may be a reason for the patient s discontinuing effective treatment, which in turn may cause a deterioration in their condition. An example would be the patient who discontinues the treatment of his asthma with a beta-agonist because of tremor and then goes into status asthmaticus, with fatal consequences. 

In another pattern of sensitization response, a worker who has had only minimal upper respiratory symptoms or no apparent effects from several weeks of low-level exposure may suddenly develop an acute asthmatic reaction to the same or a slightly higher level. The asthmatic reaction may be severe, sometimes resulting in status asthmaticus, which may be fatal if exposure continues. ... 

Bronchial asthma Two cases of death from status asthmaticus have occurred in patients receiving single doses of carvedilol. 

In patients with status asthmaticus and abnormal blood gas tensions, improvement in vital capacity and blood gas tensions may not accompany apparent relief of bronchospasm following isoproterenol. 

Note Status asthmaticus should be considered a medical emergency. 

Status asthmaticus Status asthmaticus is a medical emergency and is not rapidly responsive to usual doses of conventional bronchodilators. Oral theophylline products alone are not appropriate for status asthmaticus. 

Relief of acute bronchospasm primary treatment of status asthmaticus or other acute episodes of asthma when intensive measures are required hypersensitivity to any ingredient systemic fungal infections persistently positive sputum cultures for Candida albicans. 

Acute asthma Cromolyn has no role in the treatment of acute asthma, especially status asthmaticus it is a prophylactic drug with no benefit for acute situations. Hypersensitivity reactions Severe anaphylactic reactions may occur rarely. Renal/Hepatic function Impairment. Decrease the dose or discontinue the drug in these patients. 

Acute bronchospasm Nedocromil is not a bronchodilator and, therefore, should not be used for the reversal of acute bronchospasm, particularly status asthmaticus. Pregnancy Category B. 

Acute asthma attacks Zafirlukast is not indicated for use in the reversal of bronchospasm in acute asthma attacks, including status asthmaticus. Continue zafirlukast during acute exacerbations of asthma. 

Injection - Patients not already receiving large amounts of parenteral narcotics (HP injection only) respiratory depression status asthmaticus obstetrical analgesia (hydromorphone injection). 

Methylprednisolone Succinate and Acetate (Solu-Medrol, DepO Medrol) [Steroid] Uses Tx inflammation d/t anaphylaxis and asthma suspected SCI Action Adrenal corticost oid Dose Adul. Anaphylaxis/ status asthmaticus 125-250 mg IV/EM Suspected SCI Load w/ 30 mg/kg then inf... 

Fluticasone, Nasal (Flonase) [Anti inflammotory/Corticos-teroid] Uses Seasonal all gic rhinitis Action Topical st oid Dose Adults Feds >12 y. 2 sprays/nostril/d Feds 4-11 y. 1-2 sprays/nostril/d Caution [C, M] Contra Primary Rx of status asthmaticus Disp Nasal spray meg SE HA, dysphonia, oral candidiasis Interactions t Effects ketoconazole EMS May... 

The xanthines are readily absorbed by the oral and rectal routes. Although these agents can be administered by injection (aminophylline is a soluble salt of theophylline), intravascular administration is indicated only in status asthmaticus and apnea in premature infants. Intramuscular injection generally produces considerable pain at the injection site. 

The corticosteroids are effective in most children and adults with asthma. They are beneficial for the treatment of both acute and chronic aspects of the disease. Inhaled corticosteroids, including triamcinolone ace-tonide (Azmflcort),beclomethasone dipropionate (Beclo-vent, Vancerit), flunisolide AeroBid), and fluticasone (Flovent), are indicated for maintenance treatment of asthma as prophylactic therapy. Inhaled corticosteroids are not effective for relief of acute episodes of severe bronchospasm. Systemic corticosteroids, including prednisone and prednisolone, are used for the short-term treatment of asthma exacerbations that do not respond to (32-adrenoceptor agonists and aerosol corticosteroids. Systemic corticosteroids, along with other treatments, are also used to control status asthmaticus. Because of the side effects produced by systemically administered corticosteroids, they should not be used for maintenance therapy unless all other treatment options have been exhausted. 

Status asthmaticus is best described by which of the following statements ... 

B) Status asthmaticus is a life-threatening exacerbation of asthma. 

C) Status asthmaticus is best treated with inhaled controller medication, such as cromolyn sodium or a leukotriene modulator. 

D) Status asthmaticus always resolves without drug treatment. 

E) Status asthmaticus occurs without warning in patients whose asthma symptoms are stable and well controlled. 

B. Status asthmaticus is a dangerous exacerbation of asthma symptoms. It requires immediate and aggressive treatment with oxygen, inhaled bronchodilators, and systemic corticosteroids. Hospitalization of the patient is often indicated. By definition, status asthmaticus is not a condition in which symptoms are well controlled. Neither cromolyn sodium nor a leukotriene modulator is indicated for the treatment of status asthmaticus, as their onset of action is too slow. Status asthmaticus often does not resolve without aggressive intervention. Indeed, the patient s condition can deteriorate rapidly to death. Upper respiratory tract infection or excessive exposure to an allergen often precedes status asthmaticus, as does increased use of inhaled bronchodilators. 

Levy BD, Kitch B, and Fanta CH. Medical and ventilatory management of status asthmaticus. Intensive Care Med 1998 24 105-117. 

Contraindications Hypersensitivity to beclomethasone, acute exacerbation of asthma, status asthmaticus... 

Contraindications Primary treatment of status asthmaticus or other acute asthma episodes (inhalation) untreated localized infection of nasal mucosa... 

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