Jay Peters, MD

Initiation of early aggressive therapy is critical to averting fatal outcomes in exacerbations of acute life-threatening asthma.

The morbidity and mortality of asthma can be reduced by identifying high-risk patients, using objective and subjective measures to detect severe exacerbations, and initiating early medical intervention.

Abstract: ß-Agonists, administered by metered-dose inhaleror nebulizer, are still the mainstay of therapy for asthma exacerbations.A trial of a subcutaneous ß-agonist should beconsidered in patients who fail to respond to inhaled medications.Levalbuterol may play a role in managing refractoryasthma, particularly in patients with ischemic heart disease orsevere tachycardia. Systemic corticosteroids should be administeredto all patients presenting to the hospital withasthma unless their peak expiratory flow rate (PEFR) orforced expiratory volume in 1 second (FEV1) is at least 80% ofpredicted after 1 hour of treatment; this therapy should be institutedwithin 1 hour of presentation. For patients with severeobstruction, the combined use of an anticholinergic and aß-agonist improves PEFR and FEV1 more than ß-agonistsalone and significantly decreases the risk of hospital admission.(J Respir Dis. 2005;26(6):238-249)

Abstract: In most patients, a life-threatening exacerbation of asthma is preceded by a gradual worsening of symptoms. However, some patients have a sudden onset of worsening symptoms, and these patients are at increased risk for respiratory failure and death. Risk factors for near-fatal asthma include a history of a life-threatening exacerbation, hospitalization for asthma within the past year, delay in time to evaluation after the onset of symptoms, and a history of psychosocial problems. Regularly monitoring peak expiratory flow rate (PEFR) is particularly important because it can identify a subset of high-risk patients--specifically, those with large fluctuations in PEFR and those who have severe obstruction but minimal symptoms. Signs of life-threatening asthma include inability to lie supine, difficulty in speaking in full sentences, diaphoresis, sternocleidomastoid muscle retraction, tachycardia, and tachypnea. (J Respir Dis. 2005;26(5):201-207)