Although our study did not look closely at any changes in minute ventilation, there seemed to be no significant modifications before and during oxygen administration in respiratory rate. Hyperoxia associated with hypercarbia occurring in asthma exacerbations, and especially without any evidence of respiratory suppression, would be more easily explained by the regional release of hypoxic pulmonary vasoconstriction.
This factor had a major role in determining V/Q matching, as V/Q inequality worsened considerably after administration of 100% oxygen. This has been shown in patients with acute asthma receiving ventilation and not receiving ventilation; therefore, patients with most severe baseline condition probably have more hypoxic vasoconstriction, and they had the greatest increase in PaC02 while breathing 100% oxygen.
Our trial sample presented the typical features of severe adult asthmatic patients when they presented for care to an emergency department on average: a mean level of PEFR of 41% of predicted, a mean age of 38 years, and a female/male ratio of 2:1. Finally, 76% of our patients presented the most characteristic arterial blood gas pattern: mild-to-moderate hypoxemia (range, 58 to 97 mm Hg) along with hypocapnia (range, 28 to 39 mm Hg).
In summary in this randomized, controlled trial, we have confirmed previous observations that administration of 100% oxygen for 20 min significantly increases PaC02 and decreases PEFR as compared with administration of 28% oxygen. These observations strongly support Global Strategy for Asthma Management and Prevention recommendations that oxygen dose in severe acute asthma should be variable and should be based on achieving and maintaining target Sp02 values with a pulse oximeter > 92% for adults and 95% for children.
Because severe asthma may give rise to hypoxemia and (3-agonist therapy may worsen hypoxemia, monitoring therapy of acute asthma with pulse oximetry is ideal. The results should be used to control the administration and dose of oxygen therapy. In circumstances where acute asthma must be treated without pulse oximetry, a clinical judgment must be made as to whether oxygen therapy (if is available) is warranted to prevent life-threatening hypoxemia, despite its potential adverse effects. However, uncontrolled high-flow oxygen should be avoided.
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This exercise reveals the difficulty many of us have in telling the difference between dependency and love. It’s not surprising that those we are closest to appear and that removing them from our lungs may be painful. Acknowledging how enmeshed your breathing is with close relationships may bring up feelings of sadness, loss, resentment, or even guilt, but it is important not to label these feelings as bad or to bury them. Actually, the opposite is true. For, as you’ll see in the next story, it’s only when we recognize these feelings and bring them into the open that we create the necessary space to heal.
Bamboozled by the Committee
Karen, a business executive in her late thirties, had her first asthma attack when she was seventeen. For the last eight years she has lived with Michael, with whom she shares parenting responsibilities for his five-year-old son. When she does “The Exorcism,” Karen sees her mother and cuts her out. She gets a sense of power from this. When she’s finished she says her breathing seems much easier. But Karen is disturbed by the feeling of guilt that washes over her almost immediately. She describes her mother as a worrier and overprotective. “She’s afraid I can’t take care of myself. She’s a typical Jewish mother,” Karen adds with exasperation.
Karen did the exercise for less than a week. She claimed it made her feel guilty. “I’ve discussed this stuff with my therapist for the past six years. Why do it again?’’ she asked. Talking with her therapist about her mother was a safe way for Karen to dwell on her pain. It allowed her to vent (complain, name, blame, be the victim), but it made no impact on the asthma. Despite feeling powerful and breathing more freely after her initial imagery experience, Karen allowed her Committee to take over. The Judge pronounced her guilty, based on standards that dictate a “good” daughter’s behavior. And immediately, Karen fell into the trap of thinking that removing her mother’s image and influence from her lungs was “bad.”
Regarding the emotional issues of asthma and their relationship to its symptoms, Dr. Gerald Epstein says:
The emotional contribution (of asthma) seems to come mainly from knotted dependency problems, particularly related to struggles for independence from maternal influence, although sometimes the distressing influence can be paternal. Either way … the issue is almost always related to a parent. The asthmatic wheeze has a positive as well as a negative meaning. The positive meaning is expression of wanting to breathe freely — to become free. The negative meaning is generally considered to bespeak the fear of breaking loose from parental influence.
Black and Hispanic patients were more likely to have a history of hospitalization and reported a greater number of ED visits. They were more likely to state that they used the ED as their primary source of asthma care and prescriptions. The three groups were equally likely to have recently used systemic corticosteroids and inhaled bronchodilators, but black and Hispanic patients were less likely to have used inhaled corticosteroids. Black patients and, especially, Hispanic patients were less likely to own a spacer and a peak flowmeter, while action plans were low across all three groups. Comorbid medical conditions were equally likely (blacks, 9%; Hispanics, 4%; whites, 8%; p = 0.03).
Black and Hispanic patients exhibited more severe objective airway obstruction (based on PEFR), but blacks reported slightly less severe subjective distress. Black and Hispanic patients received more inhaled bronchodi-lator doses during the first hour following triage, and black patients were most likely to have received systemic corticosteroid treatment. All race/ethnicity groups were equally likely to be discharged from the ED with a prescription for inhaled corticosteroids (566 patients; black, 39%; Hispanic, 37%; white, 48%; p = 0.15). When the sample was restricted to only those patients who were not already receiving inhaled corticosteroids, we again found no differences (black, 12%; Hispanic, 11%; white, 13%; p = 0.86). After controlling for seven factors (ie, age, sex, education, estimated household income, insurance status, PCP status, and recent use of inhaled steroids) using multiple linear regression analysis, we found that the initial PEFR no longer differed significantly by race/ethnicity (black vs white: difference, -0.03; 95% CI, -0.06 to -0.004; p = 0.05; Hispanic vs white: difference, -0.03; 95% CI, -0.07 to -0.001; p = 0.05).
At the univariate level, hospitalization did not differ by race/ethnicity. However, the logistic regression model predicting hospitalization demonstrated that, all things being equal, black and Hispanic patients were more likely to be admitted to the hospital.