Treatment – Canadian Medical News

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.

Hyperoxia associated

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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Arach in 1935 was the first to use helium to improve air flow in patients with airways obstruction, but it was soon cast aside for other treatment modalities. Since then, it has been relegated mainly to use in upper airway obstruction or to diagnostic studies. Safety and efficacy have been demonstrated for both spontaneously breathing patients and for intubated patients receiving mechanical ventilation, but its therapeutic potential has not been fully explored.

Helium has no bronchodilating or anti-inflammatory properties and in fact is quite inert. Since airway resistance in turbulent flow is directly related to the density of the gas, helium, with its lower density than nitrogen or oxygen, results in lower airway resistance. Helium further lowers airway resistance by reducing the Reynolds number, such that some areas of turbulent flow are converted to laminar flow. The reduction in airway resistance results in a decreased work of breathing.

Although the mortality from asthma is rising, there has been a paucity of new treatments for acute severe asthma. Previous reports have shown an almost universal response to heliox in acute severe asthma. We wish to report our experience with heliox and our attempt to better define its utility by discerning patterns of response.

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Over a 2-year period (1988 to 1990) there were 312 patients, 179 women and 133 men, admitted to Mount Sinai Hospital in Hartford Conn, with acute asthma. Twelve (3.8%) of these patients had an acute respiratory acidosis as defined by a pH of 45 mm Hg. All were treated with a heliox mixture containing 60 to 70% helium and 30 to 40% oxygen. There were nine men and three women. The mean age was 33.8± 11.3 years. They had asthma for 23.4±9.6 years. Four of the patients had been intubated in the past. Eleven of the 12 patients were receiving maintenance agonist metered-dose inhaler therapy. Eight of the 12 were taking oral theophylline. One was using ipratroprium bromide by metered-dose inhaler. None of the patients was being treated with inhaled or oral corticosteroids.