Original article

Identification of the fatality-prone subject with asthma☆

The treatment of choice in severe asthma exacerbations with respiratory failure includes ventilatory support, both invasive and/or non-invasive, along with different kinds of asthma medication. Of note, the rate of mortality of patients with asthma has decreased substantially in recent years mainly due to significant advances in pharmacological treatment and other management strategies. However, the risk of death in patients with severe asthma who require invasive mechanical ventilation has been estimated between 6.5% and 10.3%. When conventional measures fail, rescue strategies, such as extracorporeal membrane oxygenation (ECMO) or extracorporeal CO2 removal (ECCO2R) may need to be implemented. While ECMO does not constitute a definitive treatment per se, it can minimize further ventilator associated lung injury (VALI) and can enable diagnostic-therapeutic maneuvers that cannot be performed without ECMO such as bronchoscopy and transfer for diagnostic imaging. Asthma is one of the diseases that is associated with excellent outcomes for patients with refractory respiratory failure requiring ECMO support, as shown by the Extracorporeal Life Support Organization (ELSO) registry. Moreover, in such situations, the use of ECCO2R for rescue has been described and utilized in both children and adults and is more widely spread in different hospitals than ECMO. In this article, we aim to review the evidence for the usefulness of extracorporeal respiratory support measures in the management of severe asthma exacerbations that lead to respiratory failure.

The asthma mortality pattern differs among countries. No published evidence is currently available on asthma mortality in a European low-middle-income country in socioeconomic transition. We analyzed the trend of asthma mortality rate in Serbia during the period 1980 2009.

a descriptive study; source of data: Republic of Serbia Institute of Statistics Death Registry. We analyzed asthma mortality data in the total population, including gender specific analysis, and in the selected >5 34 year age group. The International Classification of Diseases codes for asthma 493 (1980 1996) and J45+J46 (1997 2009) were included. Population estimates were based on 1991 and 2002 census data, with extrapolation.

The over-all average mortality rate was 7.27±2.14/100,000 inhabitants. The mortality rate peaked in 1981 at 11.3/100,000 but was 4.45/100,000 in the last year of analysis. While both overall mortality rate, as well as gender specific rates, showed clear decreases over the observed 30-year period (average absolute annual decrease of 0.195/100,000 inhabitants, 0.241/100,000 men and 0.149/100,000 women; p <0.001) with corresponding relative annual decreases of 2.9% for the whole population, 3.0% for men and 2.8% for women, a stable trend of the rate was found in the age group >5-34 years. Male-to-female ratio was 1.59±0.186, on average and it showed a stable trend over the observed period.

Although the failure of the health care system during the socioeconomic crisis of the 1990s might have transiently affected asthma mortality rates, the overall mortality rate for the disease shows a favorable decreasing trend.

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

Les facteurs de risque des allergies graves sont nombreux. Parmi les plus importants, on trouve des facteurs intrinsèques tels que l’asthme, l’âge, le sexe, certaines affections préexistantes (mastocytose, cardiopathies, troubles du rythme cardiaque) et des facteurs extrinsèques (allergènes, effort, pollution). Très souvent les accidents graves sont la conséquence de l’addition de plusieurs de ces facteurs. Le maniement des allergènes au cours de la pratique allergologique a aussi comporté ses propres risques. C’est pourquoi des conseils de bonne pratique et des recommandations précises ont été proposés pour l’immunothérapie spécifique par voie sous-cutanée ; à efficacité égale, l’immunothérapie par voie sublinguale possède, en revanche, une excellente tolérance. Bon nombre d’accidents graves sont évitables grâce à la meilleure éducation et à la prévention de ces risques, en particulier pour les allergies aux aliments, aux médicaments et au latex. Il est indispensable de prévoir un signalement des anaphylaxies et des circonstances de leur survenue.

There are numerous risk factors for severe allergic reactions. Among the most important are intrinsic factors, including asthma, age, sex, certain pre-existent chronic conditions (e.g., mastocytosis, cardiac diseases including arrthymias), and extrinsic factors (e.g., allergens, effort and pollution); severe allergic reactions are very often the result of a combination of several of these factors. The use of allergens during an allergy workup is known to carry its own risk. For this reason, “good clinical practice” plus specific recommendations have been proposed when specific immunotherapy with subcutaneous injections is administered; in contrast, sublingual immunotherapy, which is equally efficacious, is well tolerated. Most severe reactions are avoidable thanks to improved education and the prevention of risks, particularly in cases of food, drug and latex allergies. It is essential to know the signs of anaphylaxis and be prepared for their unexpected arrival.

To investigate racial/ethnic differences in acute asthma among adults presenting to the emergency department (ED), and to determine whether observed differences are attributable to socioeconomic status (SES).

Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the ED and by telephone 2 weeks after hospital discharge.

Sixty-four North American EDs.

A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma patients had a history of more hospitalizations than did whites (ever-hospitalized patients: black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year: black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%; Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ based on race/ethnicity. After accounting for several confounding variables, blacks and Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks, 24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors, the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were markedly reduced.

Despite significant racial/ethnic differences in chronic asthma severity, initial PEFR at ED presentation, and posthospital discharge outcome, ED management during the index visit was fairly similar for all racial groups. SES appears to account for most of the observed acute asthma differences, although hospital admission rates were higher among black and Hispanic patients after adjustment for confounding factors. Despite asthma treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and policymakers might specifically target the ED as a place to initiate interventions designed to reduce race-based disparities in health.