TheAnswerPage/Hospital & Critical Care Medicine Wednesday 03/10/2010 This week: Various aspects of the management of severe asthma

Asthma is a common condition affecting 5 to 10% of the US population. It is a complex syndrome with many clinical phenotypes varying from mild to acute life threatening presentations. Many patients present with asthma during their infancy, others at adult age. There are clear genetic factors (atopy) and environmental components (virus, allergens, occupational exposure) contributing to asthma. Asthma is a (mostly IgE-mediated) inflammation of both central and peripheral airways. The prevalence and mortality of asthma are both increasing for unclear reasons. Admission to an ICU represents a failure of management. Status asthmaticus is a medical emergency where appropriate management is critical.

The goals of medical therapy in acute asthma are aggressive bronchodilation and rapid correction of hypercapnia and hypoxia, if present. There are a number of so-called standard therapies.

Describe the standard medical therapies and discuss some of the following controversies related to each.

1. The effect of supplemental oxygen on hypoxic drive in asthmatics.
2. Beta agonists: What is the best mode of drug delivery in asthma, nebulizers or metered-dose inhalers (MDIs)? Are Beta₂(B₂)-agonists association with increased mortality in the acute setting?
3. What dose of which corticosteroid is optimal?
4. What is the role of anticholinergic agents in the acute setting.
5. What is the role of the theophylline
6. What is the role of the newer leukotriene inhibitors in the acute setting?

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