Tratamento atual de crianças com asma crítica e quase fatal

Abstract

Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.

Use of magnesium sulfate in continuous infusion in patients with severe acute asthma, in a pediatric emergency room

“…Through the review of electronic medical records, it was possible to classify patients according to the modified Wood–Downes severity score (Table 1). Before the continuous magnesium sulfate infusion for 4 h, a variation in the score value from 3 to 6 was observed, with a median of 4 3‐5 . After 4 h of magnesium sulfate administration, the scale values decreased to a range from 5 to 0 with a median of 1 (0–2), showing a statistically significant difference ( p < .001) (Figure 3).…”

“…Asthma is the most usual chronic disease in infancy, responsible for numerous visits to the pediatric emergency, being present in around 10% of all children 1,2 . Severe acute asthma is described as an asthma attack that does not obtain respond to conventional anticholinergic therapy, repeated doses of beta‐agonists and corticosteroids, requiring hospitalization 3 . There are some options for a second treatment scale, one of which is magnesium sulfate, intravenously 4,5 …”

Reply to: Contemporary treatment of children with critical and near-fatal asthma

“…Colleti Jr and Carvalho for their interest in our recent publication in Revista Brasileira de Terapia Intensiva . ( 1 ) We agree that avoidance of mechanical ventilation (MV) is preferable in pediatric intensive care unit (PICU) patients with critical asthma, but primarily to avoid MV-associated morbidity, as MV-associated mortality is exceptionally rare in the current era. Newth recently reported a mortality rate of 4.3% for children with near-fatal asthma in United States PICUs, which is lower than the 9.4% mortality rate among adults hospitalized nearly 2 decades ago with near-fatal asthma that was reported in the paper cited by Colleti Jr and Carvalho.…”

To: Contemporary treatment of children with critical and near-fatal asthma

“…The review article by Shein et al ( 1 ) on the treatment of acute severe asthma in children is timely due to the prevalence of the disease and often variable and inconsistent disease management, which includes adjuvant therapies and depends on the availability of resources, the local practices and the preference of doctors. The risk of death in patients subjected to mechanical ventilation for severe acute asthma was analyzed by Pendergraph et al, ( 2 ) who concluded that the in-hospital mortality rate was 60 to 90 times higher (approximately 10%) for patients who require intubation, with or without admission to an intensive care unit, than for patients who were not intubated.…”

“…The dose recommended by Shein et al. ( 1 ) is 25 to 40 mg/kg intravenously, with infusion for a period between 20 and 30 minutes. However, Irazuzta et al ( 6 ) report that the early use of high doses of magnesium sulfate with continuous infusion (50mg/kg/hour for 4 hours) expedites discharges from the emergency department and prevents hospitalizations in the intensive care unit, with a significant reduction in costs.…”