Diastolic Hypotension, Troponin Elevation, and Electrocardiographic Changes Associated With the Management of Moderate to Severe Asthma in Children

Abstract

Objective: The objective was to determine the occurrence of, and the factors associated with, diastolic hypotension and troponin elevation or electrocardiogram (ECG) ST-segment changes in a convenience sample of children with moderate to severe asthma receiving continuous albuterol nebulization.Methods: This was a prospective, descriptive study in a pediatric emergency department and an intensive care unit of a tertiary academic center. Fifty children with moderate to severe asthma (clinical asthma score > 8) who received 10 to 15 mg/hour continuous albuterol for >2 hours between June 5, 2007, and February 4, 2008, were approached. Hourly diastolic blood pressures were recorded. Cardiac troponin I (cTnI) and ECG tracings were obtained following the first 2 hours of albuterol and then subsequently every 12 hours while receiving continuous albuterol. Main outcome measures were: 1) incidence of diastolic hypotension, 2) incidence of troponin elevation, and 3) incidence of ECG STdepression.Results: Fifty patients were enrolled. Thirty-three (66%) patients developed diastolic hypotension during the first 6 hours of continuous albuterol. Diastolic blood pressure declined from baseline at 1-6 hours (p < 0.01 vs. baseline). Twelve patients (24%) had elevated cTnI, 15 patients (30%) had ST-segment change, four patients (8%) had both, and 23 patients (46%, 95% confidence interval [CI] = 32 to 60) had either a cTnI elevation or an ECG ST-segment change. Troponin elevation and diastolic hypotension were not associated (RR = 1.2, 95% CI = 0.6 to 2.3). Conclusions:In a subset of children with moderate to severe asthma, diastolic hypotension, troponin elevation, and ECG ST-segment change occur during administration of continuous albuterol. Future studies are necessary to determine the clinical significance of these findings. MEDICINE 2016;23:816-822 © 2016 by the Society for Academic Emergency Medicine A sthma represents one of the most common chronic airway inflammatory diseases of childhood, affecting over 6 million children in the United States, 1,2 and accounts for 6% of children's visit to the emergency department (ED). 3 Albuterol is a selective beta-2 (b-2) agonist and is the treatment of choice for reversing airflow obstruction when administered intermittently or continuously. 2,4 ACADEMIC EMERGENCY

A systematic review of adverse drug events associated with administration of common asthma medications in children

“…24 studies examined ICS, 10 SABA, 3 LABA, 3 combined ICS + LABA, 3 Leukotriene Receptor Antagonists 2 oral beta agonists, 2 IV cromoglycates, 2 subcutaneous anti-IgE, 2 systemic corticosteroids, 1 IV Magnesium Sulphate, and 1 anticholinergic asthma medications. Drug exposure durations ranged from less than 1 day [ 51 , 53 , 54 , 56 , 58 , 59 ] to 84 months [ 27 ], and 11 studies report drug exposure durations greater than or equal to 12 months [ 16 , 19 , 21 – 23 , 31 , 32 , 36 , 38 , 39 , 47 ]. Study population sizes ranged from 12 [ 26 ] to 6208 [ 57 ] participants with a median of 162 participants.…”

Evaluation of cardiac biomarkers in children with acute severe bronchial Asthma-A prospective study from tertiary care center in northern India

“…Cardiac biomarker at admission showed that 50% of the cases had abnormal Tn I levels, 15% had abnormal CK-MB levels and 8.3% had abnormal BNP levels. Table 4 shows the comparative findings of the present study with the studies done earlier 7, 8, 10, 11, 12, 13…”

“…Sinus tachycardia was found in 90% of our patients, 35% had T wave inversion, 25% showed ST segment depression and 20% showed QT prolongation. Table 4 shows the comparative findings of the present study with the studies done earlier 7, 8, 9…”

“…One should be careful while the patient is on beta adrenergic therapy which can cause coronary artery vasodilatation and redistribution of flow from the subendocardium to subepicardium (“steal phenomenon”) due to stimulation of coronary arteries’ beta-2 receptors, mismatch between supply and increased myocardial oxygen demand created by b-1 and b-2 stimulation and systemic vasodilatation leading to increased myocardial stress 8 . The raised cardiac biomarkers and the ECG changes suggest myocardial stress during acute exacerbation of bronchial asthma.…”

Case Report of Severe Lactic Acidosis and Persistent Diastolic Hypotension After Standard Dose Intermittent Salbutamol Nebulization in a Child: Rare Adverse Effects for Common Treatment.

“…Sarnaik et al [16] demonstrated a dose-dependent effect of high-dose continuos inhaled albuterol on DBP in two cohorts of children with status asmaticus during transport to the hospital or PICU admission (respectively 56% and 98% of children had at least one episode of low DBP). Hartford CT [17] found elevated troponin-T levels in 25% of children receiving at least 20 mcg/hr continous nebulized albuterol for a median duration of 40 hours. Carrol et al [18] noticed lower DBP in 66% of children who received 10 to 15 mg/hour continuous albuterol for > 2 hours.…”