Use of ketamine in patients with refractory severe asthma exacerbations: systematic review of prospective studies

Abstract

Purpose Asthma is a heterogeneous disease with a wide range of symptoms. Severe asthma exacerbations (SAEs) are characterized by worsening symptoms and bronchospasm requiring emergency department visits. In addition to conventional strategies for SAEs (inhaled β-agonists, anticholinergics, and systemic corticosteroids), another pharmacological option is represented by ketamine. We performed a systematic review to explore the role of ketamine in refractory SAEs. Methods We performed a systematic search on PubMed and EMBASE up to August 12th, 2021. We selected prospective studies only, and outcomes of interest were oxygenation/respiratory parameters, clinical status, need for invasive ventilation and effects on weaning. Results We included a total of seven studies, five being randomized controlled trials (RCTs, population range 44–92 patients). The two small prospective studies (n = 10 and n = 11) did not have a control group. Four studies focused on adults, and three enrolled a pediatric population. We found a large heterogeneity regarding sample size, age and gender distribution, inclusion criteria (different severity scores, if any) and ketamine dosing (bolus and/or continuous infusion). Of the five RCTs, three compared ketamine to placebo, while one used fentanyl and the other aminophylline. The outcomes evaluated by the included studies were highly variable. Despite paucity of data and large heterogeneity, an overview of the included studies suggests absence of clear benefit produced by ketamine in patients with refractory SAE, and some signals towards side effects. Conclusion Our systematic review does not support the use of ketamine in refractory SAE. A limited number of prospective studies with large heterogeneity was found. Well-designed multicenter RCTs are desirable.

VV‐ECMO as bridge and safety net for successful therapeutic polypragmasy in a case of influenza‐triggered near‐fatal asthma

“…While there is evidence for magnesium sulfate, 7 the role of ketamine or iv-administered ß-mimetics in severe asthma is still controversial. 14,15 Volatile anesthetics might offer a rescue therapy in severe asthma refractory to established drug therapy. 16,17 Mechanistically, the relief of airway obstruction by relaxation of bronchiole smooth muscles, anti-inflammatory and ß-mimetic-effects as well as histamine-antagonism and vagolytic effects are suggested.…”

“…Adjunctive medications offer possible escalation routes for severe bronchospasm refractory to inhaled ß‐mimetics and systemic corticosteroids. While there is evidence for magnesium sulfate, 7 the role of ketamine or iv‐administered ß‐mimetics in severe asthma is still controversial 14,15 . Volatile anesthetics might offer a rescue therapy in severe asthma refractory to established drug therapy 16,17 .…”

Impact of intra-operative ketamine on postoperative outcomes in abdominal surgery: a narrative review

“…Ketamine has also been investigated for its potential in preventing postoperative delirium and treating refractory asthma exacerbations, yet these results have been inconsistent ( 2 , 3 ). While some studies suggest benefits in delirium prevention, others indicate increased risk, necessitating cautious evaluation ( 2 ).…”

“…While some studies suggest benefits in delirium prevention, others indicate increased risk, necessitating cautious evaluation ( 2 ). In asthma care, the evidence for ketamine’s efficacy remains inconclusive, highlighting the need for further research in these areas ( 3 ).…”

Taste and Smell Disorders: A Critical Look at Olfactory and Gustatory Dysfunction

“…At the same time, loss of smell or taste, even temporarily, can detach people from the joy of flavors, aromas, and fond memories associated with these senses. Yet these substantial effects on patients’ lives are often underestimated or dismissed as being less concerning than other medical issues that determine their cause, especially after the recent COVID-19 pandemic [ 11 , 12 , 13 , 14 , 15 , 16 ].…”