Potentially Fatal Asthma Cheryl Lynn Walker, M.D., and Paul A. Greenberger, M.D.
DEFINITION otentially fatal asthma (PFA) defines a subset of patients with asthma who are thought to be at increased risk of dying from asthma.
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DIAGNOSIS atients in whom PFA is diagnosed meet one of the following criteria: I. required mechanical ventilation for respiratory failure or arrest; 2. had acute respiratory acidosis that did not require mechanical ventilation; 3. had two episodes or more of acute pneumomediastinum or pneumothorax associated with status asthmaticus; 4. had two or more hospitalizations for status asthmaticus in spite of long-term treatment with oral corticosteroids; 5. when hospitalizations or severe episodes of asthma justify this diagnosis in the absence of meeting any of the above criteria.
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CLINICAL SIGNIFICANCE he asthma mortality rate has increased from 1.2 to 1.7/100,000 population since 1979. This is particularly alarming because our knowledge of asthma has increased remarkably. Further, asthma is a reversible obstructive disease. PF A identifies a subset of patients who are potentially at increased risk of dying from asthma. Several investigators have reviewed asthma deaths retrospectively and found that many factors may contribute to the rising asthma death rate including: 1) physician undertreatment with corticosteroids; 2) patient overuse of .8-agonists resulting in a delay in seeking medical care; 3) the lack of availability of emergency medical care; 4) noncompliance; and 5) socioeconomic status. We feel that the prospective identification of patients who are at increased risk of dying focuses the attention of both the physician and the patient on the
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severity of the patient's disease. This may result in more aggressive treatment and follow-up on the part of the physician, and hopefully improved compliance on the part of the patient resulting in decreased asthma mortality. Other diagnoses that may complicate care include 1) denial of disease, 2) schizophrenia, 3) bipolar disorders, and 4) prednisonephobia. TREATMENT ften these patients require alternate day prednisone therapy (usually less than 60 mg q.o.d) in addition to theophylline, .8-agonist, and inhaled corticosteroid therapy. It is essential to keep the treatment regimen simple and to avoid excessive reliance on theophylline or .8-adrenergic agonists. In PF A, in addition to recognizing other confounding factors, the most important medications are prednisone and then the inhaled corticosteroids with secondary status given to bronchodilators. Patients with PF A clearly deserve special emphasis. Noncompliance for psychological reasons may require psychiatric therapy. In any case, consultative advice should be sought, both to ensure that the management is appropriate for protection of the patient and for the protection of the managing physician. For patients with severe noncompliance problems, management with depot corticosteroids should be considered. Although this treatment is not an appropriate regimen for asthma, it may be life saving in some cases of PF A. Most cases ofPFA will be manageable with moderate dose alternate-day prednisone plus inhaled corticosteroids with special attention to travel and preoperative management. While the diagnosis of PF A may frighten some patients, others will become more aware of the potential risk of their disease, which may lead to improved compliance and possibly prevent a potential fatality.
O
REFERENCES I.
Greenberger PA, Patterson R. The diagnosis of potentially fatal asthma. Allergy Proc 9:147-152,1988. 0
Allergy Proc.
167 Delivered by Ingenta to: UCL LIBRARY IP: 91.204.15.80 On: Fri, 24 Jun 2016 16:30:51 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
DEFINITION otentially fatal asthma (PFA) defines a subset of patients with asthma who are thought to be at increased risk of dying from asthma.
P
DIAGNOSIS atients in whom PFA is diagnosed meet one of the following criteria: I. required mechanical ventilation for respiratory failure or arrest; 2. had acute respiratory acidosis that did not require mechanical ventilation; 3. had two episodes or more of acute pneumomediastinum or pneumothorax associated with status asthmaticus; 4. had two or more hospitalizations for status asthmaticus in spite of long-term treatment with oral corticosteroids; 5. when hospitalizations or severe episodes of asthma justify this diagnosis in the absence of meeting any of the above criteria.
P
CLINICAL SIGNIFICANCE he asthma mortality rate has increased from 1.2 to 1.7/100,000 population since 1979. This is particularly alarming because our knowledge of asthma has increased remarkably. Further, asthma is a reversible obstructive disease. PF A identifies a subset of patients who are potentially at increased risk of dying from asthma. Several investigators have reviewed asthma deaths retrospectively and found that many factors may contribute to the rising asthma death rate including: 1) physician undertreatment with corticosteroids; 2) patient overuse of .8-agonists resulting in a delay in seeking medical care; 3) the lack of availability of emergency medical care; 4) noncompliance; and 5) socioeconomic status. We feel that the prospective identification of patients who are at increased risk of dying focuses the attention of both the physician and the patient on the
T
severity of the patient's disease. This may result in more aggressive treatment and follow-up on the part of the physician, and hopefully improved compliance on the part of the patient resulting in decreased asthma mortality. Other diagnoses that may complicate care include 1) denial of disease, 2) schizophrenia, 3) bipolar disorders, and 4) prednisonephobia. TREATMENT ften these patients require alternate day prednisone therapy (usually less than 60 mg q.o.d) in addition to theophylline, .8-agonist, and inhaled corticosteroid therapy. It is essential to keep the treatment regimen simple and to avoid excessive reliance on theophylline or .8-adrenergic agonists. In PF A, in addition to recognizing other confounding factors, the most important medications are prednisone and then the inhaled corticosteroids with secondary status given to bronchodilators. Patients with PF A clearly deserve special emphasis. Noncompliance for psychological reasons may require psychiatric therapy. In any case, consultative advice should be sought, both to ensure that the management is appropriate for protection of the patient and for the protection of the managing physician. For patients with severe noncompliance problems, management with depot corticosteroids should be considered. Although this treatment is not an appropriate regimen for asthma, it may be life saving in some cases of PF A. Most cases ofPFA will be manageable with moderate dose alternate-day prednisone plus inhaled corticosteroids with special attention to travel and preoperative management. While the diagnosis of PF A may frighten some patients, others will become more aware of the potential risk of their disease, which may lead to improved compliance and possibly prevent a potential fatality.
O
REFERENCES I.
Greenberger PA, Patterson R. The diagnosis of potentially fatal asthma. Allergy Proc 9:147-152,1988. 0
Allergy Proc.
167 Delivered by Ingenta to: UCL LIBRARY IP: 91.204.15.80 On: Fri, 24 Jun 2016 16:30:51 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
