Too Much Testing? To the Editor: In their recent article in CHEST (January 2014) on the treatment of acute asthma with albuterol, Lewis et al1 show that high levels of lactate during such treatment are highly prevalent; in addition, high plasma albuterol concentration is significantly correlated with hyperlactatemia. In a previous case involving a woman with asthma, we described lactic acidosis (pH 7.29) and a high level of arterial lactate (10.47 mmol/L) after treatment with bronchodilator aerosols (terbutaline).2 This level represents the highest level of lactate, without any grave consequences, that we were able to find in the literature. We concur with Lewis et al1 that hyperlactatemia, with or without lactic acidosis, is not necessarily a sign of immediate gravity and has no clinical consequences in these patients. We also question the utility of measuring lactates in acute asthma. Advanced tests have dramatically changed how diseases are diagnosed and treated. A great evolution in medicine! However, we have to keep in mind that clinical examination is more important than the results of these tests, even if hyperlactatemia is present. Laboratory tests should be targeted, and physicians should not order tests if they do not think they will aid in patient management. The study by Lewis et al1 helps demonstrate this concept. Pierre-Géraud Claret, MD Xavier Bobbia, MD Jean-Emmanuel de La Coussaye, MD, PhD Nîmes, France Affiliations: From CHU de Nîmes. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Pierre-Géraud Claret, CHU de Nîmes, Place du Professeur Robert Debré, Nîmes 30000, France; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0252
References 1. Lewis LM, Ferguson I, House SL, et al. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest. 2013;145(1):53-59. 2. Claret PG, Bobbia X, Boutin C, Rougier M, de la Coussaye JE. Lactic acidosis as a complication of beta-adrenergic aerosols. Am J Emerg Med. 2012;30(7):1319.e5-1319.e6.
Response To the Editor: We appreciate the letter from Dr Claret and colleagues questioning the need for serum lactate measurements in patients being treated for acute exacerbation of asthma. Our study, part of a clinical trial protocol, required repeated measures of a number of laboratory values, including plasma albuterol, serum electrolytes, and serum lactate concentrations.1 We agree with Dr Claret and colleagues that this study and others have demonstrated that most patients treated for acute exacerbation of asthma who subsequently 1436
develop elevated serum lactate concentrations have no discernable worsening of outcomes and require no alteration in management.2,3 Thus, the routine use of serum lactate measurements in these patients is not warranted. However, we and others have described occasional subjects with worsening dyspnea and stable pulmonary function who were found to have hyperlactatemia and who clinically improved when b-agonists were withheld.4,5 It is not unreasonable to consider testing of serum lactate concentrations (particularly rapid point-of-care testing) in patients with worsening subjective dyspnea, in the face of stable pulmonary function based on clinical or spirometric features, to determine if hyperlactatemia and acidosis may be the cause. Finally, the lactate concentration Dr Claret and colleagues report of 10.47 mmol/L is higher than the maximum lactate concentration measured in any of our subjects. However Koul et al6 reported a lactate concentration of 13 mmol/L in a case report of a 17-year-old who recovered uneventfully. Lawrence M. Lewis, MD Ian Ferguson, BA Stacey L. House, MD, PhD Kristen Aubuchon St. Louis, MO John Schneider, BA Columbia, MO Kirk Johnson, PhD Kazuko Matsuda, MD, PhD La Jolla, CA Affiliations: From the Washington University School of Medicine in St. Louis (Drs Lewis and House, Mr Ferguson, and Ms Aubuchon); the University of Missouri Columbia School of Medicine (Mr Schneider); and MediciNova, Inc (Drs Johnson and Matsuda). Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lewis was a principle investigator for the larger clinical trial sponsored by MediciNova, Inc. Drs Johnson and Matsuda are employed by MediciNova, Inc, the sponsoring company for the larger clinical trial. Messrs Ferguson and Schneider, Dr House, and Ms Aubuchon have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Lawrence M. Lewis, MD, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, Campus Box 8072, St. Louis, MO 63110; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0344
References 1. Lewis LM, Ferguson I, House SL, et al. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest. 2014;145(1):53-59. 2. Stratakos G, Kalomenidis J, Routsi C, Papiris S, Roussos C. Transient lactic acidosis as a side effect of inhaled salbutamol. Chest. 2002;122(1):385-386. 3. Rodrigo GJ, Rodrigo C. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma. Emerg Med J. 2005;22(6):404-408. 4. Maury E, Ioos V, Lepecq B, Guidet B, Offenstadt G. A paradoxical effect of bronchodilators. Chest. 1997;111(6):1766-1767. 5. Tobin A, Santamaria J. Respiratory failure precipitated by salbutamol. Intern Med J. 2005;35(3):199-200. 6. Koul PB, Minarik M, Totapally BR. Lactic acidosis in children with acute exacerbation of severe asthma. Eur J Emerg Med. 2007;14(1):56-58. Correspondence
References 1. Lewis LM, Ferguson I, House SL, et al. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest. 2013;145(1):53-59. 2. Claret PG, Bobbia X, Boutin C, Rougier M, de la Coussaye JE. Lactic acidosis as a complication of beta-adrenergic aerosols. Am J Emerg Med. 2012;30(7):1319.e5-1319.e6.
Response To the Editor: We appreciate the letter from Dr Claret and colleagues questioning the need for serum lactate measurements in patients being treated for acute exacerbation of asthma. Our study, part of a clinical trial protocol, required repeated measures of a number of laboratory values, including plasma albuterol, serum electrolytes, and serum lactate concentrations.1 We agree with Dr Claret and colleagues that this study and others have demonstrated that most patients treated for acute exacerbation of asthma who subsequently 1436
develop elevated serum lactate concentrations have no discernable worsening of outcomes and require no alteration in management.2,3 Thus, the routine use of serum lactate measurements in these patients is not warranted. However, we and others have described occasional subjects with worsening dyspnea and stable pulmonary function who were found to have hyperlactatemia and who clinically improved when b-agonists were withheld.4,5 It is not unreasonable to consider testing of serum lactate concentrations (particularly rapid point-of-care testing) in patients with worsening subjective dyspnea, in the face of stable pulmonary function based on clinical or spirometric features, to determine if hyperlactatemia and acidosis may be the cause. Finally, the lactate concentration Dr Claret and colleagues report of 10.47 mmol/L is higher than the maximum lactate concentration measured in any of our subjects. However Koul et al6 reported a lactate concentration of 13 mmol/L in a case report of a 17-year-old who recovered uneventfully. Lawrence M. Lewis, MD Ian Ferguson, BA Stacey L. House, MD, PhD Kristen Aubuchon St. Louis, MO John Schneider, BA Columbia, MO Kirk Johnson, PhD Kazuko Matsuda, MD, PhD La Jolla, CA Affiliations: From the Washington University School of Medicine in St. Louis (Drs Lewis and House, Mr Ferguson, and Ms Aubuchon); the University of Missouri Columbia School of Medicine (Mr Schneider); and MediciNova, Inc (Drs Johnson and Matsuda). Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lewis was a principle investigator for the larger clinical trial sponsored by MediciNova, Inc. Drs Johnson and Matsuda are employed by MediciNova, Inc, the sponsoring company for the larger clinical trial. Messrs Ferguson and Schneider, Dr House, and Ms Aubuchon have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Lawrence M. Lewis, MD, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, Campus Box 8072, St. Louis, MO 63110; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0344
References 1. Lewis LM, Ferguson I, House SL, et al. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest. 2014;145(1):53-59. 2. Stratakos G, Kalomenidis J, Routsi C, Papiris S, Roussos C. Transient lactic acidosis as a side effect of inhaled salbutamol. Chest. 2002;122(1):385-386. 3. Rodrigo GJ, Rodrigo C. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma. Emerg Med J. 2005;22(6):404-408. 4. Maury E, Ioos V, Lepecq B, Guidet B, Offenstadt G. A paradoxical effect of bronchodilators. Chest. 1997;111(6):1766-1767. 5. Tobin A, Santamaria J. Respiratory failure precipitated by salbutamol. Intern Med J. 2005;35(3):199-200. 6. Koul PB, Minarik M, Totapally BR. Lactic acidosis in children with acute exacerbation of severe asthma. Eur J Emerg Med. 2007;14(1):56-58. Correspondence
