Download Potentially Fatal Asthma

Potentially
Fatal Asthma*
Paul A. Greenberger,
M.D.,
Potentially
identify
of
fatal
asthma
patients
with
a subsequent
patients
have
to
is based
1. Some
on
fatalities
not
as
fatalities
diagnosis
events
outside
and
care
the
United
OF
PATIENTS
original
have
be understood
in such
6 (5.4%)
from
4 (3.6%)
from
population
every
listed
of
1 (0.9%)
higher
AT
2.
from
As listed
is
in Table
present
mended
the
died
of 5.4%
patients
with
recorded
her
week
with
the
in
factors
reason,
difficulty
not
in
terms
of
PFA
occurred
peak
she
a
flow
died,
her
and
In addition,
emergency
this
condition.
The
deterioration
who bad
episode
presenting
patient
had
patient
with
of
peak
flow
to our
Service
was
triamcinolone
acetonide
phylline,
and albuterol
and
flow
yet
2 h after
within
respiratory
rate
acidosis
PFA
was
onset
340
not
may
The
were
prevent
in
our
a fatality.
service
of her
a rapid
arrest
the 3
child
and one other
months
before
prednisone
or
100%
(40 mg
daily),
The
of predicted,
cyanosis
effectiveness
theopeak
and
acute
in improving
It peaks
especially
with
useful
cine,
This
the
the Division
of Allergy-Immunologu
Department
of MediUniversity
Medical School, Chicago.
was supported
by USPHS
NIAID grant Al 11403 and
Northwestern
study
Ernest
S. Bazley
and Northwestern
Reprint
requests:
303 East Chicago
Grant
to Northwestern
Memorial
University.
Dr. Greenberger,
Avenue,
Chicago
Division
60611
of Allergy-Immunology,
with
lack
noncompliance.
prevent
repeated
not
Hospital
device
in sera
is well
in as early
of suppression
of
has
of medication
of
has
depot
been
utilby depot
in
DifficuUies
with
to
PFA
of asthma
corticosteroids
for
progressively
asthma
Prednisone
phobia
Lack of availability
Excessive
delegation
cation
of responsibility
to patient
regarding
medi-
administration
Lack of education
regarding
asthma
Overutilization
of theophylline
or -adrenergic
Creating
excessively
demanding
regimens
Patient factors
Noncompliance
Prednisone
Failure
its
repeated
attempts
or hospitalizations
with
of severity
and
administration
of Patients
is
after
cortisol,
serum
suspicion
where
therapies
Associated
essential
and
information,
as methylprednisolone,
160 mg methyiprednisolone
2-Factors
from
patients,
This
of the
the
its
obtained
absorbed
many
a clinical
successful,
Physician
factors
Inaccurate
estimation
Lack
in PFA
simulated
with
their
as 30 to 60 mm
noncompliance.
In some cases
emergency
been
severe
cortisol
in 3 to 6 h for
in confirming
with
medications
agonists
or appointments
phobia
of accessibility
to care
to seek care
in emergency
services
Low intellectual
abilities
Effects of abject poverty (no telephone
Psychiatric
conditions
Delays
Depression,
*Fmm
monitoring
patients
record
are dishonest
Prednisone
blood
Underutilization
from
experience
(16 inhalations
was asymptomatic.
of symptoms,
occurred.
of
day
A 12-year-old
receiving
IJmin
flow
prednisone,
a sudden
worsening
function.
daily),
expiratory
rates
asthma.
Management
regularly
each
and
is consistent
Table
to take
could
one respiratory
acidosis
in
respiratory
who
not informed
respiratory
experienced
of
care
peak
During
rates.
with
have
flow
use of medications
such as prednisone.
an assay
to detect
prednisone,
in peripheral
recom-
population
patient
a peak
prednisolone,
patients
condition
been
in our
220 to 260 Ijmin.
She had been
advised
60 mg daily, during
this time.
However,
occurred
only
personal
deaths
in
expiratory
the
using
corticosteroids,
such
ized.”
For example,
hospitaliza-
It has
utilize
of the
or failure
intuhation
to be established.
Some
of greater
importance,
metabolite
been
patient
in
and
be
care.
asthma
One
before
may
arrest
without
outcome
absence
for asthma
rate
patient
treatment
complicates
devices.
patients
the
2, asthma
Potentially
Two or more hospitalizations
for status asthmaticus
in spite of longterm oral corticosteroids
Two episodes
of acute
pneiimomediastinum
or pneumothorax
associated
with status asthmaticus
ingestion.
includsuicide,
rate
death
greatest
room
that
that
monitoring
acidosis
present
a death
tions.
that
for respiratory
physicians
regarding
We have
utilized
PFA in
It should
a likely
death
whatever
the
emergency
have
complicating
For
been
with
to prevent
The
than
Some
.
has
prevention
is made
causes.
in Table
noncompliance
Intubation
patient
occurred
patients.
11 patients
asthma,
of 0.017%
are
effort
cardiac
is much
in general
be
asthma
PFA
patients
of 118
with
Patients
in comparison,
WITH
of
a total
Nevertheless,
patients.
ing
PFA
designation
that
and
this
of
UNIVERSITY
identified
to identify
Fatal Asthma
remains
data
or
STATUS
the
we
cannot
150 of 163 deaths
NORTHWESTERN
Since
who
hospitaL’
CURRENT
1988,’
but
Used
1-Criteria
Respiratory
in Table
52.3%
hospital,
to 1987,
the
in patients
therefore
Table
on
because
as listed
States,
of the
1986
to
risk
dependent
system
occurred
medical
used
at increased
is
care
have
during
of the
health
asthma
In
occur
outside
This
the
are
major
PFA.
in Australia,
is a designation
who
in Chicago
received
labeled
(PFA)
asthma
fatality.’
presenting
diagnosis
F.C.C.?
disorders,
Denial
schizophrenia,
anger,
antisocial
or heat)
bipolar
personality
of disease
Sleep apnea
Failure
to remove
instructed
Dysfunctional
animals
from
the
home
environment
as
families
CHEST
/ 101 / 6 / JUNE,
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21648/ on 05/11/2017
1992
I Supplement
401S
injection
is administered,
1 week.
Because
corticosteroids
than
nate day prednisone,
for noncompliant
absence
The
and
side
effects
with
the
patient
is reexamined
are
greater
with
inhaled
this form
cases
where
corticosteroids
of therapy
of patients
with
fatalities
PFA
and
has been
threatening
in repeated
absence
a
failing
to contact
effectively.
PFA must
care,
confrontation,
will
return
cases
for
Many
may
the
deaths
from
or
more
managed
or discharge
may
However,
make
effort
Report
6 National
Education
if
7
care.’#{176}
attempted
the complexity
to
8
preventable
of many
health
care
9
have
described
to identify
and
asthma.
greater
Although
than in the
asthma
are
aspects
attempt
not inevitable
of life-
of high
risk paPFA by our service
to manage
patients
the death
rate in
asthma
population
PFA has
at large,
10
11
12
in all patients.
13
CONCLUSIONS
Because
management
care must
be carried
complicating
in general,
A reassessment
visits. Some
factors
in the
individualized
of initial
generalizations
care
should
include
the need for an accurate
diagnosis
of asthma
and identification of factors
that exacerbate
symptoms;
avoidance
measures when
indicated;
for emergency
advice
certain
use;
patients;
anticipatory
infections
of social,
when
economic,
effective
and care;
pharmacotherapy;
a system
allergen
immunotherapy
in
cessation
therapy
of smoking
for exposures
intensified
therapy
or psychologic
to a specialist
patterns
and
should
be
availability.
38
(,
1989
Lung, and Blood Institute,
National
Asthma
Program
Expert
Panel Report.
Guidelines
for the
diagnosis
and management
of asthma.
Bethesda:
1991
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PA, Chow MJ, Atkinson
AJ Jr. et a!. Comparison
of prednisolone
kinetics in patients
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daily or alternateday prednisone
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Clin Pharmacol
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Chandler
MJ, Crammer
LC, Patterson
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R. Corticosteroid-dependent
asthma
and
schizophrenia.
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Detjen
PF, Creenberger
PA, Crammer
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JL. Life-threatening
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Chest
1987;
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92:460-66
of the many possible
of PFA and asthma
be provided.
out on return
Referral
on local
1 Creenberger
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asthma.
NER Allergy Proc 1988; 9:147-52
2 Walker
CL, Creenberger
PA, Patterson
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3 Weiss KB, Wagener
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populations
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CF, Rubinfeld
AR, Bowes C. Deaths
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survey. Med J Australia
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of Health and Human Services.
Advance report
of final mortality
statistics,
1987. NCHS
Monthly Vital Statistics
and
from
be
an otherwise
intensive
investigators
helpful
severe
much
there
corticosteroids
threatening
asthma
and
identification
tients. “-‘s The use of PFA and malignant
with
been
when
noncompliance
depot
approaches
asthma.
from
despite
other
has proved
problem
is
for office
environmental,
be
of
of
injections,
of asthma
death
likely
providers.
been
to patients
with malignant
as continuation
of noncon-
documentation
administration
Other
multidisciplinary
try to avoid a death
of some
a physician
depending
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to a
has
primary
returning
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asthma
could
Different
approaches
be considered,
such
frontational
patients
refers
disease
of noncompliance.
alter-
significant
increase
in symptoms.
The
lifepotential
of their asthma
becomes
very obvious
episodes
of status
asthmaticus,
when
in the
of psychologic,
factors,
their
financial
asthma”
whose
almost
impossible
to manage.’#{176} The
noncompliance
such as with medications,
examinations,
and
tion
advised
should
be reserved
may occur
in the
of effective
asthma
management.9
term
“malignant
potentially
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drug
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documenta-
402S
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21648/ on 05/11/2017
Potentially
Fatal Asthma
(Paul A Greenberger)