Management of Asthma Exacerbations in Southeast Asian Tertiary Care

BACKGROUND

There have been limited reports looking into the care of patients with asthma exacerbations admitted to tertiary hospitals in Southeast Asia. This study aims to determine the extent in which the 2019 Global Initiative for Asthma (GINA) guidelines were being met.

METHODS

A retrospective study of patients with asthma exacerbations admitted to the University of Malaya Medical Centre (UMMC) and Pantai Hospital Kuala Lumpur (PHKL), Malaysia from 1 July 2019 to 31 December 2019.

RESULTS

There were significant numbers of patients with previous admissions for asthma in both centres, with almost 50% experiencing an exacerbation in the previous year. Approximately 75% of the patients considered their asthma to be controlled when asked, despite many of them having had a history of acute exacerbations in the previous year. When cross-checked, the level of GINA-defined asthma control remained low, with only 6.4% of the patients deemed to have good control, while asthma was partially controlled in 25.6% of the patients and uncontrolled in 68% of the patients. About 72.1% of the patients reported daytime symptoms, 65.1% of the patients reported night-time symptoms, 70.9% of the patients required frequent usage of rescue inhalers and 72.1% of the patients reported some limitation in their activity prior to the current asthma exacerbation. Almost a quarter of the patients who were admitted had severe or life-threatening exacerbations as defined by GINA. These patients had more hospitalizations in a year and were more likely to have previous admissions requiring non-invasive and invasive ventilation. They were also more likely to be on GINA Step 5 treatment, had a lower mean percent predicted FEV1 and a higher baseline blood eosinophil count. Multivariate analysis revealed that baseline eosinophil count were independently associated with severe or life-threatening asthma exacerbations (odds ratio: 1.01, 95% confidence interval: 1.00-1.01, p=0.001). Failure to adhere to daily controller medications was high in this study (37.2%).

CONCLUSION

Although the management of asthma exacerbations in tertiary hospitals in Southeast Asia is largely congruous with international guidelines, there is room for improvement. As there is a marked discrepancy between patient-perceived and guideline-defined asthma control, efforts to increase awareness on the dangers of uncontrolled asthma are warranted.

Anemia and performance status as prognostic markers in acute hypercapnic respiratory failure due to chronic obstructive pulmonary disease

BACKGROUND

In patients with acute hypercapnic respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with respiratory acidosis due to COPD.

METHODS

COPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV1), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded.

RESULTS

In total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS ≥ 3, long-term oxygen therapy, anemia, diastolic blood pressure < 70 mmHg, Early Warning Score ≥ 3, severe acidosis (pH < 7.20), and serum albumin < 35 g/L. On multivariate analysis, only anemia and WHO-PS ≥ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%.

CONCLUSION

WHO-PS ≥ 3 and anemia are prognostic factors in AHRF with respiratory acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.

Recurrent breast cancer and endobronchial ultrasound-transbronchial needle aspiration

A 67 years old female with previous breast cancer and a 40-pack year smoking history presented with recurrent lower respiratory tract infections on a background of chronic obstructive pulmonary disease.

Despite a normal chest X-ray, the history of recurrent infections led to a high resolution computed tomography scan to exclude structural lung disease. This showed subcarinal lymphadenopathy, multiple nodules in the right lung and suggestion of lymphangitis. She proceeded to have EBUS-TBNA of the enlarged paratracheal and subcarinal lymph nodes. Cytology was consistent with the diagnosis of recurrent metastatic breast carcinoma. The patient went on to receive Letrozole and radiotherapy.

EBUS-TBNA is typically used to both diagnose and stage suspected lung cancer, usually in a solitary procedure. However, it is also useful in patients with undiagnosed mediastinal and hilar lymphadenopathy. This case adds to the paucity of literature whereby EBUS-TBNA was used as a quick and effective tool by which recurrent breast cancer was diagnosed.

Pulmonary hypertension and lung transplantation: Thorax publication activity review 2008-2010

A review is presented on articles published in Thorax between 2008 and 2010 relating to lung transplantation and pulmonary hypertension.