What are the complications of asthma exacerbation?

From the Guidelines

Complications of asthma exacerbation can be severe and potentially life-threatening, with the most serious complication being respiratory failure, which can lead to mechanical ventilation, and other complications such as pneumothorax, status asthmaticus, and cardiac arrest 1.

Key Complications

• Respiratory failure: occurs when the airways become so constricted that adequate oxygen cannot reach the bloodstream, potentially requiring mechanical ventilation
• Pneumothorax (collapsed lung): may develop due to air trapping and increased pressure in the lungs
• Status asthmaticus: a severe and persistent asthma attack that doesn't respond to standard treatments, can lead to respiratory acidosis from carbon dioxide retention
• Atelectasis (collapsed air sacs): from mucus plugging of airways
• Systemic complications from prolonged or frequent use of oral corticosteroids: including osteoporosis, adrenal suppression, weight gain, and increased susceptibility to infections

Risk Factors for Asthma-Related Death

• Previous severe exacerbation (eg, intubation or intensive care unit admission for asthma) 1
• Two or more hospitalizations or >3 ED visits in the past year
• Use of >2 canisters of SABA per month
• Difficulty perceiving airway obstruction or the severity of worsening asthma
• Low socioeconomic status or inner-city residence
• Illicit drug use
• Major psychosocial problems or psychiatric disease
• Comorbidities, such as cardiovascular disease or other chronic lung disease

Management

Early recognition and aggressive treatment of asthma exacerbations with bronchodilators, corticosteroids, and appropriate supportive care are essential to prevent these complications 1. Signs of impending respiratory failure include an inability to speak, altered mental status, intercostal retraction, worsening fatigue, and a PaCO2 of 42 mm Hg or greater, and intubation should not be delayed once it is deemed necessary 1. Intravenous magnesium sulfate may be considered in patients with life-threatening exacerbations and those whose exacerbations remain severe after 1 hour of intensive conventional treatment 1.

From the FDA Drug Label

If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy. Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs and with the home use of nebulizers A complication of asthma exacerbation is serious worsening of asthma, which may require reassessment of therapy 2. Other potential complications include paradoxical bronchospasm, which can be life-threatening, and fatalities associated with excessive use of inhaled sympathomimetic drugs or home use of nebulizers 2. Key complications to consider are:

• Seriously worsening asthma
• Paradoxical bronchospasm
• Fatalities associated with excessive use of inhaled sympathomimetic drugs or home use of nebulizers

From the Research

Complications of Asthma Exacerbation

• Asthma exacerbations can lead to significant morbidity and mortality, and are a major source of morbidity for adults with asthma 3
• The presence of exacerbations is an important defining characteristic of asthma severity, and can occur across a wide spectrum of chronic severity 4

Management of Asthma Exacerbations

• Early recognition and intervention, continuous monitoring, appropriate disposition, and multifaceted transitional care are key strategies for managing asthma exacerbations in the emergency department 4
• The use of ipratropium bromide as an adjunctive therapy to beta2-agonists has been shown to improve lung function and decrease hospitalization rates in both adults and children with acute asthma exacerbation 5
• However, the addition of ipratropium bromide to albuterol has not been shown to have a significant additive benefit in some studies 6

Treatment Options

• Inhaled corticosteroid/formoterol combination can be used for home management of asthma exacerbations in patients 12 years and older 7
• Short-acting beta2 agonists and oxygen can be used to assess exacerbation severity and begin treatment in the office setting 7
• The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 7

Hospitalization and Discharge

• Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 7
• Improvement in symptoms and forced expiratory volume in one second or peak expiratory flow to 60% to 80% of predicted values helps determine appropriateness for discharge 7