What is the significance of increased lactic acid in a patient with asthma (Asthma)

From the Guidelines

In an asthmatic patient with elevated lactic acid, immediate assessment and treatment are essential to prevent morbidity and mortality, and improve quality of life. The patient's condition should be evaluated based on symptoms, rescue use, and lung function, which are outside the patient’s usual range of day-to-day asthma variation, as suggested by the American Thoracic Society/European Respiratory Society statement 1.

Key Considerations

• Administer supplemental oxygen to maintain saturation above 94% and use short-acting beta-agonists like albuterol (2-4 puffs every 20 minutes for up to 1 hour) for bronchodilation, as this is a crucial step in managing asthma exacerbations.
• If severe, add ipratropium bromide (Atrovent) 2-4 puffs every 20 minutes to help control symptoms.
• Systemic corticosteroids such as prednisone (40-60 mg orally) or methylprednisolone (60-125 mg IV) should be given to reduce inflammation, as recommended by various guidelines, including the Global Initiative for Asthma 1.
• The elevated lactic acid likely results from increased work of breathing and beta-agonist therapy, which stimulates glycolysis and produces lactate, highlighting the need for careful monitoring of the patient's condition.

Monitoring and Support

• Continuous monitoring of vital signs, oxygen saturation, and arterial blood gases is crucial to ensure the patient's condition is stable and to make any necessary adjustments to treatment.
• Avoid respiratory depressants and ensure adequate hydration to prevent further complications.
• If the patient shows signs of respiratory failure (decreased consciousness, rising CO2), prepare for possible intubation, as this is a life-threatening condition that requires immediate attention.

Long-term Management

• Once stabilized, review the patient's maintenance therapy and consider adding inhaled corticosteroids if not already prescribed, as this can help to reduce the risk of future exacerbations and improve overall asthma control, as suggested by the European Respiratory Review 1. The goal is to treat the acute asthma exacerbation while monitoring and supporting the patient until lactic acid levels normalize with improved respiratory status, prioritizing morbidity, mortality, and quality of life as the primary outcomes.

From the Research

Asthmatic Patient with Increased Lactic Acid

• Lactic acidosis is a condition that can occur in asthmatic patients, particularly those receiving systemic adrenergic agonist therapy 2, 3, 4.
• Studies have shown that lactic acidosis can develop in patients with severe asthma, even in the absence of hypoxia or decreased tissue perfusion 2, 5.
• The use of beta2-agonists, such as salbutamol and terbutaline, has been associated with the development of lactic acidosis in asthmatic patients 2, 3, 4.
• Lactic acidosis can contribute to respiratory failure and complicate the assessment and management of acute, severe asthma 2, 5.
• Hyperlactatemia is a relatively frequent finding in blood gas analysis of patients hospitalized for asthma, and is associated with longer hospital stays 6.
• The mechanism of lactic acidosis in asthmatic patients is not fully understood, but it is thought to be related to the use of beta2-agonists and the resulting increase in lactate production 3, 4.
• Clinicians should be aware of the potential for lactic acidosis in asthmatic patients, particularly those receiving beta2-agonist therapy, and monitor for signs of hyperlactatemia 3, 4, 6.