Teaching Topic

Emergency Treatment of Asthma

CLINICAL PRACTICE

Emergency Treatment of Asthma

S.C. Lazarus
     

Asthma is one of the most common diseases in developing countries and has a worldwide prevalence
of 7 to 10%. It is also a common cause of urgent care and emergency department visits. From 2001
through 2003 in the United States, asthma accounted for an average 4210 deaths annually and a total
of approximately 504,000 hospitalizations and 1.8 million emergency department visits.

Clinical Pearls

  How should inhaled short-acting β2-adrenergic agonists be administered to a patient with a

severe asthma exacerbation?
Most guidelines recommend the use of nebulizers for patients with severe exacerbations; metered-
dose inhalers with holding chambers can be used for patients with mild-to-moderate exacerbations.
There is some evidence that continuous rather than intermittent administration of albuterol results in
greater improvement in PEF and FEV1 and a greater reduction in the need for admission, particularly in
patients with severe asthma. The recommended dose of nebulized albuterol is 2.5–5 mg every 20 min
over the first hr; then 2.5–10 mg every 1–4 hours as needed or 10–15 mg/hr continuously.

  What corticosteroid regimen is recommended for patients with a severe asthma

exacerbation?
In most patients with exacerbations that necessitate treatment in the emergency department, systemic
corticosteroids are warranted. Because comparisons of oral prednisone and intravenous
corticosteroids have not shown differences in the rate of improvement of lung function or in the length
of hospital stay, the oral route is preferred for patients with normal mental status and without conditions
expected to interfere with gastrointestinal absorption. The most recent National Asthma Education and
Prevention Program Expert Panel Report 3 recommends the use of 40 to 80 mg per day in one dose or
two divided doses.

Morning Report Questions

Q. What criteria can be used to determine suitability for admission to the hospital?
A. After treatment in the emergency department for 1 to 3 hours, patients who have an incomplete or
poor response, defined as an FEV1 or PEF of less than 70% of the personal best or predicted value,
should be evaluated for admission to the hospital. Patients who have an FEV 1 of less than 40%,
continuing moderate-to-severe symptoms, drowsiness, confusion, or a partial pressure of arterial
carbon dioxide of 42 mm Hg or greater should be admitted.
Q. What features can be used to determine readiness for discharge?
A. According to the authors, patients may be discharged if the FEV1 or PEF after treatment is 70% or
more of the personal best or predicted value and the lung function and improvement of symptoms are
sustained for at least 60 minutes. After discharge, patients should continue to use inhaled short-acting
β2-adrenergic agonists as needed and should be prescribed oral corticosteroids for 3 to 10 days.

Table 1. Medications for Treatment of Asthma Exacerbation in the Emergency Department.

Teaching Topic
Metastatic Melanoma
ORIGINAL ARTICLE

Improved Survival with Ipilimumab in Patients with Metastatic Melanoma

F.S. Hodi and Others
  

The World Health Organization (WHO) estimates that worldwide there are 66,000 deaths annually
from skin cancer, with approximately 80% due to melanoma. In the United States alone, an estimated
8600 persons died from melanoma in 2009.

Clinical Pearls

  What is the median survival of patients with melanoma who have distant metastases?
The median survival of patients with melanoma who have distant metastases is less than 1 year. There
has been no therapy that has been shown in a phase 3, randomized, controlled trial to improve overall
survival in patients with metastatic melanoma.

  What effect did treatment with ipilimumab have on overall survival according to the results
of this study?
The median overall survival was 10.0 months among patients receiving ipilimumab plus gp100, 10.1
months with ipilimumab alone, and 6.4 months among patients receiving gp100 alone.

Morning Report Questions

Q. What is the mechanism of action of ipilimumab?

A. CTLA-4 is an immune checkpoint molecule that down-regulates pathways of T-cell activation.
Ipilimumab is a fully human monoclonal antibody (IgG1) that blocks CTLA-4 to promote antitumor
immunity.

Q. What adverse effects are most common with ipilimumab?

A. Grade 3 or 4 immune-related adverse events occurred in 10 to 15% of patients treated with
ipilimumab. Diarrhea and fatigue were the most frequently reported adverse events, occurring in more
than 30% of patients treated with ipilimumab. Pyrexia, headache and pruritus were reported by less
than a quarter of treated patients.

Figure 1. Kaplan–Meier Curves for Overall Survival and Progression-free Survival in the Intention-to-
Treat Population.