Classification of severe asthma exacerbations: a proposal

Abstract

C Cl la as ss si if fi ic ca at ti io on n o of f s se ev ve er re e a as st th hm ma a e ex xa ac ce er rb ba at ti io on ns s: : a a p pr ro op po os sa al l C. PicadoClassification of severe asthma exacerbations: a proposal. C. Picado. ERS Journals Ltd 1996. ABSTRACT: The intensity of asthma exacerbations may vary from mild to severe. Many studies have demonstrated that the speed at which severe asthma exacerbation (SAE) develops varies among patients. In some asthmatics, the exacerbation comes on very quickly, whereas in others there is a progressive deterioration of clinical, functional and blood gas parameters.Sudden SAE are characterised by their explosive presentation and quick recovery. This evolution contrasts with that of patients with a slow onset SAE, who often need prolonged hospitalization. Absence of secretions suctioned from the airways during mechanical ventilation has been reported in sudden SAE, whereas large amounts of viscid mucus are found in patients with the slow onset SAE. The lungs of patients who died during a sudden onset SAE often show empty airways and a predominant neutrophilic infiltration in the bronchial epithelium, in contrast to the presence of abundant eosinophils in patients who died during a slow onset SAE.Sudden onset SAE may occur as sporadic cases or in outbreaks. Sporadic cases may result from the ingestion of nonsteroidal anti-inflammatory drugs (NSAID) in patients with intolerance to these products, massive exposure to common allergens and ingestion of foods containing sulphites. Asthma outbreaks have been described in many cities. In contrast to sudden onset SAE, slow onset SAE is characterized by a progressive deterioration, accompanied by an increase in the use of bronchodilators. Lack of appropriate monitoring of function by peak expiratory flow (PEF) recording, failure of patients to recognize worsening symptoms and underusage of inhaled and oral steroid treatment have been repeatedly identified as factors which are likely to be associated with slow onset SAE. The contribution of psychosocial problems, depression, denial of asthma severity and nonadherence with the treatment should not be overlooked in patients with slow onset SAE.Classification of severe asthma exacerbations into two types (sudden onset and slow onset) could help to reveal the aetiology of the attack and may also be relevant to the management of the patient.

Frequency and clinical characteristics of rapid-onset fatal and near-fatal asthma

“…Specifically, suspected respiratory infection was a trigger less often, whereas NSAID intake and gas inhalation were more frequent in ROA than in SOA patients. Together with previous observations [11,12], these results support the suggestion of PICADO [5] that severe asthma exacerbations may be classfied according to rapidity of onset.…”

“…ROA has been suggested to have a particular clinical course, with rapid impairment and occasionally fatal outcome, although improvement is also rapid when the course is favourable [4]. A classification based on those and other findings has been proposed by PICADO [5]. More neutrophils than eosinophils are known to infiltrate the bronchial submucosa [6] in ROA than in SOA, and ROA is reported to occur in the presence of a higher number of CD8z T-cells than is seen in stable asthma [7].…”

Sudden‐onset Severe Acute Asthma: Clinical Features and Response to Therapy

“…Other investigators have noted that speed of onset may influence patterns of recovery, with longer duration of symptoms predicting slower response to therapy.2. 9 More recently, interest in speed of onset of acute asthma has developed because studies of fatal and near-fatal asthma exacerbations suggest that some life-threatening episodes occur after a sudden and unexpected onset of ~y m p t o r n s .~-~ This pattern has been termed "sudden asphyxic asthma" and may represent a predominantly hyperacute, bronchospastic mechanism of deterioration.6-8 These observations have led to proposals that sudden onset of symptoms may define a distinct clinical subtype of fatal or near-fatal a~t h m a .~.~ In particular, "sudden asphyxic asthma" is thought to be characterized by explosive symptom development with rapid recovery, association with specific triggers, seasonal variation, and history of atopy.…”

Acute exacerbation in COPD and asthma

“…"Status astmaticus"; yirmi dört saatten uzun süren, ağır, hayatı tehdit eden astım ataklarının genel terminolojisi olarak kullanılmıştır, hızlı etkili beta agonistlere cevapsız, yoğun mukus artışı saptanan, hızlı veya yavaş başlayabilen ataklardır (25)(26)(27) %40'dan fazla PEF variabilitesi olması, Tip 2; önce-sinde, tetikleyen bulunmaması ve normal solunum fonksiyonları olmasına rağmen üç saat içinde gelişen ani ağır atak ile karakterizedir (28).…”