Prevalence and risk factors of lactic acidosis in children with acute moderate and severe asthma, a prospective observational study

Abstract

Lactic acidosis is a common complication of status asthmaticus in adults. However, data is sparse in children. The aim of this study was to describe the prevalence and risk factors for lactic acidosis in children hospitalised for acute moderate or severe asthma. A total of 154 children 2–17 years of age were enrolled in a prospective observational study conducted in a tertiary hospital. All had capillary blood gas assessment 4 h after the first dose of salbutamol in hospital. The primary endpoint was the prevalence of lactic acidosis. Potential contributing factors such as age, sex, BMI, initial degree of asthma severity, type of salbutamol administration (nebuliser or inhaler), steroids, ipratropium bromide, and glucose-containing maintenance fluid represented secondary endpoints. All in all, 87% of patients had hyperlactatemia (lactate concentration > 2.2 mmol/l). Lactic acidosis (lactate concentration > 5 mmol/l and anion gap ≥ 16 mmol/l) was observed in 26%. In multivariate analysis, age more than 6 years (OR = 2.8, 95% CI 1.2–6.6), glycemia above 11 mmol/l (OR = 3.2 95% CI 1.4–7.4), and salbutamol administered by nebuliser (OR = 10, 95% CI 2.7–47) were identified as risk factors for lactic acidosis in children with moderate or severe asthma. Conclusion: Lactic acidosis is a frequent and early complication of acute moderate or severe asthma in children. What is Known:• Lactic acidosis during acute asthma is associated with b2-mimetics administration.• Salbutamol-related lactic acidosis is self-limited but important to recognise, as compensatory hyperventilation of lactic acidosis can be mistaken for respiratory worsening and lead to inappropriate supplemental bronchodilator administration.What is New:• Lactic acidosis is a frequent complication of acute asthma in the paediatric population.• Age older than 6 years, hyperglycaemia, and nebulised salbutamol are risk factors for lactic acidosis during asthma.

From Bronchodilation to Lactic Acidosis: A Case Report on Salbutamol’s Adverse Effect

“…In a recent prospective study by Ruman-Colombier et al on children admitted with acute, moderate, and severe asthma, 26% presented with lactic acidosis (lactate > 5 mmol/l and AG ≥ 16 mmol/l), and nebulized salbutamol was a risk factor [12]. Furthermore, Rodrigo et al showed that high lactate concentrations can develop during the first hours of inhaled β2-agonist treatment in adult patients with severe acute asthma treated with high doses of albuterol [7].…”

The more you give, the worse it gets

“…The proposed mechanism of SILA lies in the hyperadrenergic state it induces [ 5 ]. Salbutamol-induced hyperadrenergic drive promotes glycolysis, glycogenolysis and gluconeogenesis, which leads to overproduction of pyruvate.…”

“…This hyperadrenergic state also enhances lipolysis, resulting in free fatty acids that inhibit the entrance of pyruvate into the Krebs cycle via inhibition of pyruvate dehydrogenase, thus shunting pyruvate into the anaerobic pathway [ 6 , 7 ]. Moreover, systemic corticosteroid use frequently induces a state of hyperglycaemia, which potentially provides more substrate for lactic acid production [ 5 ]. Corticosteroids also enhance β 2 -receptor sensitivity, perpetuating the vicious cycle of a hyperadrenergic state and increased lactate production [ 7 ].…”

“…However, among the paediatric population, 87% of moderate to severe asthma patients had evidence of raised serum lactate level >2.2 mmol·L −1 in a prospective observational study. In that study, older age, higher blood glucose level and salbutamol administered through nebulisation were found to be independent risk factors associated with SILA [ 5 ].…”

The relationship between albumin corrected anion gap levels and mortality in patients with asthma in the ICU

“…In addition to the above diseases, AG is closely related to asthma. Asthma can affect the normal gas exchange of the human body, cause hypoxemia, respiratory muscle fatigue, anaerobic metabolism occurs, cause metabolic acidosis, and AG in patients is often increased 8 . High AG levels, which represent hypoxia and tissue hypoperfusion, are more common in patients with worsening asthma, suggesting a poor prognosis 9 .…”