The incidence and mortality rate of asthma continues to increase, and although most asthma patients never experience critical asthma, a small percentage of asthma patients do progress to a very serious and life-threatening condition called “severe asthma”. Severe asthma patients are often young people, and it is a challenge for doctors to save the lives of these patients.
Q: Is there any difference in the treatment of asthma induced or caused by allergic rhinitis and general asthma?
Allergic rhinitis and asthma are the same airway and the same disease. They are different manifestations of allergic diseases and cannot be called rhinitis-induced or caused asthma. There is no particular difference in treatment from general asthma, but it is necessary to take into account the treatment of rhinitis. Montelukast is a good choice for allergic rhinitis combined with asthma.
Q: How is the choice of whistler mode for severe asthma and the timing of molecular targeted therapy? What is the efficacy? Why is there an increase in middle-aged and elderly asthma in recent years, and why is it suddenly sensitized?
The whistler mode during mechanical ventilation is mainly SIMV + PSV, usually with sedation plus inotropic relaxation, allowing hypercapnia. It is important not to overinflate more severely in order to bring CO2 down to normal, resulting in higher airway plateau and peak pressures. Be sure to prevent the occurrence of pneumatic injuries.
The only molecularly targeted therapy that will be available in China is anti-IgE monoclonal antibody for severe refractory allergic asthma, which can generally be used for allergic asthma that remains uncontrolled with level 4 therapy and will be more expensive. Other targeted therapies are still in the process of clinical trials and may take some time to be used in the clinic. The increase in the incidence of asthma is related to the overall air pollution, I think.
Q: Is there a specific indication for bronchoscopic lavage when resuscitating severe asthma and how effective is it?
In severe asthma resuscitation, the patient’s airway sensitivity is very high. What is the purpose of performing bronchoscopy? Only after mechanical ventilation with tracheal intubation, if a large mucus plug in the airway is suspected, it can be observed bronchoscopically and, if necessary, aspirated. Any manipulation may lead to an exacerbation of asthma during an extremely critical asthma attack.
Q: I experienced a case of a 24-year-old patient with refractory severe asthma, who could not get air in with tracheal intubation and a whistler, and had a high airway pressure alarm, very high peak pressure and very low tidal volume. However, he did not dare to use inotropic drugs. Later, a professor from a higher hospital consulted and recommended tracheotomy, and after the tracheotomy, the airway pressure suddenly came down, which is still very puzzling. (Airway nebulization 2% lidocaine after incision)
In general, when a patient is intubated for an acute asthma attack, the plateau pressure and peak pressure will be very high, and at this time the ventilation volume cannot be obtained for the desired purpose, and only permissive hypercapnic ventilation can be chosen. Tracheal intubation also significantly increases airway resistance due to its small caliber. At this point, if a tracheotomy is changed, the airway resistance will be reduced, but it is usually not possible to reduce it very low at once.
Q: The diagnosis of asthma for the first attack in the elderly is rather tangled, can you tell us about your experience? What are your specific recommendations when cardiogenic asthma is tangled with bronchial asthma?
Asthma can occur at any age. In particular, asthma can occur in old age in people with a history of asthma at a young age, or a history of allergic disease or a family history of asthma. A reversibility test of pulmonary function is a good differential diagnosis; the presence of croup on physical examination during an attack is helpful in the diagnosis of asthma.
Most cardiogenic asthma has a history of heart disease. If the diagnosis cannot be made, systemic glucocorticoids can be applied to observe the efficacy. The efficacy of asthma attacks will be obvious, and there are no contraindications for patients with cardiogenic asthma.
Q: Beta agonists for severe asthma are used a lot nowadays, and they are also very confusing. Sometimes we can encounter severe asthma with atretic lung, which is very difficult to treat.
The so-called atretic lung is a very dangerous state of asthma in which the patient’s lungs are no longer able to inhale and whistle gas. In addition to high-dose systemic hormone application, emergency tracheal intubation is required in many cases, along with sedation plus inotropes and ventilation to allow hypercapnia.
Q:1. How is rehydration in severe asthma performed? 2. For the use of tiotropium bromide in asthma, what are the indications?
For routine rehydration, there is no evidence that high dose rehydration is necessary. In severe asthma, tiotropium bromide can be used as a combination of ICS+LABA to help control asthma in combination with COPD and severe asthma. In patients with poor lung function, the benefit is even greater.
Q:How to control severe asthma combined with pulmonary alveoli and gastrointestinal bleeding?
Gastrointestinal bleeding is treated with conventional acid suppression to stop bleeding. Severe asthma combined with pulmonary alveoli is mainly to control asthma symptoms as soon as possible, relieve airway obstruction, and prevent pneumothorax from rupture of pulmonary alveoli. There is no contradiction in treatment.
Q:Is it recommended to add oral hormone if asthma is not well controlled by long-term long-acting inhalers and oral spray short-acting bronchodilators plus oral theophylline, montelukast sodium and other conventional treatments? What is the maintenance dosage?
For refractory asthma level 5 treatment, oral hormone therapy can be added, usually within 10 mg of prednisone per day, and the dosage can be gradually reduced after the control improves.