Analysis of the Effect of Non-Invasive Positive Pressure Ventilation in Emergency Treatment of Severe Bronchial Asthma with Respiratory Failure

Objective:This study aims to evaluate the clinical efficacy of non-invasive positive pressure ventilation(NIPPV)in patients with severe bronchial asthma combined with respiratory failure.Methods:90 patients with severe bronchial asthma combined with respiratory failure between September 2022 and December 2023 were selected for the study and randomly divided into the experimental group(NIPPV-assisted treatment)and the control group.The differences between the two groups were compared in terms of total effective rate of treatment,days of clinical symptom disappearance,days of hospitalization,lung function indexes,incidence of adverse reactions,and quality of life.Results:Patients in the experimental group had a significantly higher total effective rate of treatment(97.78%)than the control group(75.56%).In terms of pulmonary function indexes,patients in the experimental group showed significant improvement after treatment,especially the increase in forced expiratory volume and forced vital capacity,while these improvements were not as obvious in the control group.In addition,the incidence of adverse reactions was significantly lower in the experimental group than in the control group,suggesting that the application of NIPPV is relatively safe.Quality of life assessment also showed that patients in the experimental group had significantly better quality of life than the control group after treatment.Conclusion:This study demonstrated the effectiveness of NIPPV as an adjunctive treatment for severe bronchial asthma combined with respiratory failure.NIPPV can improve lung function,reduce the incidence of adverse effects,increase the overall effectiveness of the treatment,and contribute to the improvement of patients'quality of life.Therefore,NIPPV should be regarded as an effective and safe treatment in clinical management,especially in patients with severe bronchial asthma combined with respiratory failure,where its application has potential clinical significance.

Early tracheotomy for acute severe asthma

BACKGROUND： Few studies have reported the effects of early tracheotomy in acute severe asthmatic patients. We report two patients with acute severe asthma who were successfully treated with early tracheotomy. METHODS：The two patients with acute severe asthma were retrospectively reviewed. They had been treated at the Department of Emergency and Critical Care, Renji Hospital, Shanghai Jiaotong University School of Medicine. RESULTS： They developed progressively hypercapnia and severe acidosis, and were not improved after conventional therapies. Early tracheotomy after mechanical ventilation decreased airway resistance and work of breathing, and corrected hypercapnia and acidosis. Adequate gas exchange was maintained after tracheotomy. The two patients were subsequently weaned from mechanical ventilation and discharged. CONCLUSION：Early tracheotomy could be a valuable approach in certain patients with severe asthma.

Primary intratracheal schwannoma misdiagnosed as severe asthma in an adolescent:A case report

BACKGROUND Primary intratracheal schwannoma is an extremely rare type of benign airway tumor,especially in adolescents.The presenting symptoms are typically prolonged cough and wheezing that can be misdiagnosed as asthma in adolescent patients.CASE A 16-year-old adolescent girl admitted to a local hospital with symptoms of an irritating cough and wheezing was diagnosed with bronchial asthma and treated with budesonide and formoterol.Over the next year,the patient's wheezing and coughing symptoms gradually worsened and the antiasthma treatment was ineffective.One week prior to this admission,the patient developed dyspnea after catching a cold and was transferred to our hospital with a diagnosis of severe asthma.However,chest computed tomography and bronchoscopy showed a mass in the trachea.Primary intratracheal schwannoma was diagnosed by biopsy.Her symptoms were relieved by endoscopic resection by electrosurgical snaring combined with argon plasma coagulation.No relapse occurred during an 18 mo follow-up.CONCLUSION Primary intratracheal schwannoma should be considered in the differential diagnosis in adolescents with recurrent asthma-like attacks.

Different levels of MUC5AC and MUC5B genes expression in severe allergic versus non-allergic asthma

Asthma affects about 330 million individuals worldwide while 10%of asthmatic patients develop the severe type.The two main phe­notypes of severe asthma are allergic and non-allergic.Notably,remodeling and mucus overexpression are hallmarks of severe asthma upon dysregulation of MUC5AC and MUC5B.In severe allergic asthma due to the initiation of the allergic cascade,immune cells are recruited and a large number of inflammatory mediators will be produced leading to the overexpression of MUC5AC and MUC5B in the airways.Moreover,the production of mediators including tumor necrosis factorα(TNF-α)and interleukin 13(IL-13)will cause airways’muscle proliferation.Both overproductions of mucin and muscle proliferation will lead to remodeling progression.On the other hand,in severe non-allergic asthma,fewer immune cells are involved but still,the expression of MUC5AC is enhanced.Howev­er,MUC5B might increase less than the amount of its expression in allergic phenotype due to the lower number of involved immune cells and mediators.In the non-allergic phenotype mediators such as interleukin 17(IL-17)and transforming growth factorβ(TGF-β)are responsible for muscle proliferation.The result of mucus overexpression and muscle proliferation is remodeling progression in the non-allergic severe asthma.Therefore,we hypothesize that MUC5AC and MUC5B overexpression in severe allergic asthma is greater than in severe non-allergic asthma.Hence,remodeling progression is more intensive in severe allergic asthma.In conclusion,given the central roles of MUC5AC and MUC5B in mediating the asthma severity,they can be treated as potential therapeutic targets in severe asthma.

Severe asthma exacerbation:Changes in patient characteristics,management,and outcomes from 1997 to 2016 in 40 ICUs in the greater Paris area

Background Despite advances in asthma treatments,severe asthma exacerbation(SAE)remains a life-threatening condition in adults,and there is a lack of data derived from adult patients admitted to intensive care units(ICUs)for SAE.The current study investigated changes in adult patient characteristics,management,and outcomes of SAE over a 20-year period in 40 ICUs in the greater Paris area.Methods In this retrospective observational study,admissions to 40 ICUs in the greater Paris area for SAE from January 1,1997,to December 31,2016 were analyzed.The primary outcome was the proportion of ICU admissions for SAE during 5-year periods.Secondary outcomes were ICU and hospital mortality,and the use of mechanical ventilation and catecholamine.Multivariate analysis was performed to assess factors associated with ICU mortality.Results A total of 7049 admissions for SAE were recorded.For each 5-year period,the proportion decreased over time,with SAE accounting for 2.84%of total ICU admissions(n=2841)between 1997 and 2001,1.76%(n=1717)between 2002 and 2006,1.05%(n=965)between 2007 and 2011,and 1.05%(n=1526)between 2012 and 2016.The median age was 46 years(interquartile range[IQR]:32–59 years),55.41%were female,the median Simplified Acute Physiology Score II was 20(IQR:13–28),and 19.76%had mechanical ventilation.The use of mechanical ventilation remained infrequent throughout the 20-year period,whereas the use of catecholamine decreased.ICU and hospital mortality rates decreased.Factors associated with ICU mortality were renal replacement therapy,catecholamine,cardiac arrest,pneumothorax,acute respiratory distress syndrome,sepsis,and invasive mechanical ventilation(IMV).Non-survivors were older,had more severe symptoms,and were more likely to have received IMV.Conclusion ICU admission for SAE remains uncommon,and the proportion of cases decreased over time.Despite a slight increase in symptom severity during a 20-year period,ICU and hospital mortality decreased.Patients requiring IMV had a higher mortality rate.

Characteristics, phenotypes, mechanisms and management of severe asthma

Severe asthma is "asthma which requires treatment with high dose inhaled corticosteroids (ICS) plus a second controller (and/or systemic corticosteroids) to prevent it from becoming ’’uncontrolled’ or which remains ’’uncontrolled’ despite this therapy." The state of control was defined by symptoms, exacerbations and the degree of airflow obstruction. Therefore, for the diagnosis of severe asthma, it is important to have evidence for a diagnosis of asthma with an assessment of its severity, followed by a review of comorbidities, risk factors, triggers and an assessment of whether treatment is commensurate with severity, whether the prescribed treatments have been adhered to and whether inhaled therapy has been properly administered. Phenotyping of severe asthma has been introduced with the definition of a severe eosinophilic asthma phenotype characterized by recurrent exacerbations despite being on high dose ICS and sometimes oral corticosteroids, with a high blood eosinophil count and a raised level of nitric oxide in exhaled breath. This phenotype has been associated with a Type-2 (T2) inflammatory profile with expression of interleukin (IL)-4, IL-5, and IL-13. Molecular phenotyping has also revealed non-T2 inflammatory phenotypes such as Type-1 or Type-17 driven phenotypes. Antibody treatments targeted at the T2 targets such as anti-IL5, anti-IL5Rα, and anti-IL4Rα antibodies are now available for treating severe eosinophilic asthma, in addition to anti-immunoglobulin E antibody for severe allergic asthma. No targeted treatments are currently available for non-T2 inflammatory phenotypes. Long-term azithromycin and bronchial thermoplasty may be considered. The future lies with molecular phenotyping of the airway inflammatory process to refine asthma endotypes for precision medicine.

Emerging roles and therapeutic implications of HDAC2 and IL-17A in steroid-resistant asthma

Steroid resistance represents a major clinical problem in the treatment of severe asthma,and therefore a better understanding of its pathogenesis is warranted.Recent studies indicated that histone deacetylase 2(HDAC2)and interleukin 17A(IL-17A)play important roles in severe asthma.HDAC2 activity is reduced in patients with severe asthma and smoking-induced asthma,perhaps accounting for the amplified expression of inflammatory genes,which is associated with increased acetylation of glucocorticoid receptors.Neutrophilic inflammation contributes to severe asthma and may be related to T helper(Th)17 rather than Th2 cytokines.IL-17A levels are elevated in severe asthma and correlate with the presence of neutrophils.Restoring the activity of HDAC2 or targeting the Th17 signaling pathway is a potential therapeutic approach to reverse steroid insensitivity.

Aspirin-exacerbated respiratory disease:Update on medical management

Aspirin-exacerbated respiratory disease(AERD)is frequently diagnosed in patients with severe type 2 airway inflammation presenting with nasal polyps and severe asthma.It has been associated with a recalcitrant course with high medical and surgical requirements.The advent of recent biological and other targeted treatments show promise in the medical management of patient with AERD.The goal of complete disease control where patients no longer require recurrent surgical procedures,systemic corticosteroid exposure and may live with a stable and relatively normal quality of life is now within reach.Further work is necessary to identify biomarkers predictive of treatment response.