Intravenous magnesium sulfate therapy in severe asthma
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225 INTRAVENOUS MAGNESIUM SULFATE THERAPY IN SEVERE ASTHMA Mohd. Al-Ajmi 1 , P Mandal 2 Summary A 22-year-old female, known asthmatic since seven years, developed severe bronchospasm in the preop- erative period. Bronchospasm remained unresponsive to the inhaled beta-agonist plus anticholinergic, IV ami- nophylline and hydrocortisone but responded quickly with magnesium sulfate® ( PSI, KSA) infusion 1.25gm in 100ml normal saline over 20 minutes and another 1.25 gm over next 30 minutes as the initial infusion showed improvement in her clinical symptoms. Within half an hour of administering the 1 st infusion of magnesium sulfate (1.25 gm) the respiratory rate started reducing, rhonchi became less, SpO 2 came upto 92% and re- mained always above 90%. Encouraged by this result IV magnesium sulfate 2.5 gm in 500 ml normal saline was infused over next 24 hours along with alternate salbutamol and ipratropium nebulization every 6 hourly.With this treatment regimen the patient became asymptomatic with in next 24 hours with normal clinical parameters and FEV 1 value. Hence it may be concluded that IV magnesium sulfate can be considered for patients with acute severe asthma who do not respond to standard therapeutic medications. Key words Severe bronchospasm; Bronchodilators; Nebulization beta-agonist, Anticholinergic; IV, Magnesium sulfate. Indian Journal of Anaesthesia 2007;51 (3) : 225-227 Case Report Introduction Nebulized beta-agonist in asthmatics is considered to be the 1 st choice of bronchodilator therapy 1,2 . But frequently it has met with disappointingresults in an increasing num- ber of moderate to severe asthmatic patients who may be characterized as “poor responders” 3 . These type of pa- tients even do not respond to combination therapy with nebulized beta-agonist, anticholinergic, locally acting or in- travenously (IV) administered steroids. For them magne- sium sulfate administered either IV 4 or nebulized 5 as iso- tonic solution may be of help to achieve rapid bronchodilatation. We present here such a case of severe asthma who was unresponsive to the inhaled beta-agonist plus anticholinergic, IV aminophylline and hydrocortisone but responded quickly with IV magnesium sulfate therapy. Case report A 22-year-old female weighing 55 kg, known asth- matic since last seven years, was admitted to Armed Forces Hospital, Kuwait(AFHK) to undergo cholecystectomy for gall stone disease. She developed suddenly shortness of breath and perspiration following dust storm. She was shifted to ICU for respiratory therapy after the surgical registrar found that she had developed acute bronchospasm. On arrival in the ICU with ordinary oxygen mask she was put into continuous monitoring for SpO 2 , EKG,heart rate,respiratory rate and noninvasive blood pressure. She was put into supine head-up position with ventimask oxy- gen (35%). On examination, she was conscious and ori- ented, her respiratory rate was more than 30 per minute, she was having tracheal tug and all her accessory muscles of respiration were active. Her chest expansion was very minimal. On auscultation of her chest bilateral extensive rhonchi and fine crepitations were audible. Her forced expiratory volume in one second (FEV 1 ) was 25% of her predicted value and SpO 2 was between 80-85%. A diag- nosis of acute exacerbation of bronchial asthma was made and treatment was initiated. She was initially receiving 35% oxygen by ventimask which was gradually increased to 50%. Salbutamol (500 mg in 5 ml) and ipratropium (500 mg in 2ml) nebulization was provided alternately without any improvement in her clinical symptoms. Intravenous aminophylline 250 mg bolus plus 3mg.kg -1 .hour -1 of infu- sion was started. Hydrocortisone 200mg IV bolus too was 1. MD, Consultant & Chairman of Surgical Disciplines, 2. MD, Sr. Specialist, Dept. of Anaesthesia & ICU, Armed Forces Hospital, Kuwait (AFHK). Correspondence to: - P.Mandal, Email: [email protected] Accepted for publication on 25.3.07
Transcript of Intravenous magnesium sulfate therapy in severe asthma
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INTRAVENOUS MAGNESIUM SULFATE THERAPY INSEVERE ASTHMA
Mohd. Al-Ajmi1, P Mandal2
SummaryA 22-year-old female, known asthmatic since seven years, developed severe bronchospasm in the preop-
erative period. Bronchospasm remained unresponsive to the inhaled beta-agonist plus anticholinergic, IV ami-nophylline and hydrocortisone but responded quickly with magnesium sulfate® ( PSI, KSA) infusion 1.25gm in100ml normal saline over 20 minutes and another 1.25 gm over next 30 minutes as the initial infusion showedimprovement in her clinical symptoms. Within half an hour of administering the 1st infusion of magnesiumsulfate (1.25 gm) the respiratory rate started reducing, rhonchi became less, SpO
2came upto 92% and re-
mained always above 90%. Encouraged by this result IV magnesium sulfate 2.5 gm in 500 ml normal saline wasinfused over next 24 hours along with alternate salbutamol and ipratropium nebulization every 6 hourly.Withthis treatment regimen the patient became asymptomatic with in next 24 hours with normal clinical parametersand FEV1 value. Hence it may be concluded that IV magnesium sulfate can be considered for patients with acutesevere asthma who do not respond to standard therapeutic medications.
Key words Severe bronchospasm; Bronchodilators; Nebulization beta-agonist, Anticholinergic; IV,Magnesium sulfate.
Indian Journal of Anaesthesia 2007;51 (3) : 225-227 Case Report
IntroductionNebulized beta-agonist in asthmatics is considered to
be the 1st choice of bronchodilator therapy1,2. But frequentlyit has met with disappointingresults in an increasing num-ber of moderate to severe asthmatic patients who may becharacterized as “poor responders”3. These type of pa-tients even do not respond to combination therapy withnebulized beta-agonist, anticholinergic, locally acting or in-travenously (IV) administered steroids. For them magne-sium sulfate administered either IV 4 or nebulized5 as iso-tonic solution may be of help to achieve rapidbronchodilatation. We present here such a case of severeasthma who was unresponsive to the inhaled beta-agonistplus anticholinergic, IV aminophylline and hydrocortisonebut responded quickly with IV magnesium sulfate therapy.
Case reportA 22-year-old female weighing 55 kg, known asth-
matic since last seven years, was admitted toArmed ForcesHospital, Kuwait(AFHK) to undergo cholecystectomy forgall stone disease. She developed suddenly shortness ofbreath and perspiration following dust storm. Shewas shifted
to ICU for respiratory therapy after the surgical registrarfound that she had developed acute bronchospasm. Onarrival in the ICU with ordinary oxygen mask she was putinto continuous monitoring for SpO2, EKG,heartrate,respiratory rate and noninvasive blood pressure. Shewas put into supine head-up position with ventimask oxy-gen (35%). On examination, she was conscious and ori-ented, her respiratory rate was more than 30 per minute,she was having tracheal tug and all her accessory musclesof respiration were active. Her chest expansion was veryminimal. On auscultation of her chest bilateral extensiverhonchi and fine crepitations were audible. Her forcedexpiratory volume in one second (FEV1) was 25% of herpredicted value and SpO2 was between 80-85%. A diag-nosis of acute exacerbation of bronchial asthma was madeand treatment was initiated. She was initially receiving 35%oxygen by ventimask which was gradually increased to50%. Salbutamol (500 mg in 5 ml) and ipratropium (500mg in 2ml) nebulization was provided alternately withoutany improvement in her clinical symptoms. Intravenousaminophylline 250 mg bolus plus 3mg.kg-1.hour-1 of infu-sion was started. Hydrocortisone 200mg IV bolus too was
1. MD, Consultant & Chairman of Surgical Disciplines, 2. MD, Sr. Specialist, Dept. of Anaesthesia & ICU, Armed Forces Hospital, Kuwait(AFHK). Correspondence to: - P.Mandal, Email: [email protected] Accepted for publication on 25.3.07
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Indian Journal of Anaesthesia, June 2007
tried with limited result in her symptoms and FEV1
value(28% of predicted) after 30 minutes of treatment. SpO
2
value improved marginally and maintained between 85-88%only but no improvement in her dyspnoea or rhonchi in thechest.
At this point magnesium sulfate® ( PSI, KSA) 1.25gmin 100ml normal saline was infused over 20 minutes andanother 1.25 gm was infused over next 30minutes as theinitial infusion showed improvement in her clinical symp-toms. Within half an hour of administering the 1st infusionof magnesium sulfate (1.25 gm) the respiratory rate startedreducing, rhonchi was less, SpO
2came upto 92% and re-
mained always above 90%. Her chest movement could bevisible and the normal pattern of respiration was resumedplus she could cough out mucoid sputum. Tracheal tug dis-appeared, FEV1 value improved to 45%. Encouraged bythis result IV magnesium sulfate 2.5 gm in 500 ml normalsaline was infused over next 24 hours along with alternatesalbutamol and ipratropium nebulization every 6 hourly butaminophylline infusion was discontinued. Abed side X-raychest was unremarkable at this point. There was continu-ous improvement in her symptoms, chest findings and FEV
1
values. SpO2 value came up and remained above 98% af-ter two hours of magnesium sulfate infusion. Her FiO2 wasreduced to 35%.After 24 hours, magnesium sulfate infu-sion was discontinued but alternate salbutamol andipratropium nebulization every 6 hourly were continued.During magnesium sulfate infusion no arrhythmia orhaemodynamic changes were noticed. Biochemical param-eters in the blood were within normal limits including themagnesium level -1 mmol.L-1 (N=0.74-1.03 mmol.L-1). Shewas observed in the ICU for another day and then shiftedto ward. At that time her respiratory rate was 12-16/minute,SpO2 98-100% in room air and FEV1 was 75% of herpredicted value.
DiscussionWhen there is need for quick bronchodilatation,
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agonists remained the main stay in the initial managementof acute asthma1,2,7. However, the potential role of otheragents in the initial management of acute asthma is stillunclear.Aminophylline, many a times, in acute asthma foradults8 and children9 failed to demonstrate a beneficial re-sult. Steroids appear to reduce inflammation of the bron-chial wall and help to avoid hospital admissions10. Signifi-cant debate exists with respect to the benefit of other agents
such as magnesium sulfate in the treatment of acuteasthma. Magnesium, a predominantly intracellular cation,is an important cofactor in many enzymatic reactions andis linked to cellular homeostasis11. In addition, magnesiumhas an effect on smooth muscle cells, with hypomagnesemiacausing contraction and hypermagnesemia causing relax-ation. There is some evidence that when magnesium isinfused into asthmatic patients, it produces additionalbronchodilatation12,13. Because magnesium levels in asth-matics appear to be similar to those in control subjects14,the effect may relate to magnesium’s competitive antago-nism15 with calcium. In addition, evidence suggests thatmagnesium may reduce the neutrophilic burst16 associatedwith the inflammatory response in asthma. Thus, there isreason to believe that magnesium treatment, in the form ofIV magnesium sulfate, may be beneficial in the treatmentof acute asthma. The same result was achieved in thispatient too. Because she did not respond to initial medica-tions and observing her distress, once even we thought toput her into ventilator as there was no BiPAP or CPAPmask available with us.
The dose of initial infusion of magnesium sulfate wasselected as conservative, because we used this drug (asbronchodilator) for the first time in this patient. Many au-thors17-19 have used initial loading dose 2 gm over a periodof 20 minutes where as we infused almost half the dose ata time. But even with that dose we had achieved our goalas evident in her clinical condition and respiratory param-eters plus reduction in the other drug therapy.
Hence moderate dose of magnesium sulfate appearsto be safe and beneficial in patients with acute severeasthma unresponsive to conventional therapy.
To conclude, IV magnesium sulfate can be consid-ered for patients with acute severe asthma who do notrespond to standard therapeutic medications.
References1. National Asthma Education Program. Expert Panel Report I1:
Guidelines for the Diagnosis and Management of Asthma 1997.Bethesda, MD: National Institutes of Health 1997.
2. Beveridge RC, Grunfeld AF, et al. Guidelines for the EmergencyDiagnosis and Management of Asthma in adults. Can Med AssocJ 1996;155:25-37.
3. Skobeloff EM, Spivey WH, et al. Intravenous magnesium sul-fate for the treatment of acute asthma in the emergencydepartment.JAMA 1989 ; 262 : 1210-1213.
4. Beasley R. Isotonic nebulized magnesium sulfate for asthma.Respiratory Reviews.Com 2003;8(9).
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5. Rowe BH,Bretzlaff JA, et al. Magnesium sulfate for treatingexacerbations of acute asthma in the emergency department(Cochrane Review). The Cochrane Library, Issue 1, 2006.
6. Rowe BH, Bretzlaff JA, et al. Intravenous magnesium sulfatetreatment for acute asthma in the emergency department: A sys-tematic review of the literature. Annals of Emerg Med2000;36:181-190.
7. Cates C. Comparison of holding chambers and nebulizers forbeta-agonists in acute asthma (Cochrane Review). In: CochraneLibrary, issue 1. Oxford, United Kingdom: Update Software1998.
8. Littenberg B. Aminophylline treatment in severe, acute asthma:a meta-analysis. JAMA 1988;259:1678-1684.
9. Goodman DC, Littenberg B, et al. Theophylline in acute child-hood asthma: a meta-analysis of its efficacy. Pediatr Pulmonol1996;21:211-218.
10. Rowe BH, Keller JL, Oxman AD. Steroid use in the emergencydepartment treatment of asthma exacerbations: a meta-analysis.Am J Emerg Med 1992;10:301-310.
11. Mathew R, Altura BM. Magnesium and the lungs. Magnesium1988;7:173-187.
12. Okayama H, Aikawa T, et al. Bronchodilating effect of intrave-nous magnesium sulfate in bronchial asthma. JAMA1987;257:1076-1078.
13. Rolla G, Bucca C, et al. Acute effect of intravenous magnesiumsulfate on airway obstruction of asthmatic patients. Ann Allergy1988;61:388-391.
14. de Valk HW, Struyvenberg A, et al. Extracellular and intracellularmagnesium concentrations in asthmatic patients. Eur Respir J1993;6:1122-1125.
15. Magnesium: the mimic/antagonist of calcium [editorial]. N EnglJ Med 1984;310:1253-1255.
16. Cairns CB, Kraft M. Magnesium attenuates the neutrophil res-piratory burst in adult asthmatic patients. Acad Emerg Med1996;3:1093-1097.
17. James EG. Magnesium Sulfate and Acute SevereAsthma? Medscape Pulmonary Medicine 2005; 9.
18. Tiffany BR, Berk WA et al. Magnesium bolus or infusion fails toimprove expiratory flow in acute asthma exacerbations.Chest1993;104:831-834.
19. Bloch H, Silverman R, et al. Intravenous magnesium sulfate as anadjunct in the treatment of acute asthma.Chest 1995;107:1576-1581.
Mohd. Al-Ajmi et al. Magnesium sulfate in severe asthma
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