Asthma
                                ======
þ Atrovent (ipratropium) and Spiriva
 - parasympathetic blockers
 - Atrovent (old inhalers) CANNOT be used by those with peanut or treenut
   allergy, per the manufacturer; it cross-reacts. Also noted at the ISMP
   website (ismp.org) in a 1998 article. Apparently, this is related to soy
   lethicin, which is found in Atrovent, but from my review online, also in
   other inhalers.
 - However, I spoke with the manufacturer 2/1/12, and they say that the
   old Atrovent and Combivent CFC inhalers did have soy lecithin and were a
   risk for those with soy or peanut allergy. But the newer HFA inhalers have
   no soy lecithin and have no risk for those with peanut allergy.
   For Spiriva, here might be traces of soy lecithin used to lubricate the
   capsules but the powder has no soy lecithin; sounds safe to me.
 - As far as inhalation solution, it's all generic and I don't know.

þ Tachycardia and Albuterol
 - Does albuterol reduce heart rate in tight asthmatics? Yes.
   [Rodrigo, C. and G. Rodrigo (1998). "Salbutamol treatment of acute severe
   asthma in the ED: MDI versus hand-held nebulizer." Am J Emerg Med 16(7):
   637-42.
        The objectives of this study were to compare the efficacy of
        salbutamol delivered by either metered-dose inhaler plus spacer
        (MDI-spacer) or by wet nebulization (NEB), and to determine the
        relationships between physiologic responses and plasma salbutamol
        concentrations. Asthmatic patients presenting to the emergency
        department (ED) with acute severe asthma (forced expiratory volume in
        the first second [FEV1] less than 50% of predicted) were enrolled in a
        randomized, double-blind, parallel-group study. The MDI-spacer group
        received salbutamol, delivered via MDI into a spacer device, in four
        puffs actuated in rapid succession at 10-minute intervals (2.4 mg/h).
        The NEB group was treated with nebulized salbutamol, 1.5 mg, via
        nebulizer at 15-minute intervals (6 mg/h). Doses were calculated on
        the basis of the percentage of total dose that reaches the lower
        airway with both methods. The protocol involved 3 hours of this
        treatment. Mean peak expiratory flow rate (PEFR) and FEV1 improved
        significantly over baseline values for both groups (P=.01). However,
        there were no significant differences between both groups for PEFR and
        FEV1 at any point studied. The examination of the relationships
        between cumulative dose of salbutamol and change in FEV1 showed a
        significant linear relationship (P=.01) for both methods (MDI r=.97;
        NEB r=.97). The regression equations showed that for every 1 mg of
        salbutamol by MDI-spacer, 2.5 mg are needed from nebulization to have
        equal therapeutic response. At the end of treatment, the salbutamol
        plasma levels were 10.1+/-1.6 ng/ml for the MDI-spacer group and
        14.4+/-2.3 ng/ml for the NEB group (P=.0003). Both groups showed a
        nonsignificant heart rate decrease. A significant group-by-time
        interaction means that differences between groups increased with time
        (P=.04). Additionally, the NEB group presented a higher incidence of
        tremor (P=.03) and anxiety (P=.04), reflecting larger systemic
        absorption of salbutamol. These data indicate that when doses used are
        calculated on the basis of the percentage of total drug that reaches
        the lower airway, there was equivalent bronchodilatation after
        salbutamol administered by either MDI-spacer or nebulization in
        patients with acute severe asthma. However, nebulizer therapy produced
        greater side effects related to the increase in salbutamol absorption
        and higher plasma level.]

þ Advair for acute exacerbations?
 - Adding long-acting beta agonists (and inhaled steroids) to PO steroids and
   short-acting beta agonists.
 - Makes small but not significant difference in relapses over a 4-week period.
   [Rowe B. Addition of long-acting beta agonists to corticosteroid therapy
   after discharge for acute asthma: A randomized controlled trial. AEM 2004;
   11(5): 436]

þ Beta receptors in lung
 - different phenotypes
 - Arg-Arg subtype don't respond well to beta-agonists.

þ Medical Letter issue on asthma treatments
  <MedLtrAs.TXT>
  <MLasthma.TXT>

þ Cost of chronic asthma treatments (Medical Letter):
  <AsthCos2.TXT>

þ Triggers for Asthma
  <AsthTrig.TXT>

þ Epidemiology and Classification of Asthma
  <AsthEpid.TXT>

þ Evaluation of the Asthmatic
  <AsthEval.TXT>

þ Paradoxical asthma caused by inhalers, nebulizers, and steroids
  <paradox.TXT>

þ Role of oxygen in making hypoxemia _worse_
  <Oxygen.txt>

þ Beta Agonists for Asthma
  <AsthBeta.TXT>

þ Steroids for Asthma Exacerbations
  <AsthSter.TXT>

þ Other Asthma Treatments
  <AsthTrea.TXT>

þ Problem with giving steroids and neuromuscular blockers (paralytics):
  may cause a severe myopathy.
  <Myopath.TXT>

þ Pseudo-Asthma
  <Pseudo-A.TXT>

þ Relapses
 - A five to 15% relapse rate seems to continue to occur in acute asthma in
   the first few days despite optimum treatment.

þ Deaths from Asthma
 - extreme hypercapnia and acidosis, no arrhythmias.
   [Molfino. NEJM 1991;324:285-8.]

þ Intubation and Mechanical Ventilation
 -