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    2007). National Heart Lung and Blood Institute: Guidelines for the diagnosis and management of asthma . Retrieved on May 1, 2014 fromhttp://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

    (2008).Asthma. Retrieved on May 1, 2014 from http://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.html (2010).Asthma. Retrieved on May 1, 2014 from http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=2154921&PDFSource=13

    Asthma has a severe impact on impoverished urban populations, ie: South Side Chicago. Asthma constitutes a significant public health problem. According to a 1996 study, the Chicago Asthma hospitalization rate was 42.8 per 10,000 patients. This representstwice the amount as suburban Chicago and the United States. The study found that Medicaid and elderly patients were not only overrepresented, but also that the length of stay was substantially longer. While age-adjusted Asthma mortality rate in Chicago was4.7 times greater in African Americans compared to Caucasians, the Asthma mortality rate for Hispanics has doubled in the last decade. Nationally, the African American/Caucasian Asthma mortality ratio is 2.5:1. Asthma has a significant economic burden onthe community. Children with Asthma have accounted for 12.8 million school days missed annually. Adult Asthma accounts for 10.1 million missed work days annually. Asthma cost our HealthCare system $50.1 billion annually. This cost covers prescriptionmedication, hospital care, and physician services. Indirectly, Asthma cost $5.9 billion annually, which includes productivity loss and premature mortality. Our study, Factors Predictive of Acute Respiratory Failure in Asthmatics in Urban -UnderservedPopulations will focus on identifying the risk factors present in those with acute respiratory failure in order to quickly i dentify, address, and treat those patients whom are at highest risk. Most fatalities in Asthmatics are due to the culmination of deteriorating lungfunction that occurs over a period of time. By quickly identifying high-risk patients, we hope to prevent more fatalities.

    Every day in the United States, there are approximately: 63,000 individualsmiss school/work due to asthma 34,000 individualssuffer asthma exacerbation >5000 individuals seek care in the Emergency Department >1,300 individuals hospitalized due to asthma. 10 people die from asthma per day

    In 2009 the age-adjusted rate of 1.1 per 100,000, there wereapproximately:

    3,388 asthma linked deaths. 63%females.

    Asthma is a reversible pulmonary obstructive disease. It is triggeredby hyperactive airway response to specific stimuli. Asthma fatality iscaused by airflow obstruction due to increased bronchial hyper-responsiveness and reduced bronchial elasticity.

    Eosinophilic infiltration, glandular hypertrophy/hyperplasia, andsmooth muscle hypertrophy, and smooth muscle hypertrophy causeairway wall thickening in the large airways.

    Abnormal actin and myosin latchbridges in the smooth muscle maylead to fatality in the presence of stimulation, decreased tidal volume,and decreased/absent beta-adrenergic stimulation.

    Peribronchial inflammation and thickening of the adventitia causesthe bronchial wall to detach from the lung parenchyma, thus reducingthe ability of airways to expand and recoil, and predisposing to airwayclosure and obstruction.

    Bronchospasm, inflammation, edema, mucous plugging in the

    airways leads to respiratory failure by decreasing airflow, increasingobstruction, decreasing expiratory airflow, and prolonging eachexhalation and limiting the ability to take a new breath.

    This hyperinflation and hypoxemia elevates intrinsic PEEP andplateau pressure which in turn can cause collapse of thecardiovascular system.

    During an asthma exacerbation, prolonged hypoxia may be bluntedand patients may be falsely identified with asthma symptomsnormalizing.

    .

    Epidemiology Results

    Abstract

    Conclusion

    Develop a criterion for quick identification of severe asthma phenotypes and high risk patients. Consistent documentation of spirometry and peak flow measurements in ER and inpatient settings. Manage hospital inpatients in higher acuity rather than general units. Practice early recognition of symptom progression and administer appropriate intervention. Avoidance of sedatives and bronchospasm induced medication. Discharge note should include an asthma action plan that focuses on each patients individual needs. All patients hospitalized with acute asthma exacerbation of should be reviewed by a clinician within 30 days of

    discharge. Patient education and frequent follow-ups to ensure proper use of medication, improve patient compliance,

    and assess need for additional therapy. Take note of population specific asthma and seek social services to help improve condition and prevent

    worsening respiratory failure.

    Objective:Understanding factors that are predictive of acute respiratory failuresecondary to asthma in underserved urban populations.

    Study Site:JPH ICU/Step down (8 beds) & ER, an urban community teachinghospital in Chicagos under-served Southside.

    Study Populat ion:Adult patients with a diagnosis of Acute Respiratory Failure secondaryto asthma. The study presented at JPH ER/ICU between January,2012 and January, 2014.

    Methodology:

    Retrospective Chart Review of patients with a diagnosis of acuterespiratory failure secondary to asthma. We will review patients whohad documented asthma, an action plan, adherence to plan (full,partial, or non-Compliant), and who further developed acuterespiratory failure. We will evaluate documentation of diagnosticcriteria for respiratory failure, LOS, and morbidity and mortality rates inour community. We assessed trigger factors in our population,including a history of previous exacerbations, poor asthma control,poor inhaler technique, a history of prior respiratory tract infection,poor adherence to medication, presence of allergic rhinitis, gastro-esophageal r eflux disease, psychological dysfunction, smoking, andobesity.

    Inclusion Criteria:Patients must have a confirmed or suspected Acute RespiratoryFailure secondary to asthma, previously established diagnosis ofasthma, patients who have moderate or severe persistent asthma, ahistory of severe exacerbations, or poorly controlled asthma.

    Exclusion Criteria:Acute Respiratory Failure from causes other than from asthma.

    Recommendations

    Pathophysiology

    Diagnosis Diagnosis of Respiratory Failure in Asthmatics is based on clinical

    signs and symptoms Work of breathingHyperventilation, use of accessory

    muscles, and abdominal breathing Breath SoundsWheezing and/or absence of breath sounds Mental statusLassitude, lethargy, alertness, and fatigue

    Diagnosis of Respiratory Failure in Asthmatics is confirmed bylaboratory evidence:

    Peak Flow: < 20% of baseline Oxygen Saturation: < 88% of baseline Arterial Blood Gases: Ph < 7.35, PO2 < 60, Co2 > 50

    Our Study: Retrospective

    Number of asthma exacerbation admitted at Jackson Park Hospital: YEAR 2011885 YEAR 2012864 YEAR 2013 773 PATIENTS WITH ACUTE RESPIRATORY FAILURE SECONDARY TO STATUS ASTHMATICUS57

    Patient Past Medical History/Social History:

    MEDIAN AGE54.7 years (18 - 67 years)

    GENDER (63%) female

    DRUG USE50%) screened positive for illicit drugs: (+) Heroin > (+) Cocaine

    SMOKING STATUS(61%) tobacco

    URI(27%) reported URI preceding symptoms

    MENTAL HEALTH(28%) had psychological dysfunction/depression PRIOR HISTORY OF RESPIRATORY FAILURE 44%

    DIAGNOSTIC CRITERIA Mental Status39% Breath Sounds28% Work of Breathing 34% O2 Sat96% Pre-Intubation ABG 57% Peak Flow11%

    Findings: Over 50% of our study were 54 year old female smokers with frequent readmissions and positive drugtoxicology screen. History of psychiatric disease, prior respiratory failure, and preceding upper respiratory infectionplayed a lessor role in asthma fatality. However, these serve as possible points of intervention in both inpatientand outpatient settings.

    Evidence:Patients with drug abuse and frequent re-admissions are at higher risk of respiratory failure.Study l imitat ions: Specific to inner city underserved, adult population with a smaller sample size. Chartdocumentation and data collection were not always applicable.

    Goal:Improve outcomes and prevent hospital fatal events.

    Risk Factors for Fatal Asthma: Clinical

    Aspects

    Persistent & severe asthma

    Significant swings in Peak Expiratory

    Flow Rate

    PMHx of respiratory failure caused by

    asthma

    Prior hospitalization due to asthma

    Recent dose reduction of prednisone use

    Lack of medical care, health insurance,

    or access to healthcare

    PMHx of Psychological disorders or

    depression.

    Patient Chart Documen tation:

    PRE-INTUBATION SYMPTOMS2.78 days NEBULIZER TX4.63 average MGSO4 54% HELIOX13% NIPPV50% LENGTH OF STAY10.3 days MORTALITY RATE7.2%

    References

    http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htmhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=2154921&PDFSource=13http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=2154921&PDFSource=13http://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.htmlhttp://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm