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Intravenous isoproterenol for severe asthma
Volume 89 Number 5
Letters to the Editor
the left mainstem bronchus. This method should be tried in cases of troublesome unilateral pulmonary emphysema, either as the initial approach or following the method previously proposed? Caution is advised in the selection of patients because the procedure is not without risks. Very careful attention must be paid to avoid extra-alveolar air leak in the lung being ventilated. Sudden development of a pneumothorax could produce catastrophic results. An additional complication is the development of pneumonia in the atelectatic lung, a well-described occurrence with prolonged atelectasis. In contrast to Dr. Dickman's patient who was successfully extubated after 24 hours, larger experience may support the need for longer periods of treatment, John C. Leonidas, M.D. New England Medical Center Hospital 171 Harrison A re. Boston, Mass. 02111 Robert T. Hall, M.D. Philip G. Rhodes, M.D. Kansas City, Mo. 64108 REFERENCES
1.
Magilner AD, Capitanio MA, Wertheimer I, and Burko H: Persistent localized intrapulmonary interstitial emphysema: An observation in three infants, Radiology 111:379, 1974. Fletcher BD, Outerbridge I~W, Youssef S, and Bolande RP" Puhnonary interstitial emphysema in a newborn in~hnt treated by Iobectomy, Pediatrics 54:808, !974. Leonidas JC, Hall RT, and Rhodes PG: Conservative management of unilateral pulmonary interstitial emphysema under tension, J PEDIATR 87:776, 1975. Brooks JG, Koops BL, Hilton S, Wesenberg RL, and Simmons MA: Selective bronchial intubation for the treatment of severe localize d interstitial emphysema, Pediatr Res 10:458, 1976 (abst.) Presented at Annual Meeting of American, Pediatric Society and Society of Pediatric Research, St. Louis, Missouri, April 28-30, 1976.
Intravenous isoproterenol for severe asthma To the Editor: Intravenous isoproterenol has been recommended for the treatment of the severely ill patient with status asthmaticus. In
865
two articles" -' which discuss this therapy, attention is paid to the possible cardiovascular complications of isoproterenol but affects in the kidney are ignored. Beta adrenergic stimulation with intravenous isoproterenol has been shown to have a significant antidiuretic effect in man at dosages less than those recommended for sta.tus asthmaticus? The mechanism of antidiuresis is not completely understood. It may relate to intrarenal effects of beta adrenergic stimulation or be the result of an increase in circulating antidiuretic hormone (ADH). :~ Status asthmaticus has also been shown to result in increased levels o f ADH, possibly secondary to decreased left atrial filling.' The use of intravenous isoproterenol for severe asthma can therefore be expected to result in water intoxication, if careful attention is not paid to fluid and electrolyte balance. This is of special concern since patients with asthma are frequently given intravenous fluids in greater than maintenance amounts. Indeed, significant hyponatremia was observed in one of our patients recently, but fortunately corrected prior to becoming symptomatic. Intravenous isoproterenol is a potent drug which may be useful for life-threatening asthma but attention must be paid to the fluid and electrolyte status of patients receiving it, in addition to their cardiovascular condition. John H. DiLiberti, M.D. Assistant Professor of Pediatrics University of Oregon Health Sciences Center Chief' of" Pediatrics Emanuel Hospital 2801 N. Ganwnbein Portland, OR 97227 REFERENCES
Wood DW, Downes J J, Scheinkopf H, et al" Intravenous isoproterenol in the management of respiratory failure in childhood status asthmaticus, J Allergy Clin lmmunol 50:75, 1972. 2. Parry WH, Martorano F, and Cotton EK: Management of life-threatening asthma with intravenous isoproterenol infu~ sions, Am J Dis Child 130:39, 1976. 3. Levi J, Coburn J, and Kleeman CR: Mechanism of the antidiuretic effect of B-adrenergic stimulation in man, Arch Intern Med 136:25, 1976. 4. Baker JW, Yerger S, and Segar W: Elevated plasma antidiuretic hormone levels in status asthmaticus, Mayo Clin Proc 51:31, 1976. 1.
Letters to the Editor
the left mainstem bronchus. This method should be tried in cases of troublesome unilateral pulmonary emphysema, either as the initial approach or following the method previously proposed? Caution is advised in the selection of patients because the procedure is not without risks. Very careful attention must be paid to avoid extra-alveolar air leak in the lung being ventilated. Sudden development of a pneumothorax could produce catastrophic results. An additional complication is the development of pneumonia in the atelectatic lung, a well-described occurrence with prolonged atelectasis. In contrast to Dr. Dickman's patient who was successfully extubated after 24 hours, larger experience may support the need for longer periods of treatment, John C. Leonidas, M.D. New England Medical Center Hospital 171 Harrison A re. Boston, Mass. 02111 Robert T. Hall, M.D. Philip G. Rhodes, M.D. Kansas City, Mo. 64108 REFERENCES
1.
Magilner AD, Capitanio MA, Wertheimer I, and Burko H: Persistent localized intrapulmonary interstitial emphysema: An observation in three infants, Radiology 111:379, 1974. Fletcher BD, Outerbridge I~W, Youssef S, and Bolande RP" Puhnonary interstitial emphysema in a newborn in~hnt treated by Iobectomy, Pediatrics 54:808, !974. Leonidas JC, Hall RT, and Rhodes PG: Conservative management of unilateral pulmonary interstitial emphysema under tension, J PEDIATR 87:776, 1975. Brooks JG, Koops BL, Hilton S, Wesenberg RL, and Simmons MA: Selective bronchial intubation for the treatment of severe localize d interstitial emphysema, Pediatr Res 10:458, 1976 (abst.) Presented at Annual Meeting of American, Pediatric Society and Society of Pediatric Research, St. Louis, Missouri, April 28-30, 1976.
Intravenous isoproterenol for severe asthma To the Editor: Intravenous isoproterenol has been recommended for the treatment of the severely ill patient with status asthmaticus. In
865
two articles" -' which discuss this therapy, attention is paid to the possible cardiovascular complications of isoproterenol but affects in the kidney are ignored. Beta adrenergic stimulation with intravenous isoproterenol has been shown to have a significant antidiuretic effect in man at dosages less than those recommended for sta.tus asthmaticus? The mechanism of antidiuresis is not completely understood. It may relate to intrarenal effects of beta adrenergic stimulation or be the result of an increase in circulating antidiuretic hormone (ADH). :~ Status asthmaticus has also been shown to result in increased levels o f ADH, possibly secondary to decreased left atrial filling.' The use of intravenous isoproterenol for severe asthma can therefore be expected to result in water intoxication, if careful attention is not paid to fluid and electrolyte balance. This is of special concern since patients with asthma are frequently given intravenous fluids in greater than maintenance amounts. Indeed, significant hyponatremia was observed in one of our patients recently, but fortunately corrected prior to becoming symptomatic. Intravenous isoproterenol is a potent drug which may be useful for life-threatening asthma but attention must be paid to the fluid and electrolyte status of patients receiving it, in addition to their cardiovascular condition. John H. DiLiberti, M.D. Assistant Professor of Pediatrics University of Oregon Health Sciences Center Chief' of" Pediatrics Emanuel Hospital 2801 N. Ganwnbein Portland, OR 97227 REFERENCES
Wood DW, Downes J J, Scheinkopf H, et al" Intravenous isoproterenol in the management of respiratory failure in childhood status asthmaticus, J Allergy Clin lmmunol 50:75, 1972. 2. Parry WH, Martorano F, and Cotton EK: Management of life-threatening asthma with intravenous isoproterenol infu~ sions, Am J Dis Child 130:39, 1976. 3. Levi J, Coburn J, and Kleeman CR: Mechanism of the antidiuretic effect of B-adrenergic stimulation in man, Arch Intern Med 136:25, 1976. 4. Baker JW, Yerger S, and Segar W: Elevated plasma antidiuretic hormone levels in status asthmaticus, Mayo Clin Proc 51:31, 1976. 1.