the role of magnesium sulphate in the management of acute asthma
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THE ROLE OF MAGNESIUM SULPHATE IN THE ROLE OF MAGNESIUM SULPHATE IN THE MANAGEMENT OF ACUTE ASTHMATHE MANAGEMENT OF ACUTE ASTHMA
ByBy
DR. COLONEL (R) AZMAT ALI DR. COLONEL (R) AZMAT ALI M.B.B.S, MSc. (Medical Administration) M.B.B.S, MSc. (Medical Administration)
DEPARTMENT OF PHARMACOLOGY DEPARTMENT OF PHARMACOLOGY
ISRA UNIVERSITY ISRA UNIVERSITY
HYDERABAD, SINDH HYDERABAD, SINDH
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1
. INTRODUCTION 1
. INTRODUCTION
Mg Sulphate, an additive in the management of acute
asthma It may be effective through a variety of mechanisms
It is a common mineral in geological strata
Its other uses are
Magnesium may play a role in the pathogenesis of
asthma.
Intravenous magnesium may be helpful when
conventional therapy fails
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2. AIMS AND OBJECTIVES 2. AIMS AND OBJECTIVES
To determine the substantial evidence regarding theTo determine the substantial evidence regarding the
role of MgSO4 in acute asthma.role of MgSO4 in acute asthma.
To determine whether this may be supportive therapyTo determine whether this may be supportive therapy
for patients presenting to the emergency departmentfor patients presenting to the emergency department
with acute asthma.with acute asthma.
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extremelyextremely distressed,distressed, using using accessoryaccessorymusclesmuscles ofof respiration,respiration, areare
hyperinflatedhyperinflated andand tachypnoeic,tachypnoeic,ultimatelyultimately exhaustedexhausted andand requirerequireventrilatoryventrilatory supportsupport..ThereforeTherefore aimaim ofof studystudy isis toto preventprevent
suchsuch aa gravegrave situationsituation toto developdevelop bybytimelytimely administrationadministration ofof intravenousintravenous ororinhalationinhalation ofof magnesiummagnesium sulphatesulphate..
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4. MATERIALS AND METHODS: 4. MATERIALS AND METHODS:
4.1. 4.1. Study design:Study design: Descriptive comparative Descriptive comparative
4. 2
. 4
. 2
. Setting:Setting: Department of Medicine, Isra University Department of Medicine, Isra University Hospital, Hospital, Hyderabad, Liaquat University Hyderabad, Liaquat University Hospital, Jamshoro and Institute of Chest Hospital, Jamshoro and Institute of Chest Diseases, Kotri Diseases, Kotri
4.3. 4.3. Duration of study: Duration of study:Six months from January 2010 to June 2010Six months from January 2010 to June 2010
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4.4. Sample size:
73 patients of acute asthma were enrolled in this study.
Group I:
Patients were administered oxygen, intravenoushydrocortisone
and nebulization with ventoline solution
Group II:
Patients were administered intravenous magnesium sulfate besides
oxygen administration, parenteral Hydrocortisone and nebulization
by ventoline solution
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4.5. 4.5. Sampling technique:Sampling technique: Non Probability Sampling Non Probability Sampling
4.6. 4.6. Sample Selection:Sample Selection: 4.6.1. 4.6.1. Inclusion criteria: Inclusion criteria:1.1. Hospitalized patients with acute asthma between Hospitalized patients with acute asthma between
the ages of 10 to 40 years.the ages of 10 to 40 years. 2. 2. Patients having Peak Expiratory Flow Rate is > Patients having Peak Expiratory Flow Rate is >
50 %.50 %.
3.3. Those who give informed consent Those who give informed consent
4.6. 2. 4.6. 2. Exclusion criteria: Exclusion criteria:1.1. Congestive cardiac failureCongestive cardiac failure 2. 2. Coronary artery diseaseCoronary artery disease3.3. Diabetes mellitus Diabetes mellitus 4. 4. Renal insufficiency Renal insufficiency5.5. Hypertension Hypertension6.6. Pnemonaemias Pnemonaemias7.7. Pregnancy Pregnancy8.8. Patients with temperature > 39.8OC Patients with temperature > 39.8OC9.9. Patients who are unable to use expiratory flow meter. Patients who are unable to use expiratory flow meter.
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4.7.1. Sample collection (investigations)
Patient·s samples were collected:
Blood by Venepuncture into EDTA tube (2 ml for Blood CP)2. 2 ml blood for sugar in fluoride bottle3. 2 ml of blood in plain bottle for serum magnesium4. 2 ml of blood in heprinized syringe for ABGs
5. Urine DR and for pregnancy test in case of females
4.7. 2. Sample preparation
The samples were analyzed within 4 hours of collection
Parameters: PulseBlood pressure
Respiratory rate Peak Expiratory Flow Rate
Oxygen saturation
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4.8.4.8. Treatment protocol:Treatment protocol:After carrying out initial assessment, selected patientsAfter carrying out initial assessment, selected patients
were divided into the following groupswere divided into the following groups::
4.8.1.4.8.1. Group A:Group A:Patients received conventional treatment of 0.5 ml ofPatients received conventional treatment of 0.5 ml ofSalbutamol (2.5 mg) by neublizer and oxygen therapy,Salbutamol (2.5 mg) by neublizer and oxygen therapy,followed by 100 mg of Hydrocortisone intravenously.followed by 100 mg of Hydrocortisone intravenously.
4.8.2.4.8.2. Group B:Group B:Besides conventional treatment as in group A received after 30Besides conventional treatment as in group A received after 30minutes, a dose of Intravenousminutes, a dose of Intravenous magnesium sulfate 25 mg per Kg magnesium sulfate 25 mg per Kg bodybody weight or maximum 2 g diluted in 100 ml of normalweight or maximum 2 g diluted in 100 ml of normal
saline in 20saline in 20minutes.minutes.Administration of drugs in the both the groups were monitoredAdministration of drugs in the both the groups were monitoredby pulse oxymetry. After a period of 60 and 120 minutes vitalby pulse oxymetry. After a period of 60 and 120 minutes vitalsigns, pulse oxymetry and Peak Expiratory Flow Rate (PEFR)signs, pulse oxymetry and Peak Expiratory Flow Rate (PEFR)were again recorded for the patients in both the groups.were again recorded for the patients in both the groups.
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5. Statistical analysis:
The data were evaluated in statistical program SPSS
versions 16.0. Categorical parameters such as Gender,
Age groups etc. were presented as n(%). Numerical
variables like Age in years, Duration of asthma, PulseRate, Respiratory Rate, Systolic and Diastolic Blood
Pressure, Oxygen Saturation, Peak Expiratory Flow
Rate etc. were presented as Mean + Standard
Deviation and Student t test (2 tailed) was applied to
compare the means among the Conventional andMagnesium). All the data were calculated on 95%
confidence interval. A P value < 0.05 was considered
as statistically significant level for all the comparisons.
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RESULTSTABLE NO. 7
COMPARISON OF RESPIRATORY RATE (BREATHS / MINUTES)BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
Respiratory rate(breaths /minutes)
Conventional(n = 36)
Magnesium(n = 37)
P value
Before
After 60 minutes
After 120 minutes
32.6 + 4.84
28.7 + 6.03
21.1 + 2.95
33.7 + 5.41
26.5 + 3.89
17.9 + 2.02
0.36
0.06
< 0.001*
Results are expressed as Mean + Standard deviation calculated by studentt test
* P value is statistically significant
Table No. 1
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COMPARISON OF RESPIRATORY RATE (BREATHS / MINUTES)
BASELINE, AFTER 60 & 120 MINUTES OFTREATMENT
(n = 73)
RESULTSGraph No. 1
P = 0.36
P = 0.06
P = <0.0001
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RESULTS
Comparision of Respiration Rate Base line after 60
& 120 min of treatment
12
17
22
27
32
37
42
30 60 120
(Time Minutes)
R e s p i r a t i o n
R a t e
Conventional
Magnesium
GRAPH NO. 7
COMPARISON OF RESPIRATORY RATE (BREATHS / MINUTES)BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
Graph No. 2
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COMPARISON OF OXYGEN SATURATION
BASELINE, AFTER 60 & 120 MINUTES OFTREATMENT
RESULTSGraph No. 3
P = 0.004
P = 0.85
P = 0.23
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RESULTSGRAPH NO. 4
COMPARISON OF O Y EN SATURATION
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)C n O n S n B L n ,
60 & 120 n n
85
87
89
91
93
95
97
99
30 60 120
(T M n )
O
n S
n
Conv ntional
Magnesium
(n = 73)
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COMPARISON OF PEAK EXPIRATORY FLOW RATE (L/MINUTE)
BASELINE, AFTER 60 & 120 MINUTES OFTREATMENT
(n = 73)
RESULTSGraph No. 5
P = 0.001
P = 0.008
P = 0.23
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RESULTS
Comparision of Peak E piratory Base Line, after
60 & 120 min of treatment
150
170
190
210
230
250
30 60 120
(Time Minutes)
P e a k E
p i r a t o r y
Conventional
Magnesium
GRAPH NO. 11
COMPARISON OF PEA E PIRATORY FLO RATE (L/MINUTE)
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
Graph No. 6
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RESULTSTABLE NO. 10
COMPARISON OF PULSE (HEART RATE/MINUTE)BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
Pulse Rate (beats /minutes): Conventional
(n = 36)Magnesium
(n = 37) P value
Before
After 60 minutes
After 120 minutes
108.7 + 19.83
123.2 + 16.86
91.9 + 8.46
109.9 + 17.48
104.8 + 15.40
88.3 + 5.11
0.91
< 0.001
0.04
Results are expressed as Mean + Standard deviation calculated by student ttest* P value is statistically significant
Table No. 5
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RESULTSGRAPH
¡
.¢ 2
I ( / I )I , I
(
Graph No. 7
P = 0.04
P = < 0.0001
P = 0.91
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RESULTS
Comparision of Pulse Rate b/w Conventional &
Magnesium roup @ 0, 60 & 120 min
70
90
110
130
150
170
190
30 60 120
(Time Minutes)
P u l s
e R a t e
Conventional
Magnesium
GRAPH . 3
I ( / I ) I ,I
( )
Graph No. 8
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DISCUSSION
In the present study, the mean age was similar tothe study of Silverman RA et al.(Silverman RA,
Osborn H et al.2002) The duration of asthma in this study was also
similar to the study of Aggarwal P et al.(AggarwalP, Sharad S et al.2006)
Mean serum magnesium level in this study iscomparable with the study of Silverman RA etal.(Silverman RA, Osborn H et al.2002).
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The heart rate in the baseline and after 60 minutesof treatment in this study was insignificant in both
the groups and Aggarwal P, Sharad S et al.2006 aswell found same observation in their study. In thepresent study, the heart rate after 120 minutes wassignificantly slowed down to 88.3 + 5.11 (beats
/minutes) in the magnesium group (n = 37) and it
remained 91.9 + 8.46 (beat / minutes) in theconventional group (n = 36). These results aresimilar to the study of Aggarwal P, Sharad S etal.2006.
DISCUSSION
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Respiratory rate was significantly reduced in the magnesiumgroup after final treatment. Mean respiratory rate + SD inbaseline was 32.6+4.84 breaths / minute in the conventional
group and 33.7 + 5.41breaths / minute in magnesium group.After final treatment, mean respiratory rate + SD were 21.1+ 2.95 breath / minute (n = 36) and 17.9 + 2.02 breaths /minute (n = 37) of conventional and magnesium groupsrespectively. This finding was comparable with study of BijaniK et al. 2002, in whose study the average of respiratory rate
in baseline was 34 breaths / minute in the magnesium groupand 35 breaths / minute in the saline group. After finaltreatment the respiratory rate declined to 24 breaths/minutein the magnesium group and 30 in the saline group.
DISCUSSION
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In this study, the baseline average of PEFR were174.0 and 164 L/minute in the magnesium (n =
37) and conventional groups respectively. After 60minutes of treatment, the mean + SD inconventional (nebulization) and intravenousmagnesium plus nebulization conventional were183.1 + 34.25(n = 36) and 206.2 + 37.81(n =
37) respectively. Nannini et al. (Nannini LJ Jr,Pendino JC et al.2000) showed that compared witha single dose of sabutamol, there was a greatincrease in peak flow rate when a single dose of magnesium sulfate was added to nebulised
patient with salbutamol.
DISCUSSION
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CONCLUSION
The serious health problem posed by asthma cannot beoveremphasized. Unfortunately it is inadequately diagnosed
and is poorly managed, resulting in a vicious cycle of morbidity and mortality. Even worse is the fact that a lot of misconceptions about the illness which are widely prevalenteven among health professionals.
A single dose of intravenous magnesium sulfate and
conventional therapy (by oxygen inhalation, ventolinenebulization, and intravenous hydrocortisone) administeredto patients with severe acute asthma has been observed tobe effective in relieving the symptoms as compared toconventional therapy alone.
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RECOMMENDATIONS Education of patient is important as regards current asthma
management
Patients should understand their disease process, use of
medications, ability to react to their change disease symptoms, oractual measured peak flow
Peak flow meter must be available in all the clinics and emergencydepartments and all patients be provided their instruments onsubsidized rates.
Doctor or nurses should be encouraged to use peak flow meter.
In for flung areas of countries, physicians, should be encouraged
to use ½ MgSO4 besides conventional treatment Mechanical verifications be made available at least at Taluka and
RHC level.
Patients of asthma be registered and drug companies be instructedto provide medication on reduced rates for poor patients
Asthma society Hyderabad Chapter may be activated.
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PROFORMADemographic details:S. No: Name of Institution / Hospital:
Name: Age: Sex: 1. Male 2. Female
Occupation:
Address:
Marital status: Religion:
Date of admission: Ward:
Reg: No. Bed No:
Brief history:
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Weight (Kg):
Height:
Duration of Asthma (in years):Number of previous hospitalizations:
Time of arrival:
Hospital stay:
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