"Unveiling the Unforeseen: Diclofenac-Triggered Near-Fatal rapid onset Asthma in a Stable Asthmatic Individual Managed by NIV" A Unique Case report.

doi:10.21203/rs.3.rs-4992903/v1

Download PDF

Case Report

"Unveiling the Unforeseen: Diclofenac-Triggered Near-Fatal rapid onset Asthma in a Stable Asthmatic Individual Managed by NIV" A Unique Case report.

https://doi.org/10.21203/rs.3.rs-4992903/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

This case report details a 35-year-old woman with a history of mild intermittent asthma, who presented with rapid-onset severe respiratory distress shortly after ingesting oral diclofenac sodium for neck pain. Despite being well-controlled with inhalers for over a year, she developed near-fatal asthma, characterized by severe hypoxia, hypercapnia, and altered mental status, requiring immediate, multidisciplinary interventions. The patient was treated with high-flow oxygen, back-to-back nebulizations, and non-invasive ventilation (BiPAP), resulting in significant clinical improvement. This case highlights the rare but severe risk of NSAID-induced asthma exacerbations and signifies the importance of prompt recognition and aggressive treatment in managing life-threatening asthma episodes.

Internal Medicine

Pulmonology

Critical Care & Emergency Medicine

Near-fatal asthma

Rapid-onset acute asthma

NSAID-induced asthma

Diclofenac sodium

Non-invasive ventilation (BiPAP)

Asthma is a chronic respiratory condition marked by airway inflammation and hyper responsiveness, which can vary significantly in severity. While it is typically managed effectively with bronchodilators and anti-inflammatory medications, some asthma presentations can escalate quickly, leading to life-threatening situations. Among these severe complications are near-fatal asthma episodes and rapid-onset acute asthma exacerbations.

Near-fatal asthma represents an extreme form of the disease, characterized by severe respiratory compromise that often necessitates intensive medical intervention. Without prompt and effective treatment, this condition can progress to respiratory failure, marked by severe hypoxia, hypercapnia, altered mental status, and significant lung function impairment.

In contrast, rapid-onset acute asthma involves a sudden and severe deterioration of respiratory function in an individual who was previously stable or well-controlled. This rapid exacerbation can be triggered by various factors such as allergens, respiratory infections, or, as demonstrated in this case, ingestion of certain medications.

This case report highlights an instance where a previously stable asthmatic patient experienced a sudden onset of severe respiratory distress following the ingestion of diclofenac sodium tablets. The progression to a near-fatal asthma state required immediate, multidisciplinary interventions, providing valuable insights into the complexities and effectiveness of managing acute and life-threatening asthma exacerbations.

A 35-year-old woman with a history of mild intermittent asthma, well-controlled with inhalers for over a year without exacerbations, presented to the Emergency Treatment Unit (ETU) of TH Anuradhapura with a sudden onset of severe shortness of breath. This occurred 15–30 minutes after taking oral diclofenac sodium for mechanical neck pain, prescribed by her general practitioner.

Upon arrival at the ETU, the patient was severely breathless and confused, unable to provide a coherent history. A bystander reported that she had been well until visiting the GP after finishing work as an accountant, experiencing neck pain from prolonged screen use.

Examination:

General Appearance: Patient was severely breathless and confused, disoriented, and unable to complete sentences.
Airway: Patent.
Breathing: Poor effort with bilaterally reduced but equal chest expansion. Trachea was midline. Percussion note was resonant. Auscultation revealed silent chest.
Vital Signs: SpO2 was 65%, BP was 135/85 mmHg, heart rate was 60 bpm. Cardiovascular examination showed bounding pulses with relative bradycardia (55–65 bpm).
Disability: Patient was drowsy and confused, responsive to voice, with a GCS of 12 (E3V4M5). She could only articulate severe shortness of breath and was disoriented.
Exposure: No rashes noted. The patient was afebrile, not hypothermic, but showed early cyanosis in extremities.

Initial Investigations:

VBG: pH 7.171, pCO2 83.1 mmHg, pO2 25.2 mmHg, HCO3- 30.6 mmol/L, SpO2 30.2%, K 3.93 mmol/L, Na + 147.9 mmol/L, Lactate 5.2 mmol/L.
ECG: Normal with frequent ventricular ectopics.
CBS: 120 mg/dL.
Bedside Ultrasound: Normal ejection fraction, normal ventricular movements, right atrium/right ventricle not dilated, abdomen unremarkable, good IVC status.

Management:

The patient was managed as a case of rapid-onset near-fatal asthma. Initial treatment included high-flow oxygen via a non-rebreather mask (NRBM) at 100% oxygen, and back-to-back nebulizations with salbutamol. Despite these measures, the patient’s condition initially worsened, with dropping GCS and a repeat VBG showing worsening parameters (pH 7.162, pCO2 75.7 mmHg, pO2 33.5 mmHg, HCO3- 27.3 mmol/L, SpO2 46.7%, K 3.08 mmol/L, Na + 146.9 mmol/L, Lactate 3.8 mmol/L).

Following a specialist’s consultation, IV magnesium sulfate was administered. Given the severity of CO2 retention and the low GCS (a relative contraindication for BiPAP), the patient was nonetheless placed on non-invasive ventilation with BiPAP, alongside continued nebulization and specialist oversight.

Follow-Up:

Within 30 minutes, the patient’s GCS improved, and bilateral rhonchi, indicating a positive response, were noted. A bedside chest X-ray was normal. After 40 minutes of intensive treatment, repeat blood gas analysis showed improved parameters (pH 7.428, pCO2 33.8 mmHg, pO2 51.7 mmHg, HCO3- 22.5 mmol/L, SpO2 96% on Room Air, K 3.53 mmol/L, Na + 142.4 mmol/L, Lactate 3.0 mmol/L). The patient was gradually weaned off BiPAP and oxygen over the next 2 hours with significant clinical improvement. By the time of discharge to the medical unit, the patient had normal vitals, a clear chest on auscultation, and no oxygen support was required.

In recounting the patient’s experience, a 35-year-old woman who had been effectively managing her mild intermittent asthma for over a year, the sudden onset of severe respiratory distress came as a profound shock. She had been symptom-free until she took diclofenac sodium for neck pain, a medication she had used previously without issues. The abruptness of her symptoms, marked by intense shortness of breath and confusion, left her disoriented and unable to communicate her distress clearly.

From her perspective, the situation was both frightening and overwhelming. The urgency of the emergency response, including high-flow oxygen and non-invasive ventilation, only heightened her anxiety. Despite the fear and uncertainty, the medical team’s prompt and aggressive intervention eventually stabilized her condition. This harrowing experience showed the unpredictable risks of certain medications and the critical need for swift medical action in severe asthma exacerbations. It also reinforced the importance of remaining vigilant about any new or unusual symptoms, especially when managing a chronic condition like asthma.

Asthma is a chronic respiratory condition marked by airway inflammation and hyperresponsiveness, with varying degrees of severity. Although it is generally manageable with appropriate medications and lifestyle modifications, certain episodes can emerge unexpectedly and pose life-threatening challenges. This case report details a 35-year-old woman who had been effectively managing mild intermittent asthma with inhalers and had been symptom-free for over a year. However, she presented at the emergency unit of TH Anuradhapura with a sudden and severe respiratory crisis triggered by the ingestion of diclofenac sodium oral tablets for mechanical neck pain. The rapidity and severity of her deterioration, following a prolonged period of stability, highlighted a critical deviation from her usual asthma control. This acute exacerbation underscores the importance of recognizing medication-induced asthma exacerbations and their potential to escalate into life-threatening situations, which require urgent and vigilant medical intervention.

The literature on near-fatal asthma episodes and rapid-onset acute exacerbations highlights the varied clinical presentations and triggers of severe asthma. These cases contribute to our understanding of the complexities, triggers, management strategies, and outcomes associated with critical asthma phenotypes. This case exemplifies how a routine medication intake can precipitate a severe, life-threatening asthma crisis, emphasizing the need for heightened awareness, prompt recognition, and tailored therapeutic approaches for managing such critical respiratory events.

Sudden and rapid-onset asthma attacks are a crucial but infrequent manifestation of asthma, particularly observed in individuals with a history of Severe Life-Threatening Asthma (SLTA)(1). Our patient had a history of mild intermittent asthma but had been well-controlled without inhalers for over a year. Evidence suggests that Rapid Onset Acute Asthma (ROAA) is a rare but distinct presentation in emergency departments (ED), often more common in male patients. Although various triggers are recognized, Upper Respiratory Tract Infections (URTIs) are not typically significant in these cases. ROAA patients generally experience a rapid decline followed by a quicker response to treatment, resulting in lower hospital admission rates compared to those with Slow Onset Acute Asthma (SOAA)(2). In this case, the only identified trigger was the oral diclofenac sodium tablet taken 15–30 minutes prior for neck pain, with no other triggers found after thorough evaluation.

Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), is commonly prescribed to alleviate pain, inflammation, and swelling. It inhibits substances that cause these effects and is available in various forms, including tablets and topical applications. NSAIDs can induce severe asthma through the inhibition of cyclooxygenase-1 (COX-1), leading to increased release of cysteinyl leukotrienes (Cys-LTs) [3][4]. This pathway results in lower production of prostaglandin E2 (PGE2) due to down-regulation of cyclooxygenase-2 (COX-2), alongside increased expression of leukotriene C4 synthase in bronchial inflammatory cells. Aspirin and NSAIDs further elevate cysteinyl leukotriene synthesis, which, along with genetic factors and receptor overexpression, enhances the inflammatory response [5]. Understanding the pathogenesis of NSAID-induced asthma could improve treatment strategies. Although fatal asthma from oral diclofenac is extremely rare, the occurrence in this case is notable.

While oral diclofenac is not commonly reported as a trigger for near-fatal asthma, there have been rare instances of severe reactions. Reports include fatal anaphylactic reactions to oral diclofenac [6] and acute asthmatic attacks from diclofenac sodium eye drops [8]. This case appears to be unique in demonstrating oral diclofenac sodium as a trigger for rapid-onset near-fatal asthma.

In managing this patient, non-invasive ventilation (NIV) with BiPAP was employed due to hypercarbia and low GCS, aiming to avoid intubation and its associated complications. The management of near-fatal asthma involves a comprehensive approach, including optimizing asthma control, addressing adherence and socioeconomic issues, and recognizing the limitations of pharmacotherapy [10]. Early and aggressive treatment is crucial to maintain oxygenation, relieve airflow obstruction, and reduce airway edema and mucus plugging [11]. Emergency physicians must consider potential complications in severe asthma management [12]. Patient education on asthma as a chronic condition and adherence to treatment is vital [13].

NIV has been explored as a treatment for near-fatal asthma. Studies suggest that NIV may reduce the need for endotracheal intubation and improve outcomes compared to invasive mechanical ventilation (IMV) [14]. NIV has been shown to be safe and effective in patients with severe respiratory acidosis or altered mental status [15]. However, its use in severe acute asthma remains controversial, lacking specific randomized controlled trials or national guidelines [16]. Further research is needed to define the optimal application of NIV in near-fatal asthma cases. The limited evidence and variability in critical asthma care practices highlight the need for additional research to establish the best care strategies for near-fatal asthma [17].

This case signifies the potential for seemingly routine medications, such as diclofenac sodium, to precipitate severe and rapid-onset asthma exacerbations, even in previously well-controlled patients. The rapid progression to a near-fatal asthma state highlights the critical need for awareness of medication-induced asthma triggers and the importance of prompt, aggressive management. The effective use of non-invasive ventilation in this scenario, despite its controversial status, exemplifies the need for innovative approaches in handling severe asthma exacerbations. Overall, this case reinforces the necessity for heightened vigilance and tailored therapeutic strategies in the management of acute, life-threatening asthma events.

Acknowledgements:

We would like to express our gratitude to the medical and nursing staff at the Emergency Treatment Unit of TH Anuradhapura for their prompt and effective management of this critical case. Special thanks to the respiratory specialists and critical care team for their invaluable input during the patient's treatment and recovery. We also acknowledge the support of the patient’s family and the bystander who provided essential initial information, which greatly aided in the patient's care.

Kolbe J, Fergusson W, Garrett J (1998) Rapid onset asthma: a severe but uncommon manifestation. Thorax 53(3):241–247
American College of Chest Physicians (2000) Chest 118(6):1547. https://doi.org/10.1378/chest.118.6.1547
Picado C (2006) Mechanisms of aspirin sensitivity. Curr Allergy Asthma Rep. https://doi.org/10.1007/S11882-006-0035-2
Picado C (2004) Aspirin-Induced Asthma: What We Know Now. Clin Pulmonary Med. https://doi.org/10.1097/01.CPM.0000107608.67634.84
Sun Y, Corrigan C, Lee TH (2004) Mechanisms of aspirin-sensitive asthma. Allergology Int. https://doi.org/10.1111/J.1440-1592.2004.00319.X
Sen I, Mitra S, Gombar KK (2001) Fatal anaphylactic reaction to oral diclofenac sodium. Can J Anaesth 48(10):994–996. https://doi.org/10.1007/BF03014979
Short JA, Barr CA, Palmer CD, Goddard JM, Primhak RA (2000) Use of diclofenac in children with asthma. Anaesthesia 55(12):1182–1187. https://doi.org/10.1046/J.1365-2044.2000.01280.X
Sharir M (1997) Exacerbation of asthma by topical diclofenac. Arch Ophthalmol 115(11):1475–1476. https://doi.org/10.1001/ARCHOPHT.1997.01100150296037
Alkhawajah AM, Eifawal M, Mahmoud SF (1993) Fatal anaphylactic reaction to diclofenac. Forensic Sci Int 62(3):243–248. https://doi.org/10.1016/0379-0738(93)90098-U
Greenberger PA (2019) Potentially (near) fatal asthma. Allergy and Asthma Proceedings, 40(6), 425–430. https://doi.org/10.2500/AAP.2019.40.4257
D'Amato G, Vitale C, Lanza M, Sanduzzi A, Molino A, Mormile M, Vatrella A, Bilò MB, Antonicelli L, Bresciani M, Micheletto C, Vaghi A, Amato D, M (2016) Near fatal asthma: treatment and prevention. Eur Annals Allergy Clin Immunol 48(5):172–179
Fergeson JE, Patel SS, Lockey RF (2017) Acute asthma, prognosis, and treatment. J Allergy Clin Immunol 139(2):438–447. https://doi.org/10.1016/J.JACI.2016.06.054
Garner O, Ramey JS, Hanania NA (2022) Management of Life-Threatening Asthma: Severe Asthma Series. Chest 161(5):1363–1372. https://doi.org/10.1016/j.chest.2022.02.029
Harris M, Bostwick D (2022) A case of near-fatal asthma exacerbation. Chest 162(6):A3296. https://doi.org/10.1016/j.chest.2022.08.039
Manaster I, Rackovsky ED, Perez M, Medar SS (2022) 711: invasive versus noninvasive mechanical ventilation in pediatric asthma: a single-center study. Crit Care Med 50(1):1–2. https://doi.org/10.1097/01.ccm.0000908576.30460.27
Long F, Hu S, Huang W, Long LH, Gan J (2023) Rapid weaning from mechanical ventilation and bronchial thermoplasty for near-fatal asthma: A case report. Heliyon 9(3):e15814. https://doi.org/10.1016/j.heliyon.2023.e15814
Rogers L, Reibman J (2011) Pharmacologic approaches to life-threatening asthma. Ther Adv Respir Dis 5(2):105–114. https://doi.org/10.1177/1753465811398721

The authors declare no competing interests.

Download PDF

Version 1

posted

You are reading this latest preprint version

"Unveiling the Unforeseen: Diclofenac-Triggered Near-Fatal rapid onset Asthma in a Stable Asthmatic Individual Managed by NIV" A Unique Case report.

Status:

Version 1

Abstract

Introduction

Narrative

Patient’s Perspectiv

Discussion

Conclusion

Declarations

Acknowledgements:

References

Additional Declarations

Status:

Version 1