Key Point

In children, the increased Pco2 and acidosis from life-threatening asthma can be treated with sodium bicarbonate as an adjunctive therapy.

ROTTERDAM, THE NETHERLANDS—Life-threatening asthma in children is often resistant to treatment with bronchodilators and systemic corticosteroids. Recent research suggests that administering sodium bicarbonate—an ingredient commonly found in kitchens and medicine cabinets—in intravenous (IV) form can significantly improve pH and Pco₂ in children with life-threatening asthma.¹

Corinne M. P. Buysse, MD, and colleagues retrospectively evaluated the use of sodium bicarbonate in 17 children with life-threatening asthma. Sixteen of these children had acidosis, indicating severe respiratory distress. The acidosis was classified as mixed respiratory and metabolic in 13 patients, predominantly respiratory in one patient, and metabolic in two patients. In one patient, the initial blood gas values before administration of sodium bicarbonate in the referring hospital could not be traced. A new protocol was initiated using IV magnesium sulfate and IV sodium bicarbonate as adjunctive therapy when respiratory distress persisted despite standard treatment. According to Dr. Buysse, a pediatric intensivist at the Erasmus MC–Sophia Children’s Hospital in Rotterdam, Netherlands, “Administration of sodium bicarbonate was associated with a significant decrease in Pco2 in 17 children with life-threatening asthma. Improvement of respiratory distress was observed as well.”

BAKING SODA HELPS

Standard treatment included oxygen, frequent or continuous inhalation of nebulized albuterol (2.5 to 5 mg), ipratropium bromide (0.25 to 0.5 mg), and parenteral corticosteroids (prednisolone, 1 mg/kg every 12 hours). If respiratory distress persisted, magnesium sulfate was administered at 25 mg/kg for 10 minutes. If the asthma was still unresponsive, IV albuterol was initiated at 0.1 μg/kg/min and increased by 0.1 μg/kg/min per 10 minuutes if necessary. If the pH was less than 7.15 and respiratory distress persisted, IV sodium bicarbonate was administered at 1 mmol/kg over 30 minutes. The median dose was 0.9 mmol/kg. In one patient, respiratory distress worsened despite administration of sodium bicarbonate, and the patient was intubated. The agent was administered to three intubated patients because of persistent acidosis.

Respiratory distress and level of consciousness both improved after the administration of sodium bicarbonate in all but one patient. Pco₂ decreased significantly and pH increased significantly after sodium bicarbonate infusion. Pco₂ values ranged from 30 to 130 mm Hg before treatment and 30 to 100 mm Hg after treatment. Acidosis improved after sodium bicarbonate infusion: Preadministration pH values ranged from 6.8 to 7.3, and after administration, values increased to 7.05 to 7.35. “Life-threatening asthma can be associated with metabolic or mixed acidosis, which reduces the effectiveness of β-agonists,” explained Dr. Buysse. “Sodium bicarbonate increases pH, and this leads to a better effect of β-agonists,” she added.

SOME QUESTIONS STILL REMAIN

The authors believe that the clinical improvement observed in their study resulted from the combination of treatments aimed at reducing inflammation, bronchoconstriction, and mucous plugging. They emphasize that sodium bicarbonate has a role as an adjunctive therapy, and not as a solo agent. Although the researchers did not conduct lung function tests—because lung function is unreliable in acute severe asthma and not possible in intubated patients—the blood gas analysis indirectly reflects lung function. Dr. Buysse emphasized that the study evaluated the effects of sodium bicarbonate in children with life-threatening asthma, defined as “a progressive respiratory failure due to asthma, refractory to treatment with inhaled bronchodilators and systemic corticosteroids.” Therefore, it is not known whether the agent can be administered to prevent life-threatening asthma, or whether it would be effective in adult patients or for COPD. The authors are currently conducting a prospective study evaluating sodium bicarbonate using objective scoring systems for the severity of the asthma and level of consciousness.

—Tamara Gibb

Reference
1. Buysse CMP, de Jongste JC, de Hoog M. Life-threatening asthma in children: treatment with sodium bicarbonate reduces Pco₂. Chest. 2005;127:866-870.

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