Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 217–220

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Egyptian Journal of Chest Diseases and Tuberculosis

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What to use for bronchial asthma; nebulized or intravenous magnesium

sulfate?
Ibrahim Salah-Eldin Ibrahim ⇑, Reham Mohamed Elkolaly
Chest Department, Faculty of Medicine, Tanta University, Tanta, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Background: Asthma is characterized by airways narrowing and airflow limitation. The conventional
Received 20 December 2016 therapy for asthma exacerbation is usually efficient but sometimes patients not respond to it, conse-
Accepted 19 January 2017 quently; other additive drugs may be used as magnesium sulfate(MgSO4) either intravenously or by neb-
Available online 10 February 2017
ulization.
Objective: To compare the bronchodilator effect of MgSO4 via intravenous injection and nebulization in
Keywords: controlling asthma exacerbation.
Asthma
Methods: 40 patients with asthma exacerbation were equally and randomly enrolled in two groups. One
Magnesium sulfate
Nebulized
group received nebulized MgSO4 (A), and the other group received intravenous MgSO4 (B).
Results: Improvement was higher in group B than in group A but without significant change in PEFR also
there was no high significant difference in the two group parameters after MgSO4 treatment.
Complications were few and manageable in both groups.
Conclusion: Intravenous MgSO4 is effective affordable and cheap drug for asthma exacerbation manage-
ment with good response while nebulized MgSO4 didn’t give the aimed response in these patients.
Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

Introduction in form of b2 agonists (±anticholinergic) in addition to parental

corticosteroids if they are admitted to hospitals [6].
Asthma is one of the common chronic airway diseases that And in spite of that; corticosteroids used in emergency depart-
leads to decrease of airflow and characterized by bronchial and ment need a relatively longer time (6–8 h) to produce their anti-
bronchioles inflammation with airways smooth muscle contrac- inflammatory effect and control the acute attack [7], while inhaled
tion and increase mucous synthesis and secretion. Leading to b2 agonists give their adequate bronchodilator effect in only two
recurrent wheeze, breathing difficulties and coughing either at thirds of treated patients and the rest of patients still suffer from
night or/and early morning [1]. This airways narrowing is often the attack effect [6].
reversible with or without treatment [2]. For that reason; physicians tried to use other additive drugs to
Asthma morbidity and mortality rates are high and are mostly give rapid bronchodilator effect to manage asthma early before
related to acute exacerbations [3]. So severe asthma attacks must patients deterioration.
be treated rapidly and effectively to avoid its fatal consequences, Magnesium sulfate (MgSO4) is the drug that was previously
to decrease triggering for further future exacerbation [4] and to used as an additive line of treatment in many cases with acute sev-
prevent more decline in lung functions after these attacks [5]. ere asthma [8].
Patients having asthma exacerbations usually need rapid treat- Magnesium sulfate was studied and supposed to reduce intra-
ment to relieve their suffering, so they use inhaled bronchodilators cellular calcium influx via closure of calcium channels and inhibits
calcium release from endoblasmic reticulum [9], it also inhibits
inflammatory mediator release from mast cells and inhibits acetyl
choline release from nerve endings, that leads finally to muscle
Peer review under responsibility of The Egyptian Society of Chest Diseases and
relaxation [10].
Tuberculosis.
⇑ Corresponding author at: Chest Department, Tanta University Hospitals, Some physicians used magnesium via nebulization-especially
Elgharbyia, Tanta, Egypt. in children-during severe asthma attacks to achieve bronchodilata-
E-mail addresses: [email protected] (I.S.-E. Ibrahim), [email protected] tion and to avoid the systemic side effects of the intravenous drug
(R.M. Elkolaly).

http://dx.doi.org/10.1016/j.ejcdt.2017.01.005
0422-7638/Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
218 I.S.-E. Ibrahim, R.M. Elkolaly / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 217–220

[11]. While others used it parentrally to give rapid action and Magnesium Sulfate USP2Ò 1 g/10 ml [Magnesium SulfateÒ:
relieve of the bronchoconstriction, but this may lead to some side Sterile ampoule 10 ml. 100 mg/ml = 0.41 mMol/ml. Manufactured
effects like arrhythmia flushing, hypotension and renal intoxica- by: Egyptian int. Pharmaceutical industries co. (e.i.p.i.co.) – Egypt].
tion in high doses [2] Patients were assisted after 30 min (level 1) then after 1 h
(level 2)
N.B.; Patients who deteriorated were re-evaluated for other
Aim of the study management procedures.

To compare the bronchodilator effect of magnesium sulfate via Statistical analysis

intravenous route versus nebulization in patients with asthma
exacerbation. All data were statistically analysed by the SPSS software for
Windows (IBM SPSS Statistics 21.0). P value <0.05 was significant.
Patients and methods
Results
The study was conducted from March 2016 through July 2011
Forty patients with acute asthma were enrolled in this study;
at Tanta University Hospital, Tanta, Egypt.
they were divided into two groups. Group A consisted of 20
This study was conducted on 40 patients with acute bronchial
patients (12 female and 8 male) that received nebulized MgSO4
asthma exacerbation with the following inclusion criteria:
and group B that consisted of 20 patients (11 female and 9 male)
who received intravenous MgSO4.
– Patient with acute exacerbation of asthma according clinical
There was no statistically significant difference between the
assessment of asthma using GINA guidelines [12].
two groups as regard age, pre-treatment pulse, BP, RR and PEFR,
– Patient not controlled on conventional therapy for acute
Fischl’s index) (Table 1).
exacerbation.
After 30 min of treatment; patients were re-evaluated (Table 2).
These parameters improvement showed no significance differ-
Exclusion criteria were as follow ence between the two groups, but the improvement in group B
was more than that in group A.
Patients with stable asthma, COPD, pneumonia, heart failure or Another re-evaluation was done after one hour as follow (Table 3)
renal insufficiency, in need for endotracheal intubation, inability to Which revealed improvement in group B than that in group A;
do peak flow meter, pregnant or breastfeeding mothers or had but also without significant difference.
received oral, inhaled or parenteral bronchodilators in the past The significance of changes in group A as regard pre-treatment,
6 h, or steroids in the past 12 h. after 30 min and after one hour were as follow (Table 4).
All patients were subjected to history taking, clinical examina- The significance of changes in group B as regard pre-treatment,
tion and PEF% (wright peak flow meter) and scoring was done after 30 min and after one hour were as follow (Table 5).
according guidelines [13]. As regard results in Tables 4 and 5; the clinical parameter in
All patients received the conventional treatment of acute exac- group A showed mild improvement after I hour as regard BP and
erbation as follow: pulse with less improvement in other parameters. But in group B;
there was significant improvement in BP and RR after 30 min while
– Supplemental oxygen to have O2 sat. greater than 90%. the improvement was more significant in all parameters after I hour.
– Nebulization of 1 ml Farcolin respirator solutionÒ mixed with There were minor complications that reported in 3 patients in
9 ml saline for two sessions with interval of 15 min [Farcolin group A including headache, flushing, hypotension and nausea.
respirator solutionÒ: each 20 ml of Farcolin contains Salbutamol The adverse effects in group B were recorded in 5 patients;
sulfate 0.121 gm. Made in Egypt, by: Pharco Pharmaceuticals – including nausea, vomiting, arrhythmia and hypotension (Table 6).
Alexandria].
– Intravenous Solu-CortefÒ 100 mg once [Solu-CortefÒ: vial con- Discussion
tains powder of 100 mg Sodium hydrocortisone hemisuccinate
dissolved with 2 ml solvent of sterile bacteriostatic water for Asthma is one of the chronic respiratory disorders that has
IV injection. Manufactured by: Egyptian Int. Pharmaceutical repeated episodes of exacerbations that may be mild, moderate
Industries co. (e.i.p.i.co.) – Egypt. Under license of: Pfizer]. and even severe attack which may lead to hospital or ICU admis-
sion, intubation or even death [8].
Patients were assisted clinically every 15 min. If the patient Intravenous magnesium sulfate was used as a possible additive
didn’t improve after one hour; he was randomly enrolled in one drug for asthma exacerbation management especially in severe
of the two groups that contained 20 patients in each group. attacks [16].
Each patient was evaluated clinically for blood pressure (BP) Magnesium is an important ion in cellular and tissue homeosta-
and Fischl index that consists of seven items (pulse, respiratory sis including airways musculature via its role for different enzymes
rate (RR), pulsus paradoxicus (PP), PEF%, dyspnea, wheeze and action [16]. MgSO4 helps smooth muscle relaxation via facilitating
accessory muscle use) and scored 0–1 for each [6]. calcium ions influx to sarcoplasmic reticulum [17]. It also inhibits
These pre-treatment parameters were labeled (level zero) both acetyl choline and histamine release from nerve ending and
before MgSO4 treatment. mast cells respectively. Some authors suggest that it has a central
Group A (nebulization group): four doses of nebulization solu- sedative effect [17].
tion with 15 min apart, each dose contained 1 ml MgSO4 mixed In that study; MgSO4 injection had marvelous response in most
with 9 ml saline, to have isotonic mixture to avoid hyperosmolar patients in intravenous group while patients in group A not
broncho-constriction [14]. revealed the desired effect that most physicians aim to in asthma
Group B (injection group): 2 g of MgSO4 diluted in 30 ml saline attack management.
to have a 50 ml solution for slow intravenous injection along 20– In consistent with those results; Mohammed and his colleague
30 min [15]. [18] found in their systemic review that intravenous MgSO4 had
 I.S.-E. Ibrahim, R.M. Elkolaly / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 217–220 219

Table 1
Base line parameters before treatment of both groups.

BP RR Pulse PEFR Fischl’s index

Mean SD Mean SD Mean SD Mean SD Mean SD
Group A 153.500 10.144 31.450 3.591 108.800 12.353 386.250 87.688 4.450 1.099
Group B 157.750 9.244 31.150 3.884 108.100 10.533 355.000 87.102 4.050 1.146
t 1.385 0.254 0.193 1.131 1.125
p 0.174 0.801 0.848 0.265 1.000

Table 2
Measured parameters in both groups after 30 minutes of treatment.

BP RR Pulse PEFR Fischl’s index

Mean SD Mean SD Mean SD Mean SD Mean SD
Group A 145.000 9.319 28.450 4.097 102.600 10.625 415.750 88.113 2.850 1.424
Group B 139.250 9.072 28.600 3.775 102.350 9.821 386.500 83.840 2.800 0.951
t 1.977 0.120 0.0773 1.076 0.131
p 0.055 0.905 0.939 0.289 0.897

Table 3
Measured parameters in both groups after one hour of treatment.

BP RR Pulse PEFR Fischl’s index

Mean SD Mean SD Mean SD Mean SD Mean SD
Group A 139.500 8.256 25.850 4.320 98.400 10.475 426.750 87.529 1.600 0.754
Group B 131.000 6.609 26.750 2.489 97.750 7.691 411.750 83.387 1.500 1.100
t 3.594 0.807 0.224 0.555 0.281
p <0.001 0.425 0.824 0.582 1.000

Table 4
Parameters at base line and after 30 minutes and one hour of treatment in group A.

Pre-treatment & after After 30 m. & after 1 h. Pre-treatment & after 1 h. Between all
30 m.
t p t p t p F p
BP 2.899 0.005 1.976 0.055 4.787 <0.001 11.574 <0.001
Significance Yes No Yes Yes
RR 1.533 0.134 0.718 0.477 2.358 0.024 2.879 0.064
Significance No No No No
Pulse 1.702 0.097 1.188 0.240 2.941 0.005 4.377 0.017
Significance No No Yes Yes
PEFR 1.061 0.295 0.396 0.694 1.462 0.152 1.138 0.327
Significance No No No No
Fischl’s index 3.359 0.001 4.299 <0.001 7.658 <0.001 29.469 <0.001
Significance Yes Yes Yes Yes

Table 5
Parameters at base line and after 30 minutes and one hour of treatment in group B.

Pre-treatment & after After 30 m. & after 1 h. Pre-treatment & after 1 h. Between all
30 m.
t p t p t p F p
BP 6.388 <0.001 3.287 0.002 10.527 <0.001 53.246 <0.001
Significance Yes Yes Yes Yes
RR 2.106 0.042 1.830 0.075 4.266 <0.001 8.242 <0.001
Significance Yes No Yes Yes
Pulse 1.786 0.082 1.649 0.107 3.549 0.001 6.054 0.004
Significance No No Yes Yes
PEFR 1.165 0.251 0.955 0.346 2.105 0.042 2.249 0.115
Significance No No Yes No
Fischl’s index 4.957 <0.001 3.906 <0.001 8.863 <0.001 39.459 <0.001
Significance Yes Yes Yes Yes

significant effect in respiratory function improvement in asthmatic MgSO4 and also was high in children in addition to decreased hos-
patients, while nebulized MgSO4 had a mild improving effect on pitalization, while improvement in lung functions after MgSO4
asthmatics’ respiratory functions. nebulization was in adults no in children.
Another similar study on 1754 patients; Shan and colleagues Goodacre et al. [19] in a double-blineded placebo-controlled
[11] who studied 25 clinical trials, revealed that clinical improve- trial studied 1109 asthmatic patients that enrolled in three groups;
ment in patients was highly significant in adults after intravenous intravenous MgSO4, nebulized MgSO4, and control group. They
220 I.S.-E. Ibrahim, R.M. Elkolaly / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 217–220

Table 6 Conflicts of interest

Complication in both groups.

Group A (20 patients) Group A (20 patients) No.

Hypotension 2 (10%) 3 (15%)
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