Intravenous Magnesium Sulfate as an

Adjunct in the Treatment of Acute Asthma

Helen Bloch, Robert Silverman, Noel Mancherje, Steven Grant,
Liudvikas Jagminas and Steven M. Scharf

Chest 1995;107;1576-1581
DOI 10.1378/chest.107.6.1576
The online version of this article, along with updated information and
services can be found online on the World Wide Web at:
http://chestjournal.chestpubs.org/content/107/6/1576

Chest is the official journal of the American College of Chest

Physicians. It has been published monthly since 1935.
Copyright1995by the American College of Chest Physicians, 3300
Dundee Road, Northbrook, IL 60062. All rights reserved. No part of
this article or PDF may be reproduced or distributed without the
prior written permission of the copyright holder.
(http://chestjournal.chestpubs.org/site/misc/reprints.xhtml)
ISSN:0012-3692

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011

1995 by the American College of Chest Physicians
Intravenous Magnesium Sulfate as an
Adjunct in the Treatment of Acute
Asthma*
Helen Bloch, MD; Robert Silverman, MD; Noel Mancherje, MD;
Steven Grant, MD; Liudvikas Jagminas, MD; and
Steven M. Scharf, MD, PhD

Study objective: This study was conducted to determine 120 min was 56% predicted for the placebo-treated
whether intravenous magnesium sulfate (MgSO4), when group and 55% predicted for the magnesium-treated
used as part of a standardized treatment protocol, can group. (p=0.92) For subgroup analysis, patients were
improve pulmonary function and decrease admission divided into "severe" (baseline FEV1 <25% predicted
rate in patients presenting to the emergency department on presentation) or "moderate" (baseline FEV1, 25 to
with exacerbations of asthma. 75% predicted on presentation). For the severe group,
Design: In this randomized double-blind placebo-con- admission rates were 78.6% (11/14) for the placebo-
trolled study, patients with acute asthma were treated treated group and 33.3% (7/21) for the magnesium-
with inhaled fl-agonists at regular intervals and intra- treated group (p=0.009). For the moderate patients, ad-
venous (IV) steroids. At 30 min after entry, patients re- mission rates were 22.4% (11/49) for the placebo-treated
ceived either 2 g IV MgSO4 or IV placebo. Patients were group and 22.2% (10/25) for the magnesium-treated
monitored for up to 4 h with regular measurements of group (p=0.98). There was no significant improvement
pulmonary function. Patients who were discharged in FEV, in the moderate group for magnesium-treated
from the emergency department were contacted at 1 day patients. However, in the severe group, there was a sig-
and 7 days for follow-up. nificant improvement in FEV1 at 120 min and 240 min
Setting: Emergency departments of a university-affili- (p=0.014 and 0.026, respectively).
ated, voluntary hospital and municipal hospital. Conclusion: Intravenous MgSO4 decreased admission
Participants: Asthmatics aged 18 to 65 years during rate and improved FEV, in patients with acute severe
acute exacerbation with FEVy less than 75% predicted asthma but did not cause significant improvement in
both before and after a single albuterol treatment. patients with moderate asthma.
Interventions: Patients were given 2 g of MgSO4 or (CHEST 1995; 107:1576-81)
placebo as an adjunct to standardized emergency de-
partment procedure for acute asthma. ED=emergency department; FEVI=forced expiratory vol-
Measurements and results: One hundred thirty-five pa- ume in 1 s; IV=intravenous; MgSO4=magnesium sulfate
tients were studied. Hospital admission rates were
35.3% for placebo-treated group and 25.4% for the Key words: asthma; emergency department; magnesium;
magnesium-treated group (p=0.21). FEV, measured at treatment

Athma affects approximately 5% of the population nesium sulfate (MgSO4) is a safe and effective adjunct
and is a frequent cause of emergency depart- to the treatment of acute asthma.6 It has been shown
ment (ED) visits and hospital admissions." 2 Between to have a relaxant effect on smooth muscle in vitro.7'8
19 and 36% of patients who present to the ED with There have been a number of case reports and
acute asthma require hospital admission despite uncontrolled studies indicating its effectiveness in
treatment with ,B-agonists, methylxanthines, and cor- relieving bronchospasm.9"10 However, recent con-
ticosteroids.3-5 trolled clinical trials have not agreed on its effica-
It has been suggested that intravenous (IV) mag- cy.11-13
The goal of this placebo-controlled, double-blind,
*From the Department of Emergency Medicine and Division of randomized study was to determine if IV MgSO4 is
Pulmonary and Critical Care, Long Island Jewish Medical Cen- effective as an adjunct to a standardized treatment
ter, Long Island Campus of the Albert Einstein College of Med-
icine, New Hyde Park, NY, protocol in patients who present to the ED with an
Supported in part by the Nina Weisman Pulmonary Research acute exacerbation of asthma. Primary end points
Fund.
Manuscript received June 30, 1994; revision accepted November
16.
were admission rate and spirometry results. In addi-
Reprint requests: Dr. Bloch, Long Island Jewish Medical Cen- tion, follow-up was obtained at 24 h and 7 days af-
ter, 270-05 76th Avenue, New Hyde Park, NY 12042 ter discharge.
1 576 Clinical Investigations
Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011
1995 by the American College of Chest Physicians
 Table 1-Baseline Characteristics of All Repeated data were obtained 30 min following baseline mea-
Asthmatics (n=135)* surements. Patients were then randomized to receive either 2 g
of MgSO4 or placebo in 50 mL of normal saline solution IV over
Mg Placebo p Value 20 min. All physicians were blinded to the randomization that was
Sex
done by the pharmacy using computer-generated tables. Patients
M
were monitored for any side effects during the infusion and were
27% (18/67) 29% (20/68) NS
F 73% (49/67) 71% (48/68)
specifically asked about paresthesias, diaphoresis, weakness, or a
Age, yr 36±12.7 38.6±13.2 NS flushed sensation. All patients continued on the standard protocol,
History of intubation 16% (11/67) 9% (6/68) NS
which included obtaining repeated data at 30, 60, 120, and 240
URI past 2 weeks 55% (37/67) 59% (40/68) NS min following baseline, and receiving inhaled albuterol nebulizer
Smoking, past or present 42% (28/67) 50% (34/68) NS treatments at 0, 30, 60, 120, and 180 min. Although patients were
Theophylline use in past 55% (33/60) 48% (28/59) NS encouraged to stay for the full 240-min protocol, they were per-
24 h mitted to leave at 120 min if they demonstrated subjective
Oral steroid use in past 20% (13/65) 17.2% (11/64) NS
improvement and their FEV, was greater than 50% predicted. At
24 h
4 h, all patients were assessed for hospital admission. Guidelines
Inhaled steroids in past 24% (16/67) 21% (14/67) NS for hospital admission included shortness of breath at rest or
24 h
minimal exertion, respiratory rate greater than or equal to 28, or
ED visits past year 2.5 ±4.2 2.2 ± 4.3 NS FEV, less than 50% of predicted.
Hospital admissions past 0.6+ 1.7 0.24+.6 NS The treatment regimen of patients discharged from the hospi-
year
tal was standardized. Discharged patients were instructed to use
Attack duration, h 40.9 ± 36 42.9 ± 36.7 NS inhaled albuterol, two puffs every 4 h. Those given methylpred-
nisolone received prednisone 20 mg twice daily for 1 week. Any
*p<0.05 is considered significant. NS=not significant. Values are patient already taking theophylline or inhaled steroids at the time
expressed as mean ± SD. URI=upper respiratory tract infection. of the ED visit was told to continue his or her usual dose.
All patients discharged from the ED were called at 24 h and
then 1 week later to determine any subsequent ED visits or hos-
METHODS pital admission for asthma.
Patient Selection Data Analysis
Patients aged 18 to 65 years presenting with acute asthma to the We hypothesized that compared with placebo, adjunct therapy
ED of two teaching hospitals (Long Island Jewish Medical Cen- with magnesium would cause greater improvement in pulmonary
ter and Queens Hospital Center), between August 1990 and De- function (FEV1) and decreased hospital admission rate. Data were
cember 1991, were considered for the study. Asthma was defined analyzed using tests for unpaired variables, two-way analysis of
by the criteria set out by the American Thoracic Society.'4 variance, and logistic regression as appropriate. A p value of less
Patients were excluded if they had a history of congestive heart than or equal to 0.05 was taken as significant.
failure, diabetes mellitus, angina, chronic renal insufficiency, Patients were randomized according to a single table. The
temperature >380 C, pneumonia, or if pregnant. Patients re- group were analyzed as a whole and in subgroups. Those with an
quiring intubation, unable to perform spirometry, or unable to initial FEV, below 25% predicted were considered to have "se-
give informed consent were also excluded. Patients in whom the vere" asthma, and those with FEVI 25 to 75% predicted were
forced expired volume in 1 s (FEVI) was greater than or equal to considered to have "moderate" asthma. The division was made
75% predicted, either on ED presentation or after a single prior to unblinding the study. The cutoff of 25% was selected be-
albuterol treatment, were also excluded. All patients were treated cause this group is more frequently associated with hypercapnia
according to the same protocol. and severe obstruction.'7
The primary end points were FEV1 at 2 h after baseline and
Treatment Protocol hospital admission rates. Preinfusion FEV1 percent values were
This study was approved by the Human Subjects Review covaried to determine significant improvement in FEV1. Al-
Committee at both institutions. Baseline data were obtained on though the end points were analyzed separately, they are inter-
presentation, including a brief history and physical examination, dependent in that the hospital admission decision was in part
vital signs, spirometry, and modified Borg Scale ratings for dys- based on the FEVI.
pnea.'5 The latter is a cued, psychometric rating scale from 0 to
10, where 0 represents no dyspnea and 10 represents severe dys- RESULTS
pnea. A spirometer (Spiromate AS 600, Riko; Minato, Japan) was
used to measure FEVI. Following instructions, a minimum of two One hundred forty-nine patients originally were
spirograms was obtained at each datum point and the maximum randomized into the study; however, 135 were
FEV, was recorded. Age, sex, and height-adjusted predicted included in the final statistical analysis. Among the 14
normal values were from Knudsen et al.16 patients who were excluded, 12 were enrolled more
When patients presented in the ED, they received inhaled al- than once, 1 had irreversible airway disease, and 1
buterol treatment (2.5 mg in 2.5 mL normal saline solution by had congestive heart failure. Four patients were in-
high-flow nebulizer). Eligible patients were offered entry into the
study and informed consent was obtained. An IV line was started cluded as an intent to treat analysis because the study
and blood was drawn for complete blood cell count, electrolytes, protocol was violated. Violations include 1 patient
blood urea, nitrogen, creatinine, total magnesium, and theophyl- who received epinephrine, 1 patient who received
line level. Urine pregnancy testing was performed on all women theophylline, 1 patient with subsequent discovery of
of childbearing age. Patients whose initial FEVl was less than 40%
of the predicted value or those who had been receiving oral ste- fever, and 1 patient with subsequent discovery of
roids within the past 6 months were given 125 mg of methyl- pneumonia. In 6 patients, baseline FE1 was un-
prednisolone IV within 30 min of presentation. available because of the patients' inability to coop-
/
2011 107/6 JUNE,
Downloaded from chestjournal.chestpubs.org by guest on July 13,CHEST
/ 1995 1577
1995 by the American College of Chest Physicians
 Table 2-Clinical Data (All)* Table 3-Hospital Admission Rates*
Mg Placebo p Value Magnesium Placebo p Value
Theo level, mg/dL 9.0±5.3 7.2 ±5.0 NS All 25.4% (17/67) 35.3% (24/68) NS
Mg level baseline, mg/dL 2.02 ± 0.37 2.09 ± 0.23 NS Severe 33.3% (7/21) 78.6% (11/14) 0.009
Respiratory rate/min Moderate 22.2% (10/45) 22.4% (11/49) NS
Baseline 25.7±6.4 25.8±5.4 NS
120 min 18.9±3.1 20±4.1 NS *p<0.05 is considered significant. NS=not significant.
Wheeze
Baseline 2.63±0.60 2.43±0.63 NS ALL
120 min 1.49±0.73 1.44±0.8 NS
Heart rate/min 80
Baseline 102.6±17.8 101.4±18.0 NS D 70
z -- Magnesium
a ,
> Placebo
120 min 102.5 ± 15.7 99.9 ± 16.3 NS
60
Systolic BP, mm Hg
Baseline 126.1 ± 22.4 133.5 ±22.4 NS
-mI.
a 50
ui
- V
2
A, --- -- -

120 min 122.7± 17.4 126.0± 15.6 NS

Borg Scale £ 40
Baseline 7.3±1.6 7.4±1.9 NS °.. 30
120 min 2.8±1.9 3.0±2.2 NS
> 20 _
*Theophylline (Theo) and magnesium (Mg) levels were drawn at LL
baseline. Clinical data shown at time 0 and 120 min. p<0.05 is 10
considered significant. NS=not significant. Values expressed repre- A
sent mean ± SD. Wheeze is expressed as average ± SD where O=no 0 30 60 120 150 180 210 240
wheezing, 1=end-expiratory wheezing, 2=expiratory wheezing, TIME (MINUTES)
3=inspiratory and expiratory wheezing, 4=poor air movement.
SEVERE
erate. These were included in the analysis as a whole 80
and excluded for subgroup analysis. Of the 12 70 ------ Magnesium
patients enrolled more than once, the first visit was 60 Placebo
used for the analysis.
0-
C) z
50
Patient baseline characteristic for the study popu- Lu
< E
lation as a whole are listed in Table 1. Clinical 40 . T
*
---- ---I
parlameters are listed in Table 2. There were no sig- IL
30
nificant differences between placebo-treated and 20
MgSO4-treated groups. The hospital admission rate 10 *p<0.05
was 35.3% (24/68) in the placebo group and 25.4% f
(17/67) for the MgSO4 group (p=0.21) (see Table 3). 0 30 60 120 150 180 210 240
The FEV1 was 56% predicted at 120 min for the TIME (MINUTES)
placebo group and 55% predicted for the MgSO4
group (p=0.92) (Fig 1).
MODERATE
Severe Group 80 z
LU
Thirty-five patients were classified as severe asth- 70
_ cm
9
matics based on their initial FEV1. There were no ~ 060 -
v-0R
significant differences in baseline characteristics (Ta- a 50
ble 4). Hospital admission rates for the severe asth- Ul
matics were 78.6% (11/4) for the placebo group and C 40
33.3% (7/21) for the MgSO4 group (p=0.009). When 30 _ ------ magnesium
Placebo
FEV1 at baseline and subsequent to study drug > 20 l
administration is covaried, the impact of magnesium IL
10
is statistically significant at 120 min (p=0.014) and --L-
11
240 min (p=0.026) (Fig 1). Of note, the impact re- 0 30 60 120 150 180 210 240
mains statistically significant even though 7 patients TIME (MINUTES)
who presumably were doing well (5 of 7 having re- FIGURE 1. FEV1, percent predicted as a function of time, where
ceived MgSO4) had elected to leave the ED at 120 time 0 is ED arrival and magnesium or placebo is given at 30 min.
min. Albuterol is given at 0, 30, 60, 120, and 180 min; steroids as noted
The impact of response to initial fl-agonist therapy in text. All=all patients; severe=patients with FEV1, less than 25%o
predicted at time 0; and moderate=patients with FEV1, 25 to 75%
as well as smoking history was also evaluated. There predicted at time 0. Results are expressed as mean ± SEM.

1578 Clinical Investigations

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011
1995 by the American College of Chest Physicians
 Table 4-Baseline Characteristics of Patients with As shown in Figure 1, FEV1 improved by an
Severe Asthma (n=35)* amount not significantly different between the treat-
Mg Placebo p Value ment group at measured points. Hospital admission
rates were also similar, with the placebo group hav-
Sex ing a rate of 22.4% (11/49) as compared with an ad-
M 19% (4/21) 43% (6/14) NS
F 81% (17/21) 57% (8/14) NS mission rate of 22.2% (10/45) for patients treated
Age, yr 34±13.4 42±14 NS with magnesium (p=0.98). There were no significant
History of intubation 10% (2/21) 0% (0/14) NS differences in respiratory rate, heart rate, blood
URI past 2 weeks 43% (9/21) 50% (7/14) NS pressure, severity of wheezing, or modified Borg
Smoking, past or 33% (7/21) 29% (4/14) NS
present
Scale rates between the two groups at 120 min.
Theophylline use in 65% (13/20) 46% (6/13) NS
Follow-up
past 24 h
Oral steroid use in 14% (3/21) 29% (4/14) NS Follow-up at 1 and 7 days following hospital dis-
past 24 h charge was done for 90 of 94 patients. One patient in
Inhaled steroids in 19% (4/21) 21% (3/14) NS
the moderate group was subsequently admitted to
past 24 h
ED visits past year 2.3±2.2 1.1±1.8 NS the hospital at day 2, and 1 patient in the severe group
Hospital admission 0.43±.75 0.07 ±0.27 NS was admitted at day 3. Both of these patients had
past year received magnesium.
Attack duration, h 46.0±38.2 37.0±38.6 NS
*p<0.05 is considered significant. NS=not significant. Values are
Side Effects
expressed as mean ± SD. URIlupper respiratory tract infection. There were no life-threatening side effects noted in
patients who received magnesium. Minor side effects
was no significant effect of these variables on hospi- were noted in 58% of patients who received magne-
tal admission rate and FEV1 in the severe group. sium. These included the sensation of flushing, mild
There were no significant differences in respiratory fatigue, and burning at IV site. One patient receiv-
rate, heart rate, blood pressure, severity of wheezing, ing magnesium experienced transient urticaria in the
or modified Borg Scale rates between the two groups upper extremities.
at 120 min (Table 5).
DISCUSSION
Moderately III Patients
Ninety-four patients were classified as "moderate- This study failed to demonstrate significant bene-
ly ill" based on their initial ED presentation. Of these, fit from the use of 2 g of IV MgSO4 as an adjunct to
49 had received placebo, and 45 had received mag- a standardized treatment protocol for asthma in a
nesium. No significant differences were found be- diverse group of asthmatics. However, it does dem-
tween any baseline variables. onstrate significant improvement in the subgroup of
patients presenting to the ED with severe airway
Table 5-Clinical Data (Severe)* obstruction. Improvement was demonstrated by a
Placebo p Value
decrease in hospital admission rate and an increase in
Mg
FEV1. We did not demonstrate benefit from MgSO4
Theo level, mg/dL 8.9 ±4.5 7.0±7.23 NS in patients with more moderate airway obstruction.
Mg level baseline, ,gg/dL 1.9±0.50 2.2±0.19 NS Previous controlled studies using adjunct therapy
Respiratory rate
Baseline 27±6.8 27±5.4 NS with MgSO4 have yielded conflicting conclusions.
120 min 19.2 ± 2.7 21 ±3.9 NS Skobeloff et a16 found that giving 1.2 g of IV MgSO4
Wheeze to patients in the ED significantly improved peak
Baseline 2.9 ±0.5 2.7 ±0.6 NS flow and decreased admission rates compared to
120 min 1.8 ± 0.9 1.8 ±0.9 NS patients receiving placebo. Green and Rothrock,12
Heart rate BP, mm Hg
Baseline 103 ±18.2 113 ±17.7 NS using 2 g of MgSO4, failed to find any difference. Our
120 min 105 ±17.3 108 ±17.7 NS findings may help to explain this apparent conflict.
Systolic BP, mm Hg The group studied by Skobeloff et a16 represented a
Baseline 131 ± 23 133 ± 27 NS population with more severe asthma as demonstrated
120 min 127±14.1 122±12.5 NS by failure to respond to two A-agonist inhalational
Borg Scale
Baseline 7.6 ±1.7 7.8 ±1.6 NS treatments and an admission rate of 79%, which is
120 min 3.0t±1.7 3.25 ±2.3 NS similar to that of our placebo-treated "severe" group.
*Theophylline (Theo) and magnesium (Mg) levels were drawn at
However, patients studied by Green and Rothrock'2
baseline. Clinical data shown at time 0 and 120 min. p.0.05 is likely represented a group with less severe disease, as
considered significant. NS-not significant. Values expressed as shown by an admission rate of 17% for the placebo
mean ± SD. group, which is similar to our "moderate" placebo-
107/6 / JUNE, 1995 1579
Downloaded from chestjournal.chestpubs.org by guest on July 13,CHEST/
2011
1995 by the American College of Chest Physicians
treated group. This suggests that in the dosages used whether normalization of serum levels is in part re-
in these studies, MgSO4 may be beneficial only in sponsible for the beneficial effect of magnesium.
patients with severe asthma. Magnesium appears to be safe and well tolerated
It is not clear why MgSO4 appears to work better in the doses used in previous studies to treat acute
in the group with severe asthma. One possible asthma (1.2 to 3.0 g).6'9"12"13 In general, only mild
explanation is that patients with acute severe asthma transient reactions were noted. We did note one ur-
are relatively refractory to d-agonist therapy. There- ticarial reaction that responded promptly to diphen-
fore, if IV MgSO4 improves airway obstruction by a hydramine. In reviewing the literature, we found
different mechanism than A-agonists, this effect is less only two cases of urticarial reactions, both of which
likely to be evident in the moderate group in whom resolved after the magnesium infusion was discon-
the larger response to f-agonists might mask any tinued.28
additional improvement by IV MgSO4. It is also pos- Of the patients reached for telephone follow-up
sible that the amount of magnesium used in patients within 7 days of their ED discharge, 2 required sub-
with moderate asthma was not sufficient to offer ad- sequent ED reevaluation. Both of these patients had
ditional benefit. A dose response curve generated in received MgSO4 during their ED visit. It is possible
patients with stable asthma with moderate obstruc- that once the beneficial effect of magnesium wears
tion demonstrated maximal bronchodilatation after a off, the patient's condition can worsen despite re-
total of 3.45 g of magnesium was given.11 ceiving oral steroids. This may require further study.
It is not known whether magnesium works via A possible limitation of this study was the method
pharmacologic effects or repletion of body stores. of dividing patients into severe and moderate groups.
Regarding pharmacologic effects, several mecha- Although the decision to analyze the patients as two
nisms have been proposed to explain the potential separate groups was made prior to the unblinding,
beneficial effect of magnesium in asthma. In vitro, the study was initially designed to evaluate patients
magnesium causes relaxation of bronchial smooth as a single group, and therefore patients were ran-
muscle.8 This may occur by the modulation of domized by a single table. This accounts for the un-
calcium ion movement both within the cell and even distribution of patients in the severe group. The
through transmembrane calcium channels.18 In ad- improvement in outcome in the severe group is con-
dition, magnesium decreases the amount of neuro- sistent with other reports but needs to be confirmed
transmitter released at motor nerve terminals, di- with further study.
minishes the depolarizing action of acetylcholine at
the neuromuscular end plate, and depresses excit- CONCLUSION
ability of smooth muscle membranes.19 There is some In summary, our data indicate that when 2 g of
evidence that prostaglandin and isoproterenol-medi- MgSO4 is given as an adjunct to standardized asthma
ated vascular smooth muscle relaxation may be therapy, there is no improvement in pulmonary
magnesium dependent.20 It has been suggested that function or admission rates in patients presenting to
MgSO4 may potentiate the effect of d-agonists on the ED. However, when patients with severe asthma
adenyl-cyclase.21 It is also possible that magnesium are analyzed separately, there is a significant im-
can alter the inflammatory process. In vitro, exposing provement in FEV, and hospital admission rate when
activated polymorphonuclear cells from adult asth- magnesium is received. Thus, confirming these re-
matics to magnesium caused a decrease in super- sults in the most severe patients would support the
oxide production.22 routine use of MgSO4 in patients with severe acute
It is not known whether magnesium acutely ben- asthma. Further studies should address the optimal
efits patients by replacing deficient stores of magne- dose and infusion rates of IV MgSO4.
sium. Although studies have demonstrated normal ACKNOWLEDGMENTS: We would like to express special con-
serum magnesium levels in patients with acute asth- sideration to Pamela Arsove, MD, FACEP, for her contribution
ma,23 serum levels may not reflect body stores.24 It is in the design and implementation of the study. We would also like
to express our appreciation to Rich Thailer, PA, for computer
possible that some of our patients may have had de- work; Bernadette Belcastro and Denise Foti, for secretarial work;
pleted body stores of magnesium since only serum Neal Richmond, MD, and Dawn Williamson, MD, f or patient
recruitment; and Michael Borenstein, PhD, and Ruth Bernstein
levels were obtained. In animal studies, chronic Hyman, PhD, for statistical analysis.
magnesium deficiency leads to an increased synthe-
sis of prostanoids and increased release of hista- REFERENCES
mine.25'26 The effects of hypomagnesemia on the 1 Barnes PJ. A new approach to the treatment of asthma. N Engl
airway of patients with asthma have not been well J Med 1989; 321:1517-27
studied. It is known that f-agonist treatment of pa- 2 Cohen SH. Advances in the diagnosis and treatment of asthma.
Chest 1985; 87:(suppl):26S
tients with acute asthma can decrease serum mag- 3 Littenberg B, Gluck EH. A controlled trial of methylpred-
nesium levels by 15%.27 However, it is not known nisolone in the emergency treatment of acute asthma. N Engl

1580 Clinical Investigations

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011
1995 by the American College of Chest Physicians
 J Med 1986; 314:150-52 16 Knudson RJ, Slatin RC, Lebowitz MD, et al. The maximal ex-
4 Schneider SM. Effect of a treatment protocol on the efficacy of pirating flow-volume curve; normal standards, variability and
care of the adult acute asthmatic. Ann Emerg Med 1986; effects of age. Am Rev Respir Dis 1976; 113:587-600
15:703-06 17 Martin TG, Elenbass RM, Pingleton SH. The use of peak expi-
5 Fischl MA, Pitchenik A, Gardner LB. An index predicting re- ratory flow rates to eliminate unnecessary arterial blood gases
lapse and need for hospitalization in patients with acute bron- in acute asthma. Ann Emerg Med 1982; 11:70-3
chial asthma. N Engl J Med 1981; 305:783-89 18 Iseri LT, French JH. Magnesium: nature's physiologic calcium
6 Skobeloff EM, Spivey WH, McNamara RM, et al. Intravenous blocker. Am Heart J 1984; 108:188-93
magnesium sulfate for the treatment of acute asthma in the 19 Del Castillo J, Engback L. The nature of the neuromuscular
emergency department. JAMA 1989; 262:1210-13 block produced by magnesium. J Physiol 1954; 124:370-84
7 Altura BM, Altura BT. Magnesium and contraction of arterial 20 Altura BM, Altura BT. Magnesium ions and contraction of
smooth muscle. Microvas Res 1974; 7:145-55 vascular smooth muscles: relationship to some vascular diseases.
8 Spivey WH, Skobeloff EM, Levin RM. Effect of magnesium Fed Proc 1981; 40:2672-79
chloride on rabbit bronchial smooth muscle. Ann Emerg Med 21 Skorodin MS, Freebeck PC, Yetter B, et al. Magnesium sulfate
1990; 19:1107-12 potentiates several cardiovascular and metabolic actions of
9 Kuitert LM, Kletchko SL. Intravenous magnesium sulfate in terbutaline. Chest 1994; 105:701-5
acute, life-threatening asthma. Ann Emerg Med 1991; 20: 22 Carnes CB, Kraft M, Borish L. Magnesium attenuates neutro-
1243-45 phil activation in adult asthmatic patients [abstract]. Ann
10 Okayama H, Aikawa T, Okayama M, et al. Bronchodilating Emerg Med 1993; 22:935
effects of intravenous magnesium sulfate in bronchial asthma. 23 Falkner D, Glauser J, Allen M. Serum magnesium levels in
JAMA 1987; 257:1076-78 asthmatic patients during acute exacerbations of asthma. Am J
11 Noppen M, Vanmaele L, Impens N, et al, Bronchodilating ef- Emerg Med 1992; 10:1-3
fects of IV magnesium sulfate in acute severe bronchial asthma. 24 Reinhart RA. Magnesium metabolism: a review with special
Chest 1990; 97:373-76 reference to the relationship between intracellular content and
12 Green SM, Rothrock SG. Intravenous magnesium for acute serum levels. Arch Intern Med 1988; 148:2415-20
asthma: failure to decrease emergency treatment duration or 25 Nigam S, Averdunk R, Gunther T. Alteration of prostanoid
need for hospitalization. Ann Emerg Med 1992; 21:260-65 metabolism in rats with magnesium deficiency. Prostaglandins
13 Tiffany BR, Berk WA, Todd K, et al. Magnesium bolus or in- Leukot Med 1986; 23:1-10
fusion fails to improve spirometric performance in acute 26 Bois P, Gascon A, Beulnes A. Histamine liberating effect of
asthma exacerbations. Chest 1993; 104:831-34 magnesium deficiency in the rat. Nature 1963; 501-02
14 Standards for the diagnosis and care of patients with chronic 27 Bodenhamer MD, Bergstom R, Brown D, et al. Frequently
obstructive pulmonary disease (COPD) and asthma. Official nebulized beta-agonists for asthma: effects on serum electro-
statement of the American Thoracic Society, adopted by the lytes. Ann Emerg Med 1992; 1337:21-11
ATS Board of Directors, November 1986 28 Thorp JM, Katz VL, Campbell D, et al. Hypersensitivity to
15 Mahler DA. Dyspnea. London: Futura Publishing, 1990; 122 magnesium sulfate. Am J Obstet Gynecol 1989; 161:889-90

CHEST / 107/6 / JUNE, 1995 1581

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011
1995 by the American College of Chest Physicians
 Intravenous Magnesium Sulfate as an Adjunct in the Treatment of
Acute Asthma
Helen Bloch, Robert Silverman, Noel Mancherje, Steven Grant, Liudvikas
Jagminas and Steven M. Scharf
Chest 1995;107; 1576-1581
DOI 10.1378/chest.107.6.1576
This information is current as of July 13, 2011
Updated Information & Services
Updated Information and services can be found at:
http://chestjournal.chestpubs.org/content/107/6/1576
Cited Bys
This article has been cited by 10 HighWire-hosted articles:
http://chestjournal.chestpubs.org/content/107/6/1576#related-urls
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be
found online at:
http://www.chestpubs.org/site/misc/reprints.xhtml
Reprints
Information about ordering reprints can be found online:
http://www.chestpubs.org/site/misc/reprints.xhtml
Citation Alerts
Receive free e-mail alerts when new articles cite this article. To sign up, select the
"Services" link to the right of the online article.
Images in PowerPoint format
Figures that appear in CHEST articles can be downloaded for teaching purposes in
PowerPoint slide format. See any online figure for directions.

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011

1995 by the American College of Chest Physicians