Exacerbations In Adults Research Articles

Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial

Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone. We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up. Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval -7% to 11%, P=.67). In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

P184 Can we predict asthma exacerbations in working-age adults?

IntroductionLittle information exists on the prevalence and risk factors of asthma exacerbations in the general population. We used GP records to determine whether we can predict exacerbations in adults from...

Five-day course of budesonide inhalation suspension is as effective as oral prednisolone in the treatment of mild to severe acute asthma exacerbations in adults

Background Limited evidence is available on the use of budesonide inhalation suspension (BIS) for the treatment of mild to severe acute asthma exacerbations (AAE) in adults in an inpatient setting. This study was conducted to evaluate the efficacy of a five-day course of BIS compared with oral prednisolone (OP) in the management of adults with AAE. Methods A retrospective study examined the response of 28 patients hospitalized with mild to severe acute asthma exacerbation from January 2003 to December 2003. These patients, who were steroid free ≥1 yr, were administered a five-day course of BIS (2 × 2 mg bid) or OP (2 × 15 mg bid). PEF, FEV 1 and asthma symptom scores were recorded daily. Results The BIS ( n = 13) and OP ( n = 15) treatment groups were comparable at baseline for demographic characteristics and prebronchodilator (fenoterol) FEV 1 of 52.4% predicted normal value and 54.6% predicted normal value, respectively. Mean change of morning PEF was 152 L/min during BIS treatment and 130 L/min for OP treatment; the mean changes of morning forced expiratory volumes in 1 s (FEV 1) were 1.0 and 0.7 L, respectively. The mean change in daytime symptom scores were −1.6 and −1.3 in the BIS and the OP groups, respectively. Improvements in PEF, FEV 1 and daytime symptom scores were significantly different between baseline and after treatment in each treatment group ( p < 0.05). However, improvements in both BIS and OP groups were similar. Conclusion Budesonide inhalation suspension may be an alternative treatment of acute asthma exacerbation in adults who are at risk for systemic corticosteroids.

Is rhinovirus associated with exacerbations in adults with CF?

Is rhinovirus associated with exacerbations in adults with CF?

Comparison of home and hospital intravenous antibiotic therapy for acute pulmonary exacerbations in adults attending a regional cystic fibrosis centre

Comparison of home and hospital intravenous antibiotic therapy for acute pulmonary exacerbations in adults attending a regional cystic fibrosis centre

Human rhinoviruses and asthma in children

= Abstract = Human rhinoviruses (HRVs) is a nonenveloped, single stranded RNA virus belonging to the family Picornavirudae. Transmission by direct contact such as hand-to-hand, hand-to-nose, and hand-to-eye has been readily demonstrated in experimental settings. HRV are the most frequent causes of common cold infection, however, they are also known to replicate in the lower respiratory tract and associated with more severe respiratory illnesses such as asthma. New technique such as reverse transcriptase polymerase chain reaction and molecular typing in HRV has been developed and our understanding of the importance of these respiratory viruses. HRVs consisted of 101 serotypes that are classified into groups A and B according to sequence variations. And there is a newly identified set of HRVs, called Group C, and it is currently under investigation. In recent study using PCR techniques, HRVs accounted for approximate 50-80% of common colds and 85 % of childhood asthma exacerbations and in more than half of adult exacerbations. However, the mechanisms of HRV- induced asthma exacerbations are poorly understood. This review discusses the association between HRVs and childhood asthma. (Korean J Pediatr 2010;53:129-135)

Pharmacodynamics and tolerability of high-dose, prolonged infusion carbapenems in adults with cystic fibrosis – A review of 3 cases

Cystic fibrosis (CF) is a disease marked by repeated acute pulmonary exacerbations of infections, often caused by Pseudomonas aeruginosa and Burkholderia cepacia . As antibiotic susceptibility declines, dose optimization must be considered to provide adequate pharmacodynamic exposure. We report three cases of CF exacerbations in adults caused by multi-drug resistant P. aeruginosa and B. cepacia. Each case required dosing strategies greater than currently recognized in package inserts: meropenem 3000 mg every 8 h (3-hour infusion) and doripenem 2000 mg every 8 h (4-hour infusion). Pharmacokinetic analyses demonstrated that targeted pharmacodynamic exposures were achieved against most of the organisms, resulting in clinical improvements despite laboratory reported resistance. The high-dose, prolonged infusion regimens were well tolerated demonstrating that pharmacodynamically optimized carbapenem regimens may be used safely and effectively in patients with limited conventional treatment options.

Time course and recovery of arterial blood gases during exacerbations in adults with Cystic Fibrosis

Introduction Hypoxia and hypercapnia are closely linked to morbidity and mortality in patients with Cystic Fibrosis (CF). The aims of this study were to describe the changes in blood gases during and following an acute pulmonary exacerbation in adults with CF. Methods We performed a prospective observational study of patients with CF admitted for management of an acute exacerbation. Blood gas and spirometric analysis was performed on admission, throughout the treatment period, and 31 days after discharge (day 45). Results At presentation, eight of nineteen patients had evidence of either hypoxia (PaO 2 < 8 kPa) and/or hypercapnia (PaCO 2 > 6.6 kPa). Blood gas parameters stabilized following two weeks of intravenous antibiotic therapy, with little difference evident in between treatment completion and subsequent review following discharge. Hypercapnia reversed in three patients, with persistent hypercapnia evident in two patients. Conclusion In our study group, hypoxemia and hypercapnia were frequently observed at presentation of the acute exacerbation. Blood gases stabilized following two weeks of intravenous antibiotic therapy, with arterial PCO 2 one month following hospital discharge generally similar to that at time of discharge.

Utility of viral immunofluorescence in pulmonary exacerbations in adults with cystic fibrosis

Utility of viral immunofluorescence in pulmonary exacerbations in adults with cystic fibrosis

Corticosteroids for preventing relapse following acute exacerbations of asthma

Acute asthma is responsible for many emergency department (ED) visits annually. Between 12 to 16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation. To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. We searched the Cochrane Airways Group Specialised Register and reference lists of articles. In addition, authors of all included studies were contacted to locate unpublished studies. The most recent search was run in October 2006. Randomized controlled trials comparing two types of corticosteroids (oral, intra-muscular, or inhaled) with placebo for outpatient treatment of asthmatic exacerbations in adults or children. Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Six trials involving 374 people were included. One study used intramuscular corticosteroids, five studies used oral corticosteroids. The review was split into two reviews and although the latest search yielded no additional placebo controlled trials an additional IM study was included. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (Relative risk (RR) 0.38; 95% confidence interval (CI) 0.2 to 0.74). This favourable effect was maintained over the first 21 days (RR 0.47; 95% CI 0.25 to 0.89) and there were fewer subsequent hospitalizations (RR 0.35; 95% CI 0.13 to 0.95). Patients receiving corticosteroids had less need for beta(2)-agonists (mean difference (MD) -3.3 activations/day; 95% CI -5.6 to -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI -0.47 to 0.56) and side effects (SMD 0.03; 95% CI -0.38 to 0.44) in the first 7 to 10 days, while rarely reported, showed no significant differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. From these results, as few as ten patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. A short course of corticosteroids following assessment for an asthma exacerbation significantly reduces the number of relapses to additional care, hospitalizations and use of short-acting beta(2)-agonist without an apparent increase in side effects. Intramuscular and oral corticosteroids are both effective.

Infections, Immunity &amp; their Effects on Asthma

Infections, Immunity &amp; their Effects on Asthma

How Viral Infections Cause Exacerbation of Airway Diseases

Exacerbations of asthma and COPD are major causes of morbidity, mortality, and health-care costs. Over the last decade, studies using new molecular diagnostic techniques have established that respiratory viruses are a major cause of exacerbations of both asthma and COPD. The most prevalent viruses detected during exacerbations are the rhinoviruses. Despite the burden of disease associated with exacerbations, little is known about the mechanisms of virus-induced exacerbations of airway diseases. Exacerbations are associated with increased airway inflammation in patients with both asthma and COPD, but many questions remain unanswered regarding the key inflammatory cells and mediators involved. Identifying the key inflammatory mediators involved in exacerbations holds the promise of developing diagnostic and prognostic markers of exacerbation. In addition, such studies can identify new therapeutic targets for the development of novel drugs for the prevention and treatment of exacerbations.

Papel del rinovirus en las infecciones respiratorias en niños hospitalizados

AntecedentesEl rinovirus se considera un agente causal de cuadros catarrales banales, sin embargo se ha descrito como un agente inductor de exacerbaciones asmáticas en adultos y niños mayores. En nuestro medio no se ha descrito el papel del rinovirus en infecciones respiratorias de niños hospitalizados.ObjetivosDescribir las infecciones confirmadas por rinovirus en niños hospitalizados por infección respiratoria en un hospital de segundo nivel.Pacientes y métodosEstudio descriptivo prospectivo de las infecciones confirmadas por rinovirus en niños hospitalizados por fiebre o infección respiratoria en la temporada 2004-2005. Para el diagnóstico virológico se realizó inmunofluorescencia y reacción en cadena de la polimerasa (PCR) en aspirado nasofaríngeo. Se describen las características clínicas de los pacientes.ResultadosSe describen un total de 76 niños hospitalizados con infección por rinovirus, lo que supuso el 25 % de los pacientes hospitalizados por procesos respiratorios o fiebre. El rinovirus fue el segundo agente viral identificado tras el virus respiratorio sincitial (29,9% de los hospitalizados). El 71,1 % de los pacientes fueron menores de 2 años. Los diagnósticos más frecuentes fueron sibilancias recurrentes en el 60,5 %, bronquiolitis en 23,7 %, neumonía en el 7,9 % e infección respiratoria de vías altas en el 5,3%. Presentaron fiebre de más de 38 °C el 57,9 % de los niños e infiltrado radiológico el 23,7%. Presentaron hipoxia el 43,4% de los niños. En niños mayores de 2 años el diagnóstico fue crisis asmática en 21 de los 22 casos.ConclusionesLos rinovirus se detectaron en un importante porcentaje de los niños hospitalizados a consecuencia de infección respiratoria, siendo precedidos en frecuencia sólo por el virus respiratorio sincitial. En nuestra serie es el agente viral más frecuentemente asociado con episodios de sibilancias recurrentes en niños mayores de 2 años, y el segundo en los más pequeños.

Pharmacological strategies for self-management of asthma exacerbations: Table 1—

Written action plans are effective within asthma self-management, but there are few guidelines about the specific medication adjustments which can be recommended for self-treatment of exacerbations. This review examines pharmacological strategies for self-management of asthma exacerbations in adults, including those for inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) users. Oral corticosteroids are well-established in clinical practice and clinical trials for the treatment of severe exacerbations, including during combination therapy. Evidence supports 7-10 days treatment, with no need to taper except to reduce side-effects. Doubling the dose of ICS is not effective. Several studies have shown benefit from high-dose ICS (2,400-4,000 microg beclomethasone equivalent) for 1-2 weeks. This may be achieved by adding a high-dose ICS inhaler to maintenance ICS or ICS/LABA therapy. There is inconclusive evidence about acutely increasing the dose of maintenance budesonide/formoterol for exacerbations, and no studies of this approach with fluticasone/salmeterol. For patients taking maintenance budesonide/formoterol, use of the same medication as-needed reduces exacerbations. Short-acting beta2-agonists are still effective in producing bronchodilation during combination therapy; however, a higher dose may be required. There is a need for further studies to clarify remaining issues about self-management of asthma exacerbations, particularly with regard to side-effects of treatment and patient acceptability.

Formoterol via Turbuhaler is as effective as salbutamol via pMDI* with spacer in the treatment of acute asthma exacerbations in adults,

Formoterol via Turbuhaler is as effective as salbutamol via pMDI* with spacer in the treatment of acute asthma exacerbations in adults,

A comparison of levalbuterol with racemic albuterol in the treatment of acute severe asthma exacerbations in adults

This multicenter, randomized, double-blind trial compared nebulized levalbuterol (Lev) and racemic albuterol (Rac) in the treatment of acute asthma. Methods Adults with acute asthma exacerbations (FEV 1 20%-55% predicted) received prednisone and either Lev (1.25 mg, n = 315) or Rac (2.5 mg, n = 312). Nebulized treatments were administered every 20 minutes in the first hour, then every 40 minutes for 3 additional doses, then as necessary for up to 24 hours. The primary end point was time to meet discharge criteria. Secondary end points included changes in lung function and hospitalization rates. A subset of 160 patients had plasma ( S)-albuterol concentrations determined at study entry. Results Time to meet discharge criteria did not differ between the 2 treatments. FEV 1 improvement was greater following Lev compared with Rac, both after dose 1 and cumulatively over the entire treatment period (dose 1 in intent to treat [ITT] group: Lev 0.50 ± 0.43 L, Rac 0.43 ± 0.37 L; P = .02), particularly among the 60% of patients not on recent steroid therapy (dose 1: Lev 0.58 ± 0.47 L, Rac 0.44 ± 0.37 L; P < .01), and patients whose entry ( S)-albuterol concentrations were in the highest quartile of those measured. A small and similar proportion of Lev-treated (7.0%) and Rac-treated (9.3%) patients required hospitalization ( P = .28). Among patients not on steroids, fewer Lev- than Rac-treated patients required admission (3.8% vs 9.3%, P = .03), as was also the case for patients with high plasma ( S)-albuterol concentrations. Asthma relapses (5% in 30 days) were lower than in previous reports and did not differ between groups. Conclusions This study suggests that early, regular nebulized β 2-agonist and systemic corticosteroid therapy may reduce hospitalization and relapse rates in patients with acute severe asthma. Lev was well tolerated and compared favorably with Rac in improving airway function, particularly in those who were not on inhaled or oral corticosteroids and in those who had high plasma ( S)-albuterol concentrations at presentation.

One-Year Outcome After Severe Pulmonary Exacerbation in Adults With Cystic Fibrosis

One-Year Outcome After Severe Pulmonary Exacerbation in Adults With Cystic Fibrosis

Beyond Our Pages

Beyond Our Pages

Impact of viruses on airway diseases

There is strong epidemiological evidence that respiratory viral infections are associated with 80–85% of asthma exacerbations in children. There is less evidence in adults, but the available data suggest viruses are associated with around two-thirds to three-quarters of exacerbations in adults. These associations include severe exacerbations requiring hospitalisation. The most common viruses detected in these studies were rhinoviruses, accounting for two-thirds of viruses detected. Asthmatics have increased susceptibility to respiratory virus infection and have recently been shown to have profoundly defective interferon-β responses to virus infection, resulting in increased virus replication. Atypical bacterial infections are also associated with chronic asthma and asthma exacerbations and a recent study indicates antibiotic therapy active against atypical bacteria is effective in treatment of exacerbations. Recent data also indicates asthmatics are at increased risk of invasive pneumococcal disease, suggesting they may also have impaired antibacterial immunity. Research is urgently required to determine whether augmenting anti-infective immunity is beneficial in the treatment/prevention of asthma exacerbations. More recent data also implicates viruses in the majority of exacerbations of chronic obstructive pulmonary disease. Studies are also required investigating anti-infective host defence in chronic obstructive pulmonary disease.

Naturally Occurring Parainfluenza Virus 3 Infection in Adults Induces Mild Exacerbation of Asthma Associated with Increased Sputum Concentrations of Cysteinyl Leukotrienes

Background:Viral respiratory tract infections represent the most frequent cause of asthma exacerbation in both children and adults, but the precise mechanism of such exacerbation remains unknown. Objectives: To determine the critical mediator of naturally occurring parainfluenza virus (PIV) 3-induced mild asthma exacerbations in adults. Methods: The study subjects were 19 adult asthmatics with mild asthma exacerbation (peak expiratory flow = 60–80% of predicted before bronchodilator use and >80% of predicted after initial bronchodilator treatment). Differential cell counts and concentrations of inflammatory markers including eosinophil cationic protein (ECP), cysteinyl leukotrienes (cysLTs), interleukin (IL)-5, IL-10 and IL-12 were measured in the induced sputum obtained from adults with PIV3- (n = 9) and non-cold-induced (n = 10) exacerbation of asthma during both acute and convalescent phases. Results: PIV3 infection was confirmed by the presence of viral RNA in nasopharyngeal aspirates. Mild exacerbation of asthma was not associated with significant changes in sputum differential cell counts. Concentrations of sputum ECP and cytokines were comparable between PIV3 and non-cold-induced patients. In contrast, PIV3 infection was associated with a significant increase in sputum cysLTs during the acute phase of mild asthma exacerbation. Conclusions: Our results identified cysLTs as a critical mediator of PIV3-induced acute asthma exacerbation.