Improvement In PEF Research Articles

Lung function parameters are associated with acute mountain sickness and are improved at high and extreme altitude

At altitude, factors such as decreased barometric pressure, low temperatures, and acclimatization might affect lung function.The effects of exposure and acclimatization to high-altitude on lung function were assessed in 39 subjects by repetitive spirometry up to 6022 m during a high-altitude expedition. Subjects were classified depending on the occurrence of acute mountain sickness (AMS) and summit success to evaluate whether lung function relates to successful climb and risk of developing AMS.Peak expiratory flow (PEF), forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) increased with progressive altitude (max. +20.2 %pred, +9.3 %pred, and +6.7 %pred, all p<0.05). Only PEF improved with acclimatization (BC1 vs. BC2, +7.2 %pred, p=0.044). At altitude FEV1 (p=0.008) and PEF (p<0.001) were lower in the AMS group.The risk of developing AMS was associated with lower baseline PEF (p<0.001) and longitudinal changes in PEF (p=0.008) and FEV1 (p<0.001). Lung function was not related to summit success (7126 m). Improvement in PEF after acclimatization might indicate respiratory muscle adaptation.

Immediate effects of manual therapy on respiratory functions in healthy young individuals: a randomized controlled trial

This study aimed to investigate the immediate effects of manual therapy (MT) on the respiratory functions of healthy young individuals. The study included 104 participants, consisting of university students (87 females, 17 males, mean age 20.1 ± 2.2). Participants were randomly assigned to the MT (experimental; n = 52) and sham-MT (control; n = 52) groups. The experimental group underwent thoracic manipulations and mobilizations along with diaphragm mobilization. In the control group, the hands were placed on the same regions, but no specific intervention was applied. All participants underwent respiratory function testing before and after the intervention using a portable spirometer (PEF- Peak expiratory flow; FEV 1- Forced expiratory volume in 1 s; FVC- Forced vital capacity and FEV1/FVC- Tiffeneau index). In the experimental group, there was a significant increase in the mean PEF value following MT application from 296.3 ± 110.8 to 316.1 ± 119.1 (p = 0.018). Conversely, the mean PEF value in the control group showed a slight decrease from 337.1 ± 93.3 to 324.5 ± 89.2 (p = 0.002). No significant changes were observed in FVC, FEV1, or FEV1/FVC values pre- and post-intervention in either groups. A single MT session led to a significant improvement in PEF in healthy young individuals. Further research is needed to explore the long-term effects of MT on respiratory functions and its potential implications in clinical practice.Trial registration ClinicalTrials.gov: NCT05934240 (06/07/2023).

Hyperbaric oxygen therapy effects on pulmonary functions: a prospective cohort study

BackgroundOxygen toxicity is one potential side effect of hyperbaric oxygen therapy (HBOT). Previous small studies showed mild reductions in pulmonary functions reflecting reductions in small airway conductance after repetitive hyperbaric oxygen sessions. However, there are no updated data with well performed pulmonary tests that address the pulmonary effect of the currently used HBOT protocols.The aim of this study was to evaluate the effect of HBOT on pulmonary functions of patients receiving the currently used HBOT protocol.MethodsProspective analysis included patients, 18 years or older, scheduled for 60 daily HBOT sessions between 2016 and 2018. Each session was 90 min of 100% oxygen at 2 ATA with 5 min air breaks every 20 min, 5 days per week. Pulmonary functions, measured at baseline and after HBOT, included forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1) and peak expiratory flow rate (PEF).ResultsThe mean age was 60.36 ± 15.43 and 62.5% (55/88) were males. Most of the patients (83/88, 94.3%) did not have any pulmonary disease prior to inclusion and 30.7% (27/88) had a history of smoking.Compared to baseline values, at the completion of 60 HBOT sessions, there were no significant changes in FEV1 (0.163), FEV1/FVC ratio (0.953) and FEF25–75% (0.423). There was a statistically significant increase though not clinically relevant increase in FVC (0.1 ± 0.38 l) and PEF (0.5 ± 1.4 l) with a 0.014 and 0.001 respectively.ConclusionRegarding pulmonary functions, repeated hyperbaric oxygen exposure based on the currently used HBOT protocol is safe. Surprisingly, there was a modest non clinically significant though statistically significant improvement in PEF and FVC in the current cohort of patients who were without chronic lung diseases.Trial registrationClinicaltrials.gov, trial ID: NCT03754985, (Nov 2018) Retrospectively registered.

Study of efficacy and safety of levosalbutamol versus racemic salbutamol delivered by metered dose inhaler in children with moderate persistent asthma

Aim: To compare the efficacy and safety of Levosalbutamol versus racemic Salbutamol delivered by metered dose inhaler in children with moderate persistent asthma. Materials and Methods: Children enrolled in the study were randomized to receive MDI Levosalbutamol 2 puff thrice daily, 50 µgm/puff (group A) or MDI Racemic Salbutamol 2 puff thrice daily. 100 µgm/puff (group B).Baseline characteristics of both groups were comparable. The FEV1 % and PEF % were assessed at baseline, at 15 minutes following the first dose on day 1 and on day 8. In children who remained symptomatic on day 8, an additional evaluation on day 15 was performed. Asthma symptom score were calculated from symptom score card. Results: There was significant improvement in PEF % and FEV1 % within each group. But there was no statistically significant inter-group difference in PEF % change and FEV1 % change except mean change in PEF % and ∆PEF % of initial on day 8 (at the end of 1 week).Asthma symptom score improved significantly in both groups but there was no inter group difference. Incidence of side effects like decrease in serum potassium level and increase in heart rate were comparable in between the two groups. Conclusion: Levosalbutamol administered via MDI improved PEF % significantly more in comparison of racemic Salbutamol after regular use of one week. However, no significant differences were observed in between the two drugs with respect to pulmonary function test on day 1, FEV1 % on day 8 and asthma symptom score. The side effect profile of the two drugs was comparable. This suggests that Levosalbutamol is at least as efficacious as conventional Salbutamol in terms of clinical efficacy.

Alternative functional criteria to assess airflow-limitation reversibility in asthma

IntroductionInternational guidelines define significant bronchodilator response as absolute and percentage change from baseline in forced expiratory volume (FEV1) in the first second and/or forced vital capacity (FVC) ≥12% and 200mL. However, bronchodilator effects on other lung function parameters have also been correlated to some degree of reversible airflow limitation. ObjectivesTo determine whether changes in other lung function parameters apart from FEV1 and FVC detect functional responses to bronchodilator in asthmatic patients. Materials and methodsSpirometry and body plethysmography were performed at baseline conditions and after administration of 400μg of salbutamol by metered-dose inhaler through a space chamber device in asthmatic patients. Paired t-tests were used to compare lung function parameters between those with and without criteria for reversibility of airway obstruction according to ATS/ERS criteria. Cut-off values were obtained from the corresponding ROC curves. Measurements evaluated were FEV1, FVC, maximum mid-forced expiratory flow (FEF25–75%), residual volume (RV), inspiratory capacity (IC), airway resistance (Raw) and specific airway conductance (sGaw). ResultsFrom a total of 100 consecutive asthmatics patients (46% of them men; average age 58.7±14.1 years; 76% with mild to moderate obstruction), 50 patients had a significant bronchodilator response. All of these had noteworthy variations (p<0.004) in PEF, FEF25–75%, RV, Raw and sGaw. The most accurate in predicting a significant bronchodilator response were the absolute and percentage improvements in PEF (≥0.4L/s and 8%), FEF25–75% (≥0.087L/s and 27%) and the percentage of sGaw compared with that at baseline (≥25%). Based on these cut-off values, a sizeable number of the patients defined as non-responders had important changes in airway caliber. 17 patients had significant increments in the percentage of PEF and 10 had changes in absolute volume; 6 patients had increments in percentage and 16 in absolute change of FEF25–75%; 22 patients had increments in the percentage change of sGaw. ConclusionsChanges of FEV1 and/or FVC may underestimate significant functional response to bronchodilators in asthmatic patients with airway obstruction when considering the change in other lung function parameters.

Spirometry Findings Following Treatment with Oral and Inhalant Corticosteroids in Mild to Moderate Asthma Exacerbation in Children

Introduction: Asthma exacerbation is common in children. Treatment with oral corticosteroids (OCS) and inhaled corticosteroids are suggested for asthma exacerbation. It is shown that inhaled corticosteroids has similar outcome in reducing asthma symptoms compared to OCS. But few studies have evaluated the pulmonary function changes in these two treatments. In this study, we evaluated the changes in pulmonary function tests in children with mild-to-moderate asthma exacerbation receiving oral prednisolone and inhaled Budesonide. Methods and Materials: Forty-four children with mild-to-moderate asthma exacerbation were randomly assigned to receive oral prednisolone (2 mg/kg) or Budesonide spray (2 puffs every 12 hours, each puff contains 200 microgram Budesonide) using a spacer for one week. The first dose of the treatment was given in the emergency department. Children were followed for seven days and spirometry findings before and after treatment were evaluated. Results: There was no significant difference between pulmonary function tests before and after treatment between groups. Children receiving oral prednisolone had significantly more improvement in PEF (p=0.01). There was significant improvement in all respiratory parameters after treatment in both groups (p<0.05), but PEF had no significant change after treatment s in inhaled Budesonide group (p=0.63). Conclusion:Both inhaled Budesonide and oral prednisolone significantly improved respiratory function in children with mild-to-moderate asthma exacerbation. As there was no significant difference between groups in PFT findings and due to the low systemic effects of inhaled budesonide compared to oral prednisolone, this treatment seems to be more appropriate in mild to moderate exacerbations.

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.

Cochrane Review: Addition of long‐acting beta‐agonists to inhaled corticosteroids for chronic asthma in children

Cochrane Review: Addition of long‐acting beta‐agonists to inhaled corticosteroids for chronic asthma in children

Addition of long-acting beta-agonists to inhaled corticosteroids for chronic asthma in children.

Long-acting ss(2)- agonists (LABA) in combination with inhaled corticosteroids (ICS) are increasingly prescribed in asthmatic children. To compare the safety and benefit of adding LABA to ICS with the same or an increased dose of ICS in children with persistent asthma. We searched the Cochrane Airways Group Asthma Trials Register (May 2008). We included randomised controlled trials testing the combination of LABA and ICS versus the same or an increased dose of ICS for minimum of at least 28 days in children and adolescents with asthma. The main outcome was the rate of exacerbations requiring rescue oral steroids. Secondary outcomes included pulmonary function, symptoms, adverse events, and withdrawals. Studies were assessed independently by two review authors for methodological quality and data extraction. Confirmation was obtained from the trialists when possible. A total of 25 trials representing 31 control-intervention comparisons were included in the review randomising 5572 children. Most of the participants were inadequately controlled on current ICS dose. We assessed the addition of LABA to the same dose of ICS and to an increased dose of ICS:(1) The addition of LABA to ICS was compared to same dose ICS, namely 400 mcg/day of beclomethasone or less in 16 of the 24 studies. The mean age of participants was 10 years and males accounted for 64% of the study populations. The mean FEV(1) at baseline was 80% of predicted or above in 10 studies; FEV(1) 61% to 79% of predicted in eight studies; and unreported in the remaining study. Participants were inadequately controlled before randomisation in all but seven studies. Compared to ICS alone, the addition of LABA to ICS was not associated with a significant reduction in exacerbations requiring oral steroids (seven studies, RR 0.92 95% CI 0.60 to 1.40). Compared to ICS alone, there was a significantly greater improvement in FEV1 with the addition of LABA (nine studies; 0.08 Litres, 95% CI 0.06 to 0.11) but no statistically significant group differences in symptom-free days, hospital admission, quality of life, use of reliever medication, and adverse events. Withdrawals occurred significantly less frequently with the addition of LABA.(2) A total of seven studies assessed the addition of LABA to ICS therapy compared with an increased dose of ICS randomising 1021 children. The mean age of participants was 8 years with 67% of males. The baseline mean FEV(1) was 80% of predicted or above in 2 of the 3 studies reporting this characteristic. All trials enrolled participants who were inadequately controlled on a baseline dose equivalent to 400 mcg/day of beclomethasone or less. There was no group significant difference in the risk of an exacerbation requiring oral steroids with the combination of LABA and ICS compared to a double dose of ICS (two studies, RR 1.5 95% CI 0.65 to 3.48). The increased risk of hospital admission with combination therapy was also not statistically significant (RR 2.21 95% CI 0.74 to 6.64). Compared to double dose ICS, use of LABA was associated with a significantly greater improvement in morning PEF (four studies; MD 7.55 L/min 95% CI: 3.57 to 11.53) and evening PEF L/min (three studies, MD 5.5 L/min; 95% CI 1.21 to 9.79), but there were insufficient data to aggregate data on FEV(1), symptoms, rescue reliever use, and quality of life. There was no statistically significant difference in the overall risk of all cause withdrawals (five studies; RR 0.71; 95% CI 0.42 to 1.20. There was no group difference in the risk of overall adverse effects detected. Short term growth was significantly greater in children treated with combination therapy compared to double dose ICS (two studies: MD 1.2 cm/year; 95% CI 0.72 to 1.7). In children with persistent asthma, the addition of LABA to ICS was not associated with a significant reduction in the rate of exacerbations requiring systemic steroids, but was superior for improving lung function compared to the same dose of ICS. Similarly, compared to a double dose ICS, the combination of LABA and ICS did not significantly increase the risk of exacerbations requiring oral steroids, but was associated with a significantly greater improvement in PEF and growth. The possibility of an increased risk of rescue oral steroids and hospital admission with LABA therapy needs to be further examined.

Wearability and physiological effects of custom‐fitted vs self‐adapted mouthguards

The purpose of this study was to measure the comfort, wearability, physiological effects and its influence on athletes' physical performance, of custom-fitted compared with self-adapted mouthguards (MGs). Eleven rugby players were put under specific efforts similar to those of the competition. Each player made three consecutive tests randomly wearing a commercially available 'boil-and-bite' self-adapted mouthguard (MG2), a custom-fitted mouthguard (MG3), and no mouthguard (reference). Forced expiratory air volume at 1 s (FEV(1)), expiratory flow rates peak (PEF), forced vital capacity (FVC), rebound (RB) jump 15 s, and counter-movement jump (CMJ) were measured on each player before and after the training exercise tests. Subjective evaluations by means of a visual analog scale (VAS) questionnaire took place. Comforts, adaptability, stability, tiredness, thirst, oral dryness, nausea, ability to talk, breathe, and drink were evaluated. The wearing of the self-adapted MG showed significant improvement in PEF (P < 0.05). There were no statistically significance differences regarding the others spirometer parameters. In CMJ, there were no differences between both the MGs. On RB power was similar with both MGs and control. However, RB height reduced significantly wearing MGs. MG3 showed superior properties in comfort, adaptability, stability, and ability to talk and to breathe. MG3 showed the smallest range of changes in players' performance, suggesting improved fit, comfort, and acceptation compared with MG2. Furthermore, its greatest advantage is the individualized design according to the proper anatomy of the oral cavity. Greater efforts must be made to improve the comfort of MGs if their use is to be increased.

A proof of concept study to evaluate stepping down the dose of fluticasone in combination with salmeterol and tiotropium in severe persistent asthma

We conducted a double blind, randomised, placebo-controlled, crossover study evaluating the effects of halving inhaled steroid dosage plus salmeterol, or salmeterol and tiotropium. Eighteen life-long non-smoking severe asthmatics [mean FEV(1) 1.49 l (51%)] were run-in for 4 weeks on HFA-fluticasone propionate 1000 microg daily, and were subsequently randomised to 4 weeks of either (a) HFA-fluticasone propionate 500 microg BD/salmeterol 100 microg BD/HFA-tiotropium bromide18 microg od; or (b) fluticasone propionate 500 microg BD/salmeterol 100 microg BD matched placebo. Measurements of spirometry and body plethysmography were made. Adding salmeterol to half the dose of fluticasone led to a mean improvement (95% CI) vs. baseline in morning PEF of 41.5 (14.0-69.0)l/min [p<0.05]; and RAW of 0.98 (0.14-1.8)cm H(2)O/l/s [p<0.05]. Adding salmeterol/tiotropium produced similar improvements in PEF and RAW, but also improved FEV(1) by 0.17 (0.01-0.32)l [p<0.05]; FVC 0.24 (0.05-0.43)l [p<0.05] and reduced exhaled NO by 2.86 (0.12-5.6)ppb [p<0.05]. RV and TLC were not altered by either treatment; there were no significant changes in symptoms or quality of life compared with baseline. Addition of salmeterol/tiotropium to half the dose of fluticasone afforded small, but significant improvements in pulmonary function. These effects were not associated with commensurate changes in subjective symptoms or quality of life.

Once versus twice daily formoterol via Novolizer ® for patients with moderate to severe COPD—A double-blind, randomised, controlled trial

Study objectives To evaluate in patients with moderate to severe COPD whether a single morning dose of 24 μg formoterol from the Novolizer ® is not inferior to two divided doses of 12 μg formoterol inhaled in the morning and in the evening. Design Randomised, double blind, active-controlled, parallel-group, multi-centre study with a 2-week run-in period and a 12-week treatment phase. Setting Forty-seven outpatient centres in Germany, including private practices. Participants N = 321 symptomatic patients with moderate to severe COPD aged 40–70 years with an FEV 1 of 30–80% predicted and the requirement of 3–12 actuations of salbutamol per day on ⩾5 days during the run-in period. Treatment Eligible patients were randomised to inhale formoterol either (a) as a single 24 μg dose in the morning (OD) or (b) in two divided 12 μg doses in the morning and in the evening (b.i.d.). Measurements and results The mean age was 60.3 (SD 7.3) years, and mean baseline pre-dose FEV 1 was 1.5 l (0.5 l) or 50% (12%) of predicted, respectively. After 12 weeks of treatment, pre-dose FEV 1 improved in both groups (mean: OD, +104 ml, b.i.d., +135 ml, mean difference between groups: 31 ml). The 95% CI exceeded the pre-determined margin of 100 ml by 2 ml, so that the statistical hypothesis of non-inferiority of once daily dosing was not confirmed. No statistically significant differences were seen for improvements in PEF, MEF 75, MEF 50, and MEF 25. COPD symptoms, percentage of symptom-free days and quality of life (SGRQ) improved in both groups to a similar degree. There were no relevant differences in the incidence of adverse events. Conclusions Based on a comparable efficacy and tolerability, the dosing schedule with formoterol via Novolizer ® as once daily in the morning seems to be an alternative compared to twice daily treatment. The primary endpoint suggests the equivalence of both treatment schedules from a clinical perspective. This regimen can be considered as an alternative therapeutic approach for a subgroup of COPD patients and may help to improve patient compliance.

Oral xanthines as maintenance treatment for asthma in children.

Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti-inflammatory effects. The current role of xanthines in the long-term treatment of childhood asthma needs to be reassessed. To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma. A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2005. Randomised controlled trials,lasting at least four weeks comparing a xanthine with placebo, regular short-acting beta-agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old. Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom-free days. Thirty-four studies (2734 participants) of adequate quality were included. Xanthine versus placebo (17 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV1 , and PEF were better with xanthine. Xanthine was associated with non - specific side-effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta-agonist. Beta-agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro-intestinal side-effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated. Xanthines as first-line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add-on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first-line preventative asthma therapy in children when ICS are not available. They may have a role as add-on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk-benefit ratio compared with other agents.

Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators

Background Since the advent of inhaled ß2-agonists, anticholinergic agents and glucocorticoids, the role of aminophylline in paediatric acute asthma has become less clear. There remains some consensus that it is beneficial in children with acute severe asthma, receiving maximised therapy (oxygen, inhaled bronchodilators, and glucocorticoids). Objectives To determine if the addition of intravenous aminophylline produces a beneficial effect in children with acute severe asthma receiving conventional therapy. Search strategy The Cochrane Airways Group register of trials was used to identify relevant studies. The latest search was carried out in December 2004 Selection criteria Randomised-controlled trials comparing intravenous aminophylline with placebo in addition to usual care in children met the inclusion criteria. Data collection and analysis Two reviewers independently assessed studies and extracted data. Disagreement in the selection of trials was resolved by consensus. Attempts were made to contact authors to verify accuracy of data. Main results Seven trials met the inclusion criteria (380 participants). Methodological quality was high. All studies recruited children with acute severe asthma and requiring hospital admission. Six studies sought participants who were unresponsive to nebulised short-acting beta-agonist and administered systemic steroids to study participants. In two studies where some children were able to perform spirometry, baseline FEV1 was between 35 and 45% predicted. The addition of aminophylline to steroids and ß2-agonist significantly improved FEV1% predicted over placebo at 6-8 hours, 12-18 hours and 24 hours. Aminophylline led to a greater improvement in PEF% predicted over placebo at 12-18 hours. There was no significant difference in length of hospital stay, symptoms, frequency of nebulsations and mechanical ventilation rates. There were insufficient data to permit aggregation for oxygenation and duration of supplemental oxygen therapy. Aminophylline led to a three-fold increase in the risk of vomiting. There was no significant difference between treatment groups with regard to hypokalaemia, headaches, tremour, seizures, arrhythmias and deaths. Authors' conclusions In children with a severe asthma exacerbation, the addition of intravenous aminophylline to ß2-agonists and glucocorticoids (with or without anticholinergics) improves lung function within 6 hours of treatment. However there is no apparent reduction in symptoms, number of nebulised treatment and length of hospital stay. There is insufficient evidence to assess the impact on oxygenation, PICU admission and mechanical ventilation. Aminophylline is associated with a significant increased risk of vomiting. PLAIN LANGUAGE SUMMARY Acute asthma is a common paediatric emergency prevalent in many countries. Treatment aims to reverse asthma by opening up the airways and targeting the underlying inflammation of the airways. Beta-agonists, anticholinergic agents and glucocorticoids are currently the most commonly used strategies. In the past, aminophylline has been extensively used for the management of acute asthma, despite side effects. However, its use has declined with the availability of effective inhaled bronchodilators and glucocorticoids. The purpose of this review was to assess whether the use of intravenous aminophylline in children receiving maximised inhaled bronchodilators and glucocorticoids produced additional beneficial effects. We identified a small number of good quality trials which compared aminophylline with placebo in children given inhaled bronchodilators and glucocorticoid therapy. This review found evidence that children treated with aminophylline had a greater improvement in lung function than children treated with placebo, when both groups received inhaled bronchodilators and steroids and they responded incompletely to these initial therapies. However, aminophylline use also resulted in greater risk of vomiting. Aminophylline use in children may be appropriate if children have a role in severe acute exacerbations of asthma where response to maximised therapy (inhaled bronchodilators and glucocorticoids) is poor. These results are based on small numbers and further work in this area is required. Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Beneficial Effects of Albuterol Therapy Driven by Heliox versus by Oxygen in Severe Asthma Exacerbation

To determine and define the beneficial effects of heliox-driven albuterol therapy on severe asthma exacerbation and clinical factors that affect greater response. The authors conducted two randomized, double-blinded, controlled trials in patients with severe asthma exacerbation. The first trial recruited 80 patients in the emergency department (ED). They received three consecutive doses of albuterol delivered by a nebulizer powered by either O(2) (O(2) group) or heliox (He/O(2) = 80:20; heliox group). Changes in peak expiratory flow rate (PEF) were compared, and factors influencing the response to heliox-driven albuterol therapy were identified. The second trial of 80 patients was conducted in older patients, a subpopulation associated with greater response in the first trial. In the first trial, the heliox group had more rapid and greater improvement in PEF compared with the O(2) group. There tended to be more patients in the heliox group reaching the predetermined dischargeable PEF (>60% predicted) after three albuterol treatments (odds ratio, 2.58; 95% confidence interval = 1.03 to 6.46; p = 0.069). For patients eventually discharged from the ED, the ED stay was shorter by 10 minutes per patient in the heliox group compared with the O(2) group (p = 0.007). Logistic regression showed older age and lower pretreatment PEF to be associated with favorable heliox responses. The second trial, which recruited older patients (older than 40 years), showed greater improvement in PEF and dyspnea score with heliox-driven albuterol therapy in patients with lower pretreatment PEF. Heliox-driven albuterol may be a useful adjunct therapy for older asthmatic patients with severe asthma exacerbation.

Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators.

Since the advent of inhaled beta2-agonists, anticholinergic agents and glucocorticoids, the role of aminophylline in paediatric acute asthma has become less clear. There remains some consensus that it is beneficial in children with acute severe asthma, receiving maximised therapy (oxygen, inhaled bronchodilators, and glucocorticoids). To determine if the addition of intravenous aminophylline produces a beneficial effect in children with acute severe asthma receiving conventional therapy. The Cochrane Airways Group register of trials was used to identify relevant studies. The latest search was carried out in December 2004 Randomised-controlled trials comparing intravenous aminophylline with placebo in addition to usual care in children met the inclusion criteria. Two reviewers independently assessed studies and extracted data. Disagreement in the selection of trials was resolved by consensus. Attempts were made to contact authors to verify accuracy of data. Seven trials met the inclusion criteria (380 participants). Methodological quality was high. All studies recruited children with acute severe asthma and requiring hospital admission. Six studies sought participants who were unresponsive to nebulised short-acting beta-agonist and administered systemic steroids to study participants. In two studies where some children were able to perform spirometry, baseline FEV1 was between 35 and 45% predicted. The addition of aminophylline to steroids and beta2-agonist significantly improved FEV1% predicted over placebo at 6-8 hours, 12-18 hours and 24 hours. Aminophylline led to a greater improvement in PEF% predicted over placebo at 12-18 hours. There was no significant difference in length of hospital stay, symptoms, frequency of nebulsations and mechanical ventilation rates. There were insufficient data to permit aggregation for oxygenation and duration of supplemental oxygen therapy. Aminophylline led to a three-fold increase in the risk of vomiting. There was no significant difference between treatment groups with regard to hypokalaemia, headaches, tremour, seizures, arrhythmias and deaths. In children with a severe asthma exacerbation, the addition of intravenous aminophylline to beta2-agonists and glucocorticoids (with or without anticholinergics) improves lung function within 6 hours of treatment. However there is no apparent reduction in symptoms, number of nebulised treatment and length of hospital stay. There is insufficient evidence to assess the impact on oxygenation, PICU admission and mechanical ventilation. Aminophylline is associated with a significant increased risk of vomiting.

Comparison of Inhaled Fluticasone with Intravenous Hydrocortisone in the Treatment of Adult Acute Asthma

Several studies published in the second half of the 1990s have shown a therapeutic early effect of inhaled corticosteroids in acute asthma. However, systemic corticosteroids are considered the standard of care. To compare the effect of repeated doses of inhaled fluticasone with the standard treatment of systemic corticosteroids in adult patients with severe acute asthma. One hundred six patients (mean age, 33.5 +/- 8.8 years) were randomly assigned to receive fluticasone (3,000 microg/hour) administered through a metered-dose inhaler and spacer at 10-minute intervals for 3 hours, or 500 mg of intravenous hydrocortisone. In addition, all patients received inhaled albuterol and ipratropium bromide. Subjects treated with fluticasone showed 30.5 and 46.4% greater improvements in PEF and FEV1, respectively, compared with the hydrocortisone group. The fluticasone group had better PEF and FEV1 at 120, 150, and 180 minutes (p < 0.05). Also, the fluticasone group showed higher rates of patients who obtained the discharge threshold at 90, 120, and 150 minutes. This therapeutic benefit was particularly evident in those patients with the most severe obstruction. Subjects with a baseline FEV1 of less than 1 L treated with fluticasone showed a significant increase in pulmonary function (p = 0.001) and a significant decrease in hospitalization rate (p = 0.05). The use of repeated doses of inhaled fluticasone was more effective than intravenous hydrocortisone and was associated with an early improvement. This therapeutic benefit was particularly evident in those patients with the most severe obstruction.

Oral versus intravenous corticosteroids in adults hospitalised with acute asthma

Background Systemic corticosteroids are routinely used in the management of acute asthma, however the optimum route of administration for patients requiring hospitalisation is unclear. Intravenous (IV) corticosteroids are used in practice, but they may not offer any advantage over oral corticosteroids. Aim To compare the efficacy of oral and IV administration of corticosteroids in the treatment of adults hospitalised with acute asthma. Method Adults admitted to hospital for treatment of acute asthma were randomised to receive oral prednisolone 100 mg once daily or hydrocortisone 100 mg IV 6 hourly for 72 h following admission. All patients concurrently received inhaled corticosteroids and bronchodilators. Improvements in peak expiratory flow rate (PEF) from baseline were compared for 72 h. Results Forty-seven patients were randomized, 30 females, 17 males. Twenty-four received oral prednisolone and 23 received IV hydrocortisone. At baseline the oral and IV groups were similar (mean, SD) in age (38.3, 12.8 vs 37.3, 12.9, P=0.80) and initial percent predicted (PP) PEF (61, 16.7 vs 69, 13.0, P=0.11). After 72 h both groups had similar improvements in PEF (27%, 26 vs 27%, 19, P=0.96). Conclusion Corticosteroids administered orally and IV had similar efficacy in the treatment of adults hospitalised with acute asthma.

Stenting at the Flow-limiting Segment in Tracheobronchial Stenosis due to Lung Cancer

Airway stenting at the wave-speed flow-limiting segment (the choke point) is assessed. We determined prospectively the precise location of the choke point using the flow–volume curve, endobronchial ultrasonography, ultrathin bronchoscopy, and three-dimensional computed tomography scan before and after stenting in 64 patients with extrincic compression due to lung cancer. We noted distinct flow–volume curve patterns specific to the type of stenosis. The tracheal stenosis group indicated fixed narrowing patterns with an expiratory plateau, bronchial stenosis group dynamic collapse patterns with an expiratory flow deterioration (choking), carinal stenosis group combined fixed and dynamic patterns, and extensive stenosis group complex patterns containing elements of all the former. After stenting, almost full-function patterns with significant improvement in PEF were observed in all groups (p < 0.01, p < 0.05, p < 0.001, p < 0.01, respectively). In patients with extensive stenosis, implantation of additional stents was required when the choke points were observed to have migrated to the areas of malacia with cartilage destruction by the tumor. Secondary stenting at migrated choke points resulted in a significant improvement in PEF over the initial stenting (p < 0.01). Stenting at the choke point improved expiratory flow limitation by increasing the cross-sectional area, supporting the weakened airway wall and relieving dyspnea.

Rapid-Onset Asthma Attack: A Prospective Cohort Study About Characteristics and Response to Emergency Department Treatment

(1) To determine the frequency of rapid-onset asthma attacks (ROAAs) and slow-onset asthma attacks (SOAAs) in adult patients with acute, severe disease (18 to 50 years old), who presented to an emergency department (ED); and (2) to establish whether ROAA patients differ from SOAA patients in terms of clinical and spirometric characteristics; and (3) in terms of the response of treatment. Four hundred three patients (with peak expiratory flow [PEF] or FEV(1) of < 50% of predicted value) with acute exacerbations of asthma were enrolled in the trial using a prospective cohort study. Asthma attacks were classified as an ROAA (< 6 h of symptoms) or an SOAA (> or = 6 h). All patients were treated with albuterol, four puffs at 10-min intervals (100 microg per actuation), delivered by metered-dose inhaler with a spacer device during 3 h. On the basis of previously determined criteria, 11.3% of patients were classified as having a ROAA. Male patients comprised 53.6% of the ROAA group (p = 0.03). In ROAA patients, the exacerbation was less likely to be attributed to respiratory tract infection (p = 0.001) and more likely to have no identifiable cause (p = 0.0001). Also, ROAA patients had lower pulmonary function (FEV(1)) at presentation (mean difference, - 0. 13; 95% confidence interval [CI], - 0.22 to - 0.04 L; p = 0.04) than SOAA patients. At the end of treatment, ROAA patients had an overall 48.0 L/min (95% CI, 14.1 to 81.8 L/min) greater improvement in PEF and a 0.31 L (95% CI, 0.08 to 0.54 L) greater improvement in FEV(1) than SOAA patients. Also, ROAA patients presented with less accessory muscle use (p < 0.05) and higher oxygen saturation (p = 0. 005). Finally, SOAA patients showed an increased incidence of hospital admission (relative risk, 3.89; 95% CI, 1.01 to 15.0). Data from this study support the notion that ROAAs constitute a distinct but uncommon acute asthma ED presentation, with a predominance of male patients. Upper respiratory tract infection was not believed to be a significant trigger factor in these patients, and ROAA patients had rapid deterioration of their conditions followed by a more rapid response to treatment and a lower hospital admission rate than SOAA patients. Thus, we have identified a subgroup of patients who appear to have common characteristics with patients with sudden-onset near-fatal/fatal asthma.