Inhaled Beta-agonist Therapy Research Articles

Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment

Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US. Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests. Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids. Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.

269 Impact of an Asthma Care Pathway on the Emergency Department Management of Asthma

Introduction of care pathways has been theorized to improve adherence to evidence-based guidelines and improve quality of care metrics. In 2014, an interprofessional team developed and implemented an evidence-based asthma care pathway, including a nursing medical directive and pre-printed order set, supported with education. We sought to assess performance in quality markers of asthma care such as time to corticosteroids and the rational use of diagnostic studies in line with published national and international guidelines for emergency department (ED) management of asthma. A retrospective review of ED patients greater than 16 years of age with a discharge diagnosis of asthma was conducted pre- (September 2013 through March 2014) and post-intervention (April 2014 through January 2015). Measures were: use of peak-expiratory flow rate testing (PEFR), chest x-ray (CXR) performance, and time-based outcomes from triage: time to inhaled beta-agonist therapy, time to inhaled anticholinergic therapy, time to steroid administration, length-of-stay (LOS) and use of pre-printed orders (PPO). A total of 495 cases met criteria (pre-intervention N=290 and post-intervention N=205). Improvements were seen for both time based metrics (median, range) and percent utilization of diagnostic testing after the intervention. Pre- and post-intervention groups showed respectively; PEFR performed (23% vs 45%), CXR performed (30% vs 23%), median time-to-inhaled beta-agonist (44 minutes, 233) vs 38 minutes, 505), median time to inhaled anticholinergic therapy (40 minutes, 233) vs 30 minutes, 266), median time to steroid administration (105 minutes, 414 vs 91.5 minutes, 502), and median LOS (206 minutes, 1320 vs 184.5 minutes, 884). PPO use in the post-intervention group was 4.4%. The implementation of an asthma care pathway, despite infrequent use of the PPO component of the pathway at our institution, appears to have led to an improvement in quality measures of ED asthma care. Opportunities for further improvements may be attained through ongoing provider education and increased protocol adherence.

Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma.

Inhaled beta-agonist therapy is central to the management of acute asthma. This review evaluates the benefit of an additional use of intravenous beta(2)-agonist agents. To determine the benefit of adding intravenous (IV) beta(2)-agonists to inhaled beta(2)-agonist therapy for acute asthma treated in the emergency department. Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register which is a compilation of systematic searches of MEDLINE, EMBASE, CINAHL, and CENTRAL as well as handsearching of 20 respiratory journals. Bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. The search was performed in September 2012. Only RCTs were considered for inclusion. Studies were included if patients presented to the emergency department with acute asthma and were treated with IV beta(2)-agonists with inhaled beta(2)-agonist therapy and existing standard treatments versus inhaled beta(2)-agonists and existing standard treatments. Two review authors independently extracted data and confirmed their findings with corresponding authors of trials. We obtained missing data from authors or calculated from data present in the papers. We used fixed-effect model for odds ratios (OR) and for mean differences (MD) we used both fixed-effect and random-effects models and reported 95% confidence intervals (CI). From 109 potentially relevant studies only three (104 patients) met our inclusion criteria: Bogie 2007 (46 children), Browne 1997 (29 children) and Nowak 2010 (29 adults). Bogie 2007 investigated the addition of intravenous terbutaline to high dose nebulised albuterol in children with acute severe asthma, requiring intensive care unit (ICU) admission. Browne 1997 investigated the benefit of adding intravenous salbutamol to inhaled salbutamol in children with acute severe asthma in the emergency department. Nowak 2010 investigated addition of IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) among adults, and was reported as a conference abstract only.There was no significant advantage (OR 0.29; 95%CI 0.06 to 1.38, one trial, 29 adults) for adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) with regard to hospitalisation rates.Various outcome indicators for the length of stay were reported among the trials. Browne 1997 reported a significantly shorter recovery time (in terms of cessation of 30 minute salbutamol) for children in the IV salbutamol with inhaled salbutamol group (four hours) versus the 11.1 hours for the inhaled salbutamol group (P = 0.03). Time to cessation of hourly nebuliser was also significantly shorter (P = 0.02) for the IV plus inhaled salbutamol group (11.5 hours versus 21.2 hours), and they were ready for emergency patient discharge on average 9.7 hours earlier than the inhaled salbutamol group (P < 0.05). In a paediatric ICU study Bogie 2007 reported no significant advantage in length of paediatric ICU admission (hours) for adding IV terbutaline to nebulised albuterol (MD -12.95, 95% CI: -38.74, 12.84).Browne 1997 reported there were only six out of 14 children with a pulmonary index score above six in the IV plus inhaled salbutamol group at two hours compared with 14 of the 15 in the inhaled salbutamol group (P = 0.02)In Browne 1997 there was a higher proportion of tremor in the IV plus inhaled salbutamol group than in the inhaled salbutamol group (P < 0.02). Nowak 2010 did not report any statistically significant adverse effects associated with adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids). Troponin levels were elevated in three children in the IV terbutaline + nebulised albuterol group at 12 and 24 hours in Bogie 2007 There is very limited evidence from one study (Browne 1997) to support the use of IV beta(2)-agonists in children with severe acute asthma with respect to shorter recovery time, and similarly there is limited evidence (again from one study Browne 1997) suggesting benefit with regard to pulmonary index scores; however this advantage needs to be considered carefully in relation to the increased side effects associated with IV beta(2)-agonists. We identified no significant benefits for adults with severe acute asthma. Until more, adequately powered, high quality clinical trials in this area are conducted it is not possible to form a robust evaluation of the addition of IV beta(2)-agonists in children or adults with severe acute asthma.

P REHOSPITAL A STHMA M ANAGEMENT

The treatment of acute asthma exacerbation consumes a significant portion of emergency medical services (EMS) system resources. Because few studies have addressed EMS treatment of asthma, most EMS providers model their approach to treatment on strategies thought to be effective in the emergency department. During the treatment of asthma, a patient's history and current airway and respiratory status are important components of the initial assessment. Although the general evaluation may address a patient's appearance, vital signs, mental status, level of fatigue, and ability to speak normally, the initial assessment of an asthmatic patient must focus specifically on his or her respiratory effort and quality and on objective measurement of the patient's blood oxygenation. Inhaled beta-agonist therapy is the widely recommended first choice of treatment, but anticholinergic agents and steroids may also have degs. Although not routine treatments, parenteral magnesium and epinephrine may also be beneficial for certain patients. Endotracheal intubation is a procedure of last resort and should be reserved for patients at immediate risk of respiratory arrest. Finally, EMS providers must be alert to the danger of using a “treat and release” approach, as recommended by some protocols, in the treatment of acute asthma. The quick results and benefit that short-acting treatments provide can easily and erroneously lead a provider to believe that an attack has been adequately controlled when, in fact, a more serious exacerbation may be imminent. Treatment protocols, therefore, should discourage EMS personnel from this practice and advise them to always transport asthmatic patients they have treated to the hospital to undergo more extended care and monitoring.

Asthma and allergy: a worldwide problem of meanings and management?

Asthma and allergy: a worldwide problem of meanings and management?

Association Between Inhaled β-Agonists and the Risk of Unstable Angina and Myocardial Infarction

beta-Adrenoceptor agonists (beta-agonists) are commonly used to treat obstructive lung diseases, and preliminary studies have suggested they are associated with an increased risk of adverse cardiovascular outcomes. We further examined the association between acute coronary syndromes and inhaled beta-agonist therapy. We performed a nested, case-control study using data that were collected as part of a larger, ongoing, prospective study of quality improvement in the primary care clinics of seven Veterans Administration Medical Centers. We identified 630 patients with unstable angina or acute myocardial infarction hospitalized between 1996 and 1999. We frequency matched these case patients to 10,486 control subjects according to clinic location, and randomly assigned each an "index date." The computerized pharmacy database at each center was used to ascertain beta-agonist use. Cardiovascular risk factors were assessed from mailed questionnaires and electronic medical records, which included inpatient and outpatient diagnoses, medications, and laboratory results. In comparison with patients who had not filled a beta-agonist prescription during the 90 days prior to their index date, patients who had filled a beta-agonist prescription had an increased risk of experiencing an acute coronary syndrome. The increased risk of an acute coronary syndrome persisted after adjusting for age and cardiovascular risk factors, including hypertension, diabetes, and smoking history. Moreover, there was a dose-response relationship with an adjusted odds ratio (OR) of 1.38 for one to two metered-dose inhaler (MDI) canisters (95% confidence interval [CI], 0.86 to 2.23), an OR of 1.57 for three to five MDI canisters (95% CI, 1.01 to 2.46), and an OR of 1.93 for six or more MDI canisters (95% CI, 1.23 to 3.03). After stratifying for receipt of a beta-blocker prescription, the adjusted OR in subjects who did not receive a beta-blocker was 1.55 for one to two MDI canisters (95% CI, 0.60 to 3.99), an OR of 4.07 for three to five canisters (95% CI, 2.17 to 7.64), and an OR of 3.83 for six or more canisters (95% CI, 2.02 to 7.29). Subjects who had received both beta-blockers and beta-agonists had no increase in risk in acute coronary syndromes unless they had filled six or more beta-agonist MDI canisters. A prescription for inhaled beta-agonists may increase the risk of myocardial infarction and unstable angina in patients with COPD.

Intravenous beta2-agonists for acute asthma in the emergency department.

Inhaled beta-agonist therapy is central to the management of acute asthma. The use of intravenous beta-agonist agents may also be beneficial in this setting. To determine the benefit of intravenous (IV) beta2-agonists for severe acute asthma treated in the emergency department. Randomised controlled trials (RCT) were identified using the Cochrane Airways Group Register which is a compilation of systematic searches of MEDLINE, EMBASE, CINAHL, and CENTRAL as well as hand searching of 20 respiratory journals. Bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. Only RCTs were considered for inclusion. Studies were included if patients presented to the emergency department with acute asthma and were treated with IV selective or nonselective beta2-agonists versus placebo, inhaled beta2-agonists, or other standard of care. Pulmonary function, vital signs, arterial gasses, adverse effects, and/or clinical success could be reported as outcome measures. Two reviewers independently selected potentially relevant articles and selected articles for inclusion. Methodological quality was independently assessed using two scoring systems and two reviewers. Data were extracted independently by two reviewers, and confirmed with corresponding authors. Missing data were obtained from authors or calculated from data present in the papers. Trials were combined using a random effects model for odds ratios (OR) or weighted mean differences (WMD) and reported with 95% confidence intervals (95% CI). From 746 identified references, 55 potentially relevant articles were identified and 15 were included. The trials included 584 patients. Overall, selective IV beta2-agonist use conferred no advantage over the comparator regimes. For example, it was associated with a lower PEFR after 60 mins compared to inhaled beta2-agonist, although the difference was not statistically significant (-24.7 l/min; 95%CI 2.9, -52.3). There was no difference in heart rate (4.5 bpm; 95% CI -4.9, 14.0). In the well performed blinded studies there was no difference in autonomic side effects between treatments (Odds Ratio 2.2 (95%CI 0.9, 5.7). There is no evidence to support the use of IV beta2-agonists in patients with severe acute asthma. These drugs should be given by inhalation. No subgroups were identified in which the IV route should be considered.

Interpretation of Positive Results of a Methacholine Inhalation Challenge and 1 Week of Inhaled Bronchodilator Use in Diagnosing and Treating Cough-Variant Asthma

In diagnosing cough due to asthma, methacholine chloride inhalation challenge (MIC) interpreted in a traditional fashion has been shown to have positive predictive values from 60% to 82%. To determine whether any features of positive results of an MIC or the results of a 1-week trial of inhaled beta-agonist therapy were helpful in predicting when the cough was due to asthma. The study design was a prospective, randomized, double-blind, placebo-controlled, crossover format performed in adult, nonsmoking subjects, who were referred for diagnosis and treatment of chronic cough. The subjects had no other respiratory complaints or medical conditions for which they were taking medications, the results of baseline spirometry and chest roentgenograms were normal, and the results of MIC were positive. After obtaining baseline data, including MICs on 2 separate days, objective cough counting, and self-assessment of cough severity using a visual analog scale, subjects were randomized to receive 2 inhalations (1.3 mg) of metaproterenol sulfate or placebo by metered dose inhaler attached to a spacer device every 4 hours while awake. At 1 week, data identical to baseline were collected, and subjects received the other metered dose inhaler for 7 days. At 1 week, data identical to baseline were collected. After completion of the protocol, subjects were followed up in the clinic to observe the final response of the cough to specific therapy. Based on the disappearance of the cough with specific therapy, the cough was due to asthma in 9 of 15 subjects and nonasthma in 6 of 15 subjects. Baseline data were similar between groups. With respect to MICs, there were no significant differences between groups in the cumulative dose of methacholine that provoked a 20% decrease in forced expiratory volume in 1 second from the postsaline baseline value (PD20 values), slopes of dose-response curves, and maximal-response plateaus. Cough severity significantly improved after 1 week of metaproterenol use compared with the severity of the cough at baseline (P = .03) and with placebo (P = .02) only in subjects with asthma. No matter how the results are analyzed, positive MIC results, without observing response to therapy, are only consistent with asthma as the cause of the cough. The results are only diagnostic of asthma when they are followed by a favorable response to asthma therapy. After 1 week of inhaled beta-agonist, only the cough due to cough-variant asthma is significantly better.

Shrinking lungs syndrome in systemic lupus erythematosus: improvement with inhaled beta-agonist therapy

The pathogenesis and therapy of shrinking lungs syndrome in patients with systemic lupus erythematosus remains controversial. It has been previously reported that corticosteroid treatment can be effective. We report a patient with shrinking lungs syndrome who presented a good response to inhaled beta-agonist therapy. Therapeutic approach to this syndrome is discussed.

Does Quality of Care Affect Rates of Hospitalization for Childhood Asthma?

Hospitalization rates for childhood asthma are three times as high in Boston, Massachusetts, as in Rochester, New York; New Haven, Connecticut, rates are intermediate. We undertook this study to determine how care for children admitted for asthma varies across these communities. We performed a community-wide retrospective chart review. We reviewed a random sample of all asthma hospitalizations, from 1988 to 1990, of children 2 to 12 years old living in these communities (n = 614). Abstracted data included demographics, illness severity, and treatment before admission. Compared with Rochester children, Boston children were less likely to have received maintenance preventive therapy (inhaled corticosteroids or cromolyn [odds ratio (OR), 0.4 (0.2, 0.9)]), acute "rescue" therapy (oral corticosteroids [OR, 0.2 (0.1, 0.4)]), or inhaled beta-agonist therapy [OR, 0.5 (0.3, 1.0)]. A larger proportion of admitted asthmatic patients in Boston (34%) were in the least severely ill group-oxygen saturation 95% or above-compared with patients in Rochester (20%). The quality of ambulatory care, including choice of preventive therapies and thresholds for admission, likely plays a key role in determining community hospitalization rates for chronic conditions such as childhood asthma.

Asthma mortality and inhaled beta agonist therapy

Australian and New Zealand Journal of MedicineVolume 21, Issue 5 p. 753-763 Asthma mortality and inhaled beta agonist therapy R. Beasley, Corresponding Author R. Beasley Senior Lecturer in Medicine, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Dr R. Beasley, Department of Medicine, Wellington School of Medicine, P.O. Box 7343, Wellington South, New Zealand.Search for more papers by this authorH. Windom, H. Windom Research Fellow, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this authorN. Pearce, N. Pearce HRC Senior Research Fellow, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this authorC. Burgess, C. Burgess Senior Lecturer in Clinical Pharmacology, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this authorJ. Crane, J. Crane Senior Lecturer in Medicine, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this author R. Beasley, Corresponding Author R. Beasley Senior Lecturer in Medicine, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Dr R. Beasley, Department of Medicine, Wellington School of Medicine, P.O. Box 7343, Wellington South, New Zealand.Search for more papers by this authorH. Windom, H. Windom Research Fellow, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this authorN. Pearce, N. Pearce HRC Senior Research Fellow, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this authorC. Burgess, C. Burgess Senior Lecturer in Clinical Pharmacology, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this authorJ. Crane, J. Crane Senior Lecturer in Medicine, Department of Medicine, Wellington School of Medicine, Wellington, New Zealand.Search for more papers by this author First published: October 1991 https://doi.org/10.1111/j.1445-5994.1991.tb01385.xCitations: 58AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume21, Issue5October 1991Pages 753-763 RelatedInformation

Circulating autoantibodies to recombinant lipocortin-1 in asthma

One of the postulated mechanisms of corticosteroid action is through the de novo synthesis and release of lipocortins. We assayed circulating antibodies to lipocortin-1 in sera obtained from normal (n = 67) and asthmatic (n = 57) subjects using an ELISA technique. Asthmatic subjects with a wide range of severity, with the mildest needing only occasional inhaled beta-agonist therapy to the most severe needing maintenance oral corticosteroid treatment, were recruited from our Asthma Clinic and classified into five categories according to the need of therapy. Median values of IgM and IgG lipocortin-1 antibody for normal subjects were 19.3 (interquartile range (r) = 11.0-30.4) and 16.9 (r = 10.54-29.4) ELISA units (EU) ml-1 respectively. These levels were significantly elevated in asthmatic subjects: IgM = 43.9 EU ml-1 (r = 31.7-64.5) and IgG = 29.0 EU ml-1 (r = 21.2-44.7) (P less than 0.001). There was no significant relationship between the levels of lipocortin antibody and the clinical severity of asthma. Asthmatics with significantly raised levels of antibody were found within all five categories of severity. We conclude that the level of this antibody is not related to severity of asthma, to previous or current corticosteroid therapy or to the development of corticosteroid resistance.

Effect of Theophylline on Sleep and Sleep-disordered Breathing in Patients with Chronic Obstructive Pulmonary Disease

To investigate the effect of theophylline on sleep and sleep-disordered breathing in patients with chronic obstructive pulmonary disease (COPD), we studied 12 male nonhypercapnic subjects with a mean +/- SEM age of 62.8 +/- 2.5 yr and a FEV1 of 1.36 +/- 0.11 L using a randomized double-blind crossover protocol. Sustained-action theophylline (250 mg three times or four times a day) or placebo was administered for 2 days, and the alternate drug was administered on the following 2 days. Sleep studies were performed on Nights 2 and 4 with spirometry at 9:00P.M. and 7:00A.M. Two puffs of metaproterenol or albuterol were administered at 10:00P.M. on both study nights. A theophylline level, drawn at bedtime (10:00 to 11:00P.M.), was 14.2 +/- 0.78 micrograms/ml on the theophylline nights and less than 2 on placebo nights. The morning FEV1 was significantly better during theophylline administration (1.27 +/- 0.12 versus 1.00 +/- 0.11 L, p less than 0.001). The mean arterial oxygen saturation (SaO2) and transcutaneous carbon dioxide pressure (PCO2) were also better during NREM sleep on theophylline nights. Neither the mean SaO2 and transcutaneous PCO2 during REM sleep nor the apnea plus hypopnea index (events per hour of sleep) differed between placebo and theophylline nights. Theophylline administration did not impair the amount or architecture of sleep as neither total sleep time nor the fraction of time spent in Stages 1, 2, and 3/4 and REM differed between the two regimens. The number of arousals per hour of sleep was slightly less on theophylline nights (19.9 +/- 1.7 versus 24.9 +/- 2.7, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Regular inhaled beta agonist therapy is associated with poorer asthma control compared with intermittent therapy

Regular inhaled beta agonist therapy is associated with poorer asthma control compared with intermittent therapy

Does urinary salbutamol reflect compliance with the aerosol regimen in patients with asthma?

Compliance with inhaled beta agonist therapy in a group of asthmatic patients in general practice has been monitored using a high performance thin layer chromatographic assay of salbutamol in urine. Urine salbutamol levels were lower than expected in five of 51 patients and much higher than expected in a further 11 patients. These results suggest the assay may be clinically useful for monitoring compliance of asthmatic patients with inhaled salbutamol.