Management Of Obstructive Airways Disease Research Articles

Sputum microbiota and inflammatory subtypes in asthma, COPD, and its overlap

BackgroundAirway microbiota in asthma-COPD overlap (ACO) remains unknown. ObjectiveThis study with ACO-enriched population aimed to clarify airway microbiota in ACO and in mixed granulocytic inflammation, often detected in ACO and chronic airway diseases. MethodsThis is an observational cross-sectional study. Patients with asthma with airflow limitation, ACO and COPD were enrolled. Blood tests, pulmonary function, exhaled nitric oxide and sputum tests were conducted. Sputum microbiota was evaluated using the 16S rRNA gene sequencing technique. ResultsA total of 112 patients (13 asthma, 67 ACO, 32 COPD) were examined. There were no significant differences in α-diversity among the three diseases. The relative abundances of phylum Bacteroidetes, class Bacteroidia, and genus Porphyromonas were associated with decreased eosinophilic inflammation, and were significantly lower in ACO than in COPD. In a comparison of sputum inflammatory subtypes, the proportion of Haemophilus was numerically highest in the mixed granulocytic subtype, followed by the neutrophilic subtype. Likewise, the proportion of Haemophilus was the highest in the intermediate-high (2%–8%) sputum eosinophil group and lowest in the severe (8%≤) eosinophil group. Clinically, Haemophilus proportion was associated with sputum symptoms. Finally, the proportion of Streptococcus was associated with higher blood eosinophil counts and severest airflow limitation. ConclusionBacteroidia and Porphyromonas abundances in sputum are associated with the eosinophil-low phenotype, and ACO may be characterised by a decrease in these taxa. A mild elevation of sputum eosinophil does not preclude the presence of Haemophilus, which should be noted in the management of obstructive airway diseases.

Breath-actuated INhalation TheRapy: survey of phySicians’ PErCepTion (INTROSPECT) in Nepal

Objective Breath-actuated inhalers (BAIs) are gaining attention in the management of obstructive airway diseases (OADs). In Nepal, a BAI containing fluticasone propionate/salmeterol (FPS) has been available for a year. This survey is aimed at determining the perception and experience of physicians in Nepal concerning BAIs. Methods A cross-sectional, questionnaire-based survey was conducted. A total of 141 physicians participated and filled the survey. Results Most physicians felt that the right device should be easy to teach, learn and remember. They considered coordination and multiple steps as the primary challenges with pressurized metered-dose inhalers and dry powder inhalers, respectively. Most of them agreed that BAIs could address these challenges. BAIs were not only preferred by most of the physicians for asthma and chronic obstructive pulmonary disease but were also the preferred choice in newly diagnosed patients. Physicians believed that if current patients were shifted to BAIs, it could improve inhalation technique (88%) and compliance/adherence (81%). Almost all of them (92–97%) agreed that teaching the breathing technique and the cleaning process was easier and faster in BAIs. BAIs were considered easy and simple to use. Also, BAI’s dose-counter helps patients to increase adherence to inhalation therapy. Conclusions In this INTROSPECT survey, physicians in Nepal believed that BAIs could address the key challenges faced with using pMDIs and DPIs in asthma and COPD patients.

Effectiveness of Interventions Targeting Treatable Traits for the Management of Obstructive Airway Diseases: A Systematic Review and Meta-Analysis

The management of obstructive airway diseases (OADs) is complex. The treatable traits (TTs) approach may be an effective strategy for managing OADs. To determine the effectiveness of interventions targeting TTs for managing OADs. Ovid Embase, Medline, CENTRAL, and CINAHL Plus were searched from inception to March 9, 2022. Studies of interventions targeting at least 1 TT from pulmonary, extrapulmonary, and behavioral/lifestyle domains were included. Two reviewers independently extracted relevant data and performed risk-of-bias assessments. Meta-analyses were performed using random-effects models. Subgroup and sensitivity analyses were carried out to explore heterogeneity and to determine the effects of outlying studies. Eleven studies that used the TTs approach for OAD management were identified. Traits targeted within each study ranged from 13 to 36. Seven controlled trials were included in meta-analyses. TT interventions were effective at improving health-related quality of life (mean difference [MD]=-6.96, 95% CI:-9.92 to-4.01), hospitalizations (odds ratio [OR]=0.52, 95% CI: 0.39 to 0.69), all-cause-1-year mortality (OR= 0.65, 95% CI: 0.45 to 0.95), dyspnea score (MD=-0.29, 95% CI:-0.46 to-0.12), anxiety (MD=-1.61, 95% CI:-2.92 to-0.30), and depression (MD=-2.00, 95% CI:-3.53 to-0.47). Characterizing TTs and targeted interventions can improve outcomes in OADs, which offer a promising model of care for OADs.

The present and future of inhalation therapy for the management of obstructive airway diseases: Emphasis on pressurized metered-dose inhalers

The present and future of inhalation therapy for the management of obstructive airway diseases: Emphasis on pressurized metered-dose inhalers

Nebulization in the pandemic of coronavirus disease 2019

Inhaled therapy is the cornerstone in the management of obstructive airway diseases (OADs). Nebulization is often used for the delivery of bronchodilators and corticosteroids among the elderly and children. The present pandemic of coronavirus disease 2019 (COVID-19), caused by a newly identified, highly contagious, novel coronavirus, called severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), is responsible for great morbidity and mortality globally. There is a great concern regarding person-to-person transmissibility of this virus. There is also a great concern of viral transmission of this virus to the health-care personnel and the bystanders through aerosol-generating procedures including frequently used nebulization therapy. Most of the patients with OAD, during the current pandemic, who were undergoing nebulization therapy, on getting infected with SARS-CoV-2 or on its suspicion, have been shifted to other handheld devices out of fear of transmission of infection. Presently, there exist not enough evidences either on the safety or on the risk of transmissibility of SARS-CoV-2 during nebulization in COVID-19 patients. In addition, there are concerns about nebulization in OAD cases even in the absence of COVID-19 and about the use of inhaled or systemic corticosteroids in these cases. We have made some observations based on all the current information available related to these issues, which may help provide some guidance in the use of nebulizer therapy and also discussed the measures to be taken to minimize the risk of infection, if any, during the procedure.

The role of spirometry in the management of obstructive airways disease: How pharmacists should get involved.

The role of spirometry in the management of obstructive airways disease: How pharmacists should get involved.

The long-acting β2 -adrenoceptor agonist olodaterol attenuates pulmonary inflammation.

Background and Purposeβ2-adrenoceptor agonists are widely used in the management of obstructive airway diseases. Besides their bronchodilatory effect, several studies suggest inhibitory effects on various aspects of inflammation. The aim of our study was to determine the efficacy of the long-acting β2-adrenoceptor agonist olodaterol to inhibit pulmonary inflammation and to elucidate mechanism(s) underlying its anti-inflammatory actions.Experimental ApproachOlodaterol was tested in murine and guinea pig models of cigarette smoke- and LPS-induced lung inflammation. Furthermore, effects of olodaterol on the LPS-induced pro-inflammatory mediator release from human parenchymal explants, CD11b adhesion molecule expression on human granulocytes TNF-α release from human whole blood and on the IL-8-induced migration of human peripheral blood neutrophils were investigated.Key ResultsOlodaterol dose-dependently attenuated cell influx and pro-inflammatory mediator release in murine and guinea pig models of pulmonary inflammation. These anti-inflammatory effects were observed at doses relevant to their bronchodilatory efficacy. Mechanistically, olodaterol attenuated pro-inflammatory mediator release from human parenchymal explants and whole blood and reduced expression of CD11b adhesion molecules on granulocytes, but without direct effects on IL-8-induced neutrophil transwell migration.Conclusions and ImplicationsThis is the first evidence for the anti-inflammatory efficacy of a β2-adrenoceptor agonist in models of lung inflammation induced by cigarette smoke. The long-acting β2-adrenoceptor agonist olodaterol attenuated pulmonary inflammation through mechanisms that are separate from direct inhibition of bronchoconstriction. Furthermore, the in vivo data suggest that the anti-inflammatory properties of olodaterol are maintained after repeated dosing for 4 days.

Adverse reactions to anticholinergic agents used in the management of obstructive pulmonary disease

Summary Muscarinic acetylcholine receptor antagonists are widely used in the management of obstructive airways disease. There nevertheless exists only limited evidence that these receptor antagonists improve prognosis and their use is complicated by systemic adverse reactions affecting many organ systems. Contemporary anticholinergic agents cause fewer adverse reactions and have lower systemic bioavailability than their predecessors, yet their use may be associated with increased cardiovascular morbidity and mortality.

Distinguishing adult-onset asthma from COPD: a review and a new approach.

Adult-onset asthma and chronic obstructive pulmonary disease (COPD) are major public health burdens. This review presents a comprehensive synopsis of their epidemiology, pathophysiology, and clinical presentations; describes how they can be distinguished; and considers both established and proposed new approaches to their management. Both adult-onset asthma and COPD are complex diseases arising from gene–environment interactions. Early life exposures such as childhood infections, smoke, obesity, and allergy influence adult-onset asthma. While the established environmental risk factors for COPD are adult tobacco and biomass smoke, there is emerging evidence that some childhood exposures such as maternal smoking and infections may cause COPD. Asthma has been characterized predominantly by Type 2 helper T cell (Th2) cytokine-mediated eosinophilic airway inflammation associated with airway hyperresponsiveness. In established COPD, the inflammatory cell infiltrate in small airways comprises predominantly neutrophils and cytotoxic T cells (CD8 positive lymphocytes). Parenchymal destruction (emphysema) in COPD is associated with loss of lung tissue elasticity, and small airways collapse during exhalation. The precise definition of chronic airflow limitation is affected by age; a fixed cut-off of forced expiratory volume in 1 second/forced vital capacity leads to overdiagnosis of COPD in the elderly. Traditional approaches to distinguishing between asthma and COPD have highlighted age of onset, variability of symptoms, reversibility of airflow limitation, and atopy. Each of these is associated with error due to overlap and convergence of clinical characteristics. The management of chronic stable asthma and COPD is similarly convergent. New approaches to the management of obstructive airway diseases in adults have been proposed based on inflammometry and also multidimensional assessment, which focuses on the four domains of the airways, comorbidity, self-management, and risk factors. Short-acting beta-agonists provide effective symptom relief in airway diseases. Inhalers combining a long-acting beta-agonist and corticosteroid are now widely used for both asthma and COPD. Written action plans are a cornerstone of asthma management although evidence for self-management in COPD is less compelling. The current management of chronic asthma in adults is based on achieving and maintaining control through step-up and step-down approaches, but further trials of back-titration in COPD are required before a similar approach can be endorsed. Long-acting inhaled anticholinergic medications are particularly useful in COPD. Other distinctive features of management include pulmonary rehabilitation, home oxygen, and end of life care.

Multidimensional assessment of older people with asthma and COPD: clinical management and health status

the diagnosis and management of obstructive airway diseases (OADs) such as asthma and chronic obstructive pulmonary disease (COPD) can be challenging in older people. to assess the clinical, functional, biological and behavioural characteristics relevant to the management of older people with OAD. a cross-sectional study was conducted in a tertiary teaching hospital. Older people (> 55 years) (n = 100) with an OAD underwent a multidimensional assessment (MDA) involving questionnaires, clinical assessments, physiological measurements and biomarkers. the assessment identified a mean (SD) of 11.3 (2.5) clinical management issues and 3.1 (1.8) comorbid conditions per participant. Common problems were: airways hyper-responsiveness (80%); airway inflammation (74%); activity limitation (74%) and systemic inflammation (60.5%). The number and type of issues were similar irrespective of a diagnosis of asthma or COPD (P = 0.2). The degree of health status impairment correlated significantly with the number of clinical management issues detected (r = 0.59; P < 0.0001). older people with OAD experience multiple clinical issues that adversely impact their health status. The number and type are similar irrespective of diagnosis. This MDA identifies significant clinical issues that may not be addressed in a diagnosis centred approach suggesting that a multidisciplinary approach is necessary when assessing and managing older people with OAD.

Phenotype specific treatment of obstructive airways disease in infancy and childhood: new recommendations of the Swiss Paediatric Pulmonology Group.

In 2003 and 2004 the Swiss Paediatric Pulmonology Group (SAPP) revised the recommendations for the management of obstructive airways disease in infancy and childhood (Paediatrica 2004;15:13-28) and published recommendations for the management of acute bronchiolitis in infancy (Paediatrica 2003;14:18-21). The concept underlying these new guidelines is the fact that childhood wheezing illness encompasses a range of disorders or phenotypes with a similar clinical manifestation (wheeze, cough and breathlessness) but varying pathology, aetiology, prognosis and response to treatment. Based on the available scientific evidence, phenotype-specific and age-dependent management of wheezing illness is advocated in the revised guidelines. Major changes compared to earlier recommendations include a stepwise approach to management depending on age, phenotype and severity of disease and use of beta 2-agonists purely on an on-demand basis. Comparison of these recommendations with epidemiological data on current treatment practice of obstructive airways disease in Swiss children suggests that many children with bronchiolitis and mild viral wheeze might be overtreated while management of children with severe persistent symptoms could be improved.

Phenotype specific treatment of obstructive airways disease in infancy and childhood: new recommendations of the Swiss Paediatric Pulmonology Group.

In 2003 and 2004 the Swiss Paediatric Pulmonology Group (SAPP) revised the recommendations for the management of obstructive airways disease in infancy and childhood (Paediatrica 2004;15:13-28) and published recommendations for the management of acute bronchiolitis in infancy (Paediatrica 2003;14:18-21). The concept underlying these new guidelines is the fact that childhood wheezing illness encompasses a range of disorders or phenotypes with a similar clinical manifestation (wheeze, cough and breathlessness) but varying pathology, aetiology, prognosis and response to treatment. Based on the available scientific evidence, phenotype-specific and age-dependent management of wheezing illness is advocated in the revised guidelines. Major changes compared to earlier recommendations include a stepwise approach to management depending on age, phenotype and severity of disease and use of beta 2-agonists purely on an on-demand basis. Comparison of these recommendations with epidemiological data on current treatment practice of obstructive airways disease in Swiss children suggests that many children with bronchiolitis and mild viral wheeze might be overtreated while management of children with severe persistent symptoms could be improved.

Effect of T-440, a novel type IV phosphodiesterase inhibitor, on allergen-induced immediate and late asthmatic reaction and leukocyte infiltration into the airways of guinea pigs.

Type IV phosphodiesterase (PDE IV) is expressed in many tissues including airway smooth muscle and inflammatory cells, suggesting that this isozyme has a regulatory role in the pathogenesis of bronchial asthma. We investigated the effect of a novel selective PDE IV inhibitor, T-440, on immediate asthmatic reaction (IAR), late reaction (LAR) and leukocyte infiltration into the airways after allergen challenge in guinea pigs. Inhalation of ovalbumin by sensitized guinea pigs induced an immediate increase in specific airway resistance that peaked at 15 min. LAR was only produced in combination with chronic treatment with metyrapone, an inhibitor of the biosynthesis of adrenocortical steroids, and was suppressed by administration of dexamethasone, suggesting that the expression of LAR is dependent on an intrinsic steroid hormone. These reactions were accompanied by increases in the number of eosinophils and neutrophils recovered in bronchoalveolar lavage fluid. Oral administration of T-440 significantly inhibited IAR, LAR and the infiltration of eosinophils, whereas it suppressed neutrophil accumulation with relative low potency. These findings imply that the inhibition of PDE IV activity is a reasonable target for the management of obstructive airway diseases associated with airway inflammation such as asthma.

Physician Perceptions and Management of COPD

To assess awareness and understanding of obstructive airway diseases by primary-care physicians, the authors surveyed a randomly selected population of 75 primary care practitioners. During one-on-one interviews, physicians were presented with a standardized case scenario and a subsequent series of open-ended questions concerning asthma and COPD. Each respondent was presented in randomized fashion with one of two versions of a case description of a hypothetical 52-year-old male smoker with a recent upper respiratory tract infection and persistent productive cough. The only difference between case descriptions was that one included explicit reference to an earlier tentative diagnosis of chronic bronchitis (CB version); the other description made no specific mention of this diagnostic term (NCB version). Chest radiographs were requested by 80 percent of physicians and sputum cultures by 50 percent, these percentages not differing significantly between CB and NCB groups. Spirometry was requested less often than either of the foregoing tests (21 percent). The CB group requested spirometry significantly more often than the NCB group (38 percent vs 5 percent, p < 0.05). The most frequently mentioned primary diagnosis was bronchitis/pneumonia (33 percent), followed by bronchitis (28 percent) and chronic bronchitis (16 percent), all of which were similar in both groups. However, the diagnostic term "COPD" was the primary diagnosis in 16 percent of the CB group, compared with 8 percent in the NCB group (p > 0.05). Oral antibiotics were the most frequently chosen first-line drug therapy (63 percent). In subsequent questions concerning the management of obstructive airway diseases, primary practitioners distinguished COPD from asthma conceptually, but their prescribed therapy for the two disorders was less distinct. beta 2-agonists were selected most frequently and similarly as initial therapy for both disorders (53 percent). Minor differences between first-line therapeutic choices included nonsignificant trends toward the more frequent mention of anticholinergic bronchodilators for COPD than for asthma (10 percent vs 0 percent) and the more frequent selection of inhaled corticosteroids for asthma (12 percent vs 5 percent). The authors conclude that to the extent that questionnaire responses reflect actual practice, primary care practitioners (1) have a low index of suspicion for obstructive airway disease, (2) markedly underutilized spirometry as a screening tool, (3) consider beta 2-agonists first-line therapy for COPD and asthma, and (4) despite considering COPD and asthma different disease processes, choose similar medications for each disorder.

Diagnosis and Management of Obstructive Airways Disease in the Elderly

Diagnosis and Management of Obstructive Airways Disease in the Elderly

Formoterol

Formoterol, a long-acting beta 2-selective adrenoceptor agonist, produces dose-proportional bronchodilation in patients with obstructive airways disease with a reversible component. A significant effect occurs within minutes of inhalation of a therapeutic formoterol dose and persists for approximately 12 hours. Oral formoterol has a slower onset of action than the inhaled formulations, but also produces prolonged bronchodilatory effects. Inhaled formoterol has shown a therapeutic efficacy equivalent to or better than comparable dosages of the conventional beta 2-agonists salbutamol, fenoterol and terbutaline in short and long term trials, in both adults and children with asthma. Its prolonged duration of action permits a twice-daily dosage regimen and results in improved control of nocturnal symptoms by reducing the 'morning dip'. Formoterol also compares well with oral slow release theophylline. In addition, significantly more patients with chronic obstructive airways disease (COAD) had an improvement in symptoms when treated with formoterol compared with salbutamol or fenoterol. Noncomparative studies indicate formoterol also provides effective prophylaxis of exercise-induced asthma. Development of tachyphylaxis has not been observed. Formoterol is generally well tolerated. Adverse effects observed represent predictable extensions of its pharmacology. Tremor and palpitations are most frequently reported. The incidence of adverse events is dose-proportional and therefore related to the route of administration, being more frequent following oral than inhalation therapy. The long-acting beta 2-agonists, including formoterol, represent a significant advance over current maintenance or prophylactic bronchodilator therapy with intermediate-acting beta 2-agonists such as salbutamol, fenoterol and terbutaline, predominantly because of the twice daily administration regimen. However, comparisons with other long-acting beta 2-agonists, such as salmeterol, evaluation of its role in improving symptom control in patients failing to respond to prophylactic therapy, and clarification of the optimal role of beta 2-agonists in asthma maintenance therapy are required to fully determine the value of formoterol in the management of obstructive airways disease.

Recent advances in the management of obstructive airways disease. Auxiliary MDI aerosol delivery systems.

Aerosol delivered through metered-dose inhalers (MDI) offers a potentially convenient way to deliver bronchodilator agents and corticosteroids to the lungs of patients with asthma and COPD. Unfortunately, most patients are unable to coordinate satisfactorily their actuation with inhalation, a problem overcome by using auxiliary MDI aerosol delivery systems. Left to their own judgment, patients often inhale the aerosol with a high inspiratory flow rather than slowly to produce optimal aerosol deposition within the airways. This problem has been corrected by one of the auxiliary MDI aerosol delivery systems (InspirEase) through auditory, visual, and tactile feedback mechanisms. MDI devices release aerosol at a high jet velocity in large particle sizes, depositing most of the aerosol in the oropharynx which can lead to potential systemic absorption of adrenergic agonists with CNS and cardiovascular side effects, oral thrush, and suppression of adrenocortical activity. All the auxiliary MDI aerosol systems promote delivery of small aerosol particles and markedly diminish oropharyngeal impaction. Of all the systems, only InspirEase provides volume and flow feedback controls to ensure an optimal inhalation maneuver. Auxiliary MDI aerosol systems should always be used for aerosolized corticosteroid administration because they minimize oropharyngeal deposition and improve aerosol delivery efficiency.

Recent advances in the management of obstructive airways disease. Miami, Florida, February 1-2, 1985.

Recent advances in the management of obstructive airways disease. Miami, Florida, February 1-2, 1985.

Management of Obstructive Airways Disease in Pediatric Patients with New Beta2 Sympathomimetic Bronchodilators

To determine the safety and efficacy of treatment with metaproterenol in children under six years, 23 asthmatic pediatric patients between the ages of IX and six years were selected. Nine showed mild symptoms; nine had moderate symptoms; and five had severe asthma. Patients with significant cardiovascular, renal, hepatic or metabolic disease, as well as those with known intolerance to sympathomimetic agents were excluded.

An approach to the management of obstructive airways disease

No abstract available.