Use Of Bronchodilator Therapy Research Articles

Decreasing Use of Bronchodilators in Bronchiolitis

Source: Shanahan KH, Monuteaux MC, Nagler J, et al. Early use of bronchodilators and outcomes in bronchiolitis. Pediatrics. 2021;148(2):e2020040394; doi.10.1542/peds.2020-040394Investigators from Boston Children’s Hospital, Boston, MA, conducted a retrospective analysis to assess US trends in care provided to infants presenting to emergency departments (EDs) and diagnosed with bronchiolitis and evaluate the effect of bronchodilator use on patient outcomes. For the study, they reviewed data from the Pediatric Health Information System (PHIS), an administrative database that includes encounter, demographic, diagnosis, procedure, and medication data on children seen at tertiary care pediatric hospitals in the US. Participants were infants <12 months old seen in the ED of 1 of 49 hospitals between 2010 and 2018 with an ICD-9 or ICD-10 diagnosis of bronchiolitis.Data on the identified patients were abstracted from the PHIS database and used to determine patient- and hospital-level outcomes, including bronchodilator use (albuterol, nebulized epinephrine, ipratropium, and levalbuterol), hospitalization rates, admission to an ICU, ED return visits within 3 days of index visit, and noninvasive and mechanical ventilation. Patient-level temporal trends in these outcomes were assessed with logistic regression models. For the hospital-level analyses, data from 2015 to 2018 were included and limited to hospitals in highest and lowest quartiles of “early” bronchodilator use, defined as administration of bronchodilators to study patients on the day of the index ED encounter. Multivariate logistic regression was used to assess the association between high or low bronchodilator use on outcomes after controlling for patient age and All Patient Refined Diagnosis Related Group (APR-DRG) severity scores.Data on 466,696 ED visits for infants with bronchiolitis were analyzed. The median age of study patients was 5 months, 59.9% were male, and 71.5% were publicly insured. Overall, 32.0% of patients were treated with bronchodilators. During the period 2010 to 2018, there were statistically significant decreases in bronchodilator use (51.5% to 22.8%), hospital admission rate (34.3% to 33.1%), and ED return visits (5.9% to 5.2%), and increases in ICU admission rates (2.4% to 4.3%) and use of noninvasive (1.0% to 2.9%) and mechanical (0.7% to 1.5%) ventilation. Hospital-level analyses included data on 56,852 patients treated at hospitals with high early use of bronchodilators and 54,458 treated at low early use hospitals. After controlling for age and APR-DRG score, there were no differences in outcomes between high and low bronchodilator use hospitals for hospital admission (odds ratio [OR], 0.93; 95% CI, 0.7, 1.3), ICU admissions (OR, 1.5; 95% CI, 0.7, 3.1), ED return visits (OR, 1.2; 95% CI, 0.99, 1.4), noninvasive ventilation (OR, 3.5; 95% CI, 0.7, 19.1) or mechanical ventilation (OR, 8.2; 95% CI, 0.99, 67.5).The authors conclude that use of bronchodilator therapy for infants seen at ED with bronchiolitis decreased between 2010 and 2018, and hospital-level use of bronchodilators was not associated with outcomes.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The history of bronchiolitis management includes multiple instances of a seemingly beneficial intervention later being found to have little or no effect on patient outcomes. Corticosteroids (See AAP Grand Rounds. 2017;38:41), bronchodilators, hypertonic nebulized saline (See AAP Grand Rounds. 2016;35:39), and high-flow nasal cannula therapies all have been used for bronchiolitis and been targets for de-implementation when found not be effective.1Bronchodilators had been found in large meta-analysis not to reduce hospital admission, length of stay, or the time to resolution of symptoms.2 Trial sequential analysis, a methodology for meta-analysis that uses the order of studies to account for error including publication bias, has been used to analyze hypertonic saline3 and may help to explain the reason that early publications are more likely to show positive results even when there are none.The current researchers found that bronchodilator use decreased over time, although there were contemporaneous increases in ICU admission and use of noninvasive and mechanical ventilation. These increases, in the words of the current authors, “are similar to published increases … from 2000–2016” and likely are not caused by decreased bronchodilator usage. Hospital variation of early bronchodilator use still exists, without significant difference in outcomes between high- and low-utilization hospitals.Bronchodilator usage in bronchiolitis decreased substantially from 2010 to 2018, without any increases in hospital admissions, ED return visits, or differences in outcomes.The results of the current study support AAP guidelines that recommend limited use of bronchodilator therapy.4

Year in review 2017: Chronic obstructive pulmonary disease and asthma.

Year in review 2017: Chronic obstructive pulmonary disease and asthma.

Long-Acting Bronchodilator Use in the Management of Stable COPD.

To review the management of chronic obstructive pulmonary disease (COPD), with a focus on updated information regarding the use of long-acting bronchodilators in the prevention of exacerbations and outcomes associated with this disease. A literature search of the MEDLINE databases through November 2017 was conducted. All published articles regarding use of bronchodilator therapy in the management of COPD were evaluated. References of selected articles, data from poster presentations, and abstract publications were additionally reviewed. Available English-language data from reviews, abstracts, presentations, and clinical trials of the treatment of stable COPD with bronchodilator therapy in humans were reviewed; relevant clinical data were selected and included. COPD is a prevalent medical condition worldwide that results in functional impairment, and worsened quality of life and overall health status. Numerous treatment options are available; the rationale for the optimal agents to utilize in a particular patient case is dependent on a multitude of patient-specific factors and severity of disease. In this review, a discussion of the role of long-acting bronchodilators, including long-acting β agonists and long-acting muscarinic antagonists will be explored. Additionally, an update on the roles of novel delivery devices for delivering respiratory medications in this medical condition will be described. Although numerous treatment options are available, management of COPD remains a clinical challenge. Long-acting bronchodilators represent a significant class of medications that have the potential to reduce exacerbations and related hospitalizations and improve overall health outcomes.

Proactive Use of High-Flow Nasal Cannula With Critically Ill Subjects.

It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population. The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 (n = 88) received mechanical ventilation for ≥ 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 (n = 83) were placed on HFNC when oxygen requirements escalated (>4 L/min). Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, P = .001) and use of bronchodilator therapy (81% vs 61%, P = .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, P = .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, P = .03) and hospital days (12 vs 8 d, P = .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, P = .10) and faster time to intubation when HFNC failed (19 vs 9 h, P = .08). Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.

DIFFERENTIATED APPROACH TO THE APPOINTMENT OF BRONCHODILATOR THERAPY IN PATIENTS WITH COPD. EXAMPLES FROM PRACTICE

The article deals with the issues of differentiated approach to the appointment of bronchodilator therapy in COPD patients on the basis of a comprehensive assessment of the SGRQ quality of life questionnaire, CAT questionnaire, BODE prognostic index, and clinical and functional indicators (FEV1 and MRC index). Clinical examples of patient management are presented. The aim of the study was to study new approaches to the differentiated use of bronchodilator therapy. Material and methods: The study included 49 male patients treated in Regional Clinical Hospital No. 4 and the Pulmonary Center in Chelyabinsk in 2016-17. The analysis of drug therapy in all patients was conducted. The quality of life (QoL) was assessed using two questionnaires: the Russian-language version of the St. George Hospital (SGRQ) questionnaire, and the CAT universal questionnaire. The prognostic evaluation index BODE is calculated. Results and conclusions: 1. Combined preparation of glycopyrronium bromide / indacaterol 50/110 mcg is an effective and safe means for conducting bronchodilator therapy in patients with different variants of the course of COPD. 2. When double bronchodilator therapy is used, the increase in FEV1 by more than 60 ml is observed, especially in patients with a high risk of exacerbations and marked symptoms of the disease. 3. Application of quality of life questionnaires allows to be guided by correctness of the chosen medical tactics both in early, and in the remote periods of supervision of patients with COPD. 4. The use of prognostic indices in the selection of treatment tactics allows to evaluate the correctness of prescriptions at the early stages of patient management.

Bronchodilators for the prevention and treatment of chronic lung disease in preterm infants.

Chronic lung disease (CLD) occurs frequently in preterm infants. Bronchodilators have the potential effect of dilating small airways with muscle hypertrophy. Increased compliance and tidal volume and decreased pulmonary resistance have been documented with the use of bronchodilators in infants with CLD. Therefore, bronchodilators might have a role in the prevention and treatment of CLD. To determine the effect of bronchodilators given as prophylaxis or as treatment for CLD on mortality and other complications of preterm birth in infants at risk for or identified as having CLD. On 2016 March 7, we used the standard strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (from 1966), Embase (from 1980) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We applied no language restrictions. Randomised and quasi-randomised controlled trials involving preterm infants were eligible for inclusion. Initiation of bronchodilator therapy for prevention of CLD had to occur within two weeks of birth. Treatment of patients with CLD had to be initiated before discharge from the neonatal unit. The intervention had to include administration of a bronchodilator by nebulisation, by metered dose inhaler (with or without a spacer device) or by intravenous or oral administration versus placebo or no intervention. Eligible studies had to include at least one of the following predefined clinical outcomes: mortality, CLD, number of days on oxygen, number of days on ventilator, patent ductus arteriosus (PDA), pulmonary interstitial emphysema (PIE), pneumothorax, intraventricular haemorrhage (IVH) of any grade, necrotising enterocolitis (NEC), sepsis and adverse effects of bronchodilators. We used the standard method described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Two review authors extracted and assessed all data provided by each study. We reported risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) with 95% confidence interval (CI) for dichotomous outcomes and mean difference (MD) for continuous data. We assessed the quality of the evidence by using the GRADE approach. For this update, we identified one new randomised controlled trial investigating effects of bronchodilators in preterm infants. This study, which enrolled 73 infants but reported on 52 infants, examined prevention of CLD with the use of aminophylline. According to GRADE, the quality of the evidence was very low. One previously included study enrolled 173 infants to look at prevention of CLD with the use of salbutamol. According to GRADE, the quality of the evidence was moderate. We found no eligible trial that studied the use of bronchodilator therapy for treatment of individuals with CLD. Prophylaxis with salbutamol led to no statistically significant differences in mortality (RR 1.08, 95% CI 0.50 to 2.31; RD 0.01, 95% CI -0.09 to 0.11) nor in CLD (RR 1.03, 95% CI 0.78 to 1.37; RD 0.02, 95% CI -0.13 to 0.17). Results showed no statistically significant differences in other complications associated with CLD nor in preterm birth. Investigators in this study did not comment on side effects due to salbutamol. Prophylaxis with aminophylline led to a significant reduction in CLD at 28 days of life (RR 0.18, 95% CI 0.04 to 0.74; RD -0.35, 95% CI -0.56 to -0.13; NNTB 3, 95% CI 2 to 8) and no significant difference in mortality (RR 3.0, 95% CI 0.33 to 26.99; RD 0.08, 95% CI -0.07 to 0.22), along with a significantly shorter dependency on supplementary oxygen in the aminophylline group compared with the no treatment group (MD -17.75 days, 95% CI -27.56 to -7.94). Tests for heterogeneity were not applicable for any of the analyses, as each meta-analysis included only one study. Data are insufficient for reliable assessment of the use of salbutamol for prevention of CLD. One trial of poor quality reported a reduction in the incidence of CLD and shorter duration of supplementary oxygen with prophylactic aminophylline, but these results must be interpreted with caution. Additional clinical trials are necessary to assess the role of bronchodilator agents in prophylaxis or treatment of CLD. Researchers studying the effects of bronchodilators in preterm infants should include relevant clinical outcomes in addition to pulmonary mechanical outcomes. We identified no trials that studied the use of bronchodilator therapy for treatment of CLD.

Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico.

Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA). To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico. A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6 289 374), Hispanic enrollees in the United States (n = 795 039), and Hispanic enrollees in Puerto Rico (n = 267 016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016. Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a β-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs). Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P < .01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]). We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.

Exacerbations of COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) are defined as sustained worsening of a patient’s condition beyond normal day-to-day variations that is acute in onset, and that may also require a change in medication and/or hospitalization. Exacerbations have a significant and prolonged impact on health status and outcomes, and negative effects on pulmonary function. A significant proportion of exacerbations are unreported and therefore left untreated, leading to a poorer prognosis than those treated. COPD exacerbations are heterogeneous, and various phenotypes have been proposed which differ in biologic basis, prognosis, and response to therapy. Identification of biomarkers could enable phenotype-driven approaches for the management and prevention of exacerbations. For example, several biomarkers of inflammation can help to identify exacerbations most likely to respond to oral corticosteroids and antibiotics, and patients with a frequent exacerbator phenotype, for whom preventative treatment is appropriate. Reducing the frequency of exacerbations would have a beneficial impact on patient outcomes and prognosis. Preventative strategies include modification of risk factors, treatment of comorbid conditions, the use of bronchodilator therapy with long-acting β2-agonists or long-acting muscarinic antagonists, and inhaled corticosteroids. A better understanding of the mechanisms underlying COPD exacerbations will help to optimize use of the currently available and new interventions for preventing and treating exacerbations.

Alternative Healthcare with Modern Medicine

The treatment of Chronic Lung patients or any patient that presents with acute or chronic shortness of breath. Has the obstacle of overcoming the severe anxiety that is associated with the feeling of dyspnea. Although, their Abg results could show completely normal results the feeling still needs to be treated. Just the use of bronchodilator therapy along with steriods does not always produce the results of decreasing the patient’s discomfort. Therefore, requiring anywhere from continuous nebulisation to sedation and intubation. Majority of the patient’s intubations could have been prevented with earlier intervention and management of their anxiety. Which would decrease hospital admission time and costs?

The effects of anxiety and depression symptoms on treatment adherence in COPD patients

Chronic obstructive pulmonary disease (COPD) may cause some psychiatric disorders such as depression and anxiety, similar to other chronic diseases. Treatment adherence may be affected by worsening of cognitive functions. We aimed to show whether the symptoms of anxiety and depression affect treatment adherence by patients. Seventy-eight COPD patients were analysed at the first visit. The use of bronchodilator therapy was revised for standardization before they attended a second visit after six months. Hospital Anxiety and Depression Scale (HADS), Anxiety Sensitivity Index-3 (ASI-3) and SF-36 Questionnaire were carried out at that visit. 'National Guide of Turkish Thoracic Society for Asthma' was used for scoring method of use of the bronchodilator and evaluating treatment adherence (including maintenance therapy). Sixty-two of 78 patients, 53 (85.5%) men and nine (14.5%) women with a mean age of 64.9 ± 9.9 joined the second visit. Thirty-three patients (53.2%) had a high-treatment adherence (HTA), whereas 29 (46.8%) had a low-treatment adherence (LTA). There were high scores of anxiety in 18 (29%) and depression in 11 (17.7%) patients. There was no statistical difference between the HTA and LTA groups in means of age, gender, educational level, presence of comorbidity, classification of COPD, high anxiety scores according to HADS and ASI-3 scores. Of the patients, 41.4% in the LTA group were still smoking, whereas it was only 12.1% in the HTA group (P = 0.009). The LTA group had higher depression scores (P = 0.004) than the HTA group. Dyspnea was found more frequent in LTA patients (P = 0.047); vitality score was also statistically low in this group (P = 0.01). As a result, continuing smoking and the presence of depression symptoms may decrease adherence to treatment. Therefore, to increase the adherence to treatment and reduce symptoms such as dyspnea, it is important to treat any depressive symptoms that are present and to help patients cease smoking.

Indacaterol/glycopyrronium bromide fixed-dose combination for the treatment of COPD

Chronic obstructive pulmonary disease (COPD) is a worldwide problem causing prolonged and progressive morbidity as well as premature mortality. Pharmacologic treatment consists primarily in the relief of symptoms and preventing or minimizing the consequences of exacerbations. Central to the pharmacologic management of COPD is the use of bronchodilator therapy. Two major classes of agents are frequently used: β-adrenoceptor agonists and antimuscarinic agents. These drugs are used mainly in the inhalational form, primarily as rescue medication, but occasionally for maintenance in combination therapy. The availability of "ultra-long"-acting β-adrenoceptor agonists and long-acting antimuscarinic agents opens the way for combinations of these agents to be used in maintenance therapy. Such a combination offers the potential of enhanced efficacy due to additive effects and better compliance as the result of once-daily treatment. This article reviews the rationale for current bronchodilator therapy of COPD as well as the current status of a fixed-dose combined inhaler using two novel long-acting agents: glycopyrronium bromide and indacaterol maleate.

Use of Magnesium Sulfate for Pediatric Patients With Acute Asthma Exacerbations

The number of children with a diagnosis of asthma has increased significantly over the years, and asthma currently is the most common pediatric chronic disease. Asthma continues to take the lives of children at an alarming rate. Proper diagnosis, education, and appropriate management are essential for decreasing morbidity and mortality. Asthma can be diagnosed with a thorough medical history, family history, and physical examination. Diagnostic and assessment tools such as pulmonary function tests and pediatric asthma scores are valuable for determining the severity of asthma. Immediate assessment and initiation of appropriate medications and management are essential for a positive outcome. The use of bronchodilator therapy with corticosteroids is the gold standard for acute asthma exacerbation, but it may not be effective for certain moderate to severe exacerbations. This article discusses the prevalence, pathophysiology, and diagnosis and treatment of asthma, including the role of magnesium sulfate for acute asthma exacerbations.

Decreasing overuse of therapies in the treatment of bronchiolitis by incorporating evidence at the point of care*1

Objective To describe the effect of evidence-based point-of-care algorithms and rules, based on guideline recommendations, on the overuse of therapies for bronchiolitis. Study design Pre-postintervention for infants <1 year of age admitted with a first-time episode of bronchiolitis. Data collected for guideline-eligible patients discharged between January 15, 2002, and March 27, 2002, were compared with data collected for guideline-eligible patients discharged from the hospital with a diagnosis of bronchiolitis during the same time period in the first 5 years after the original guideline implementation (1997 to 2001). The primary outcome of interest was use of bronchodilator therapy. Secondary outcomes included use of guideline order sets, resource utilization, length of stay, and readmission. Results A total of 256 patients from 2002 were compared with 1272 historic patients. In 2002, the odds of receiving any bronchodilator, more than 1, more than 2, and more than 4 bronchodilators were all significantly less than predicted by the 1997 to 2001 year-to-year trend. The odds of receiving a nasopharyngeal wash for respiratory syncytial virus and a chest radiography (OR = 0.680, CL = 0.476, 0.973) were also significantly lower than what was predicted from use trends of previous years. Conclusions Evidence-based point-of-care instruments can have a significant effect on unwarranted treatment variation.

Decreasing overuse of therapies in the treatment of bronchiolitis by incorporating evidence at the point of care

ObjectiveTo describe the effect of evidence-based point-of-care algorithms and rules, based on guideline recommendations, on the overuse of therapies for bronchiolitis. Study designPre-postintervention for infants <1 year of age admitted with a first-time episode of bronchiolitis. Data collected for guideline-eligible patients discharged between January 15, 2002, and March 27, 2002, were compared with data collected for guideline-eligible patients discharged from the hospital with a diagnosis of bronchiolitis during the same time period in the first 5 years after the original guideline implementation (1997 to 2001). The primary outcome of interest was use of bronchodilator therapy. Secondary outcomes included use of guideline order sets, resource utilization, length of stay, and readmission. ResultsA total of 256 patients from 2002 were compared with 1272 historic patients. In 2002, the odds of receiving any bronchodilator, more than 1, more than 2, and more than 4 bronchodilators were all significantly less than predicted by the 1997 to 2001 year-to-year trend. The odds of receiving a nasopharyngeal wash for respiratory syncytial virus and a chest radiography (OR=0.680, CL=0.476, 0.973) were also significantly lower than what was predicted from use trends of previous years. ConclusionsEvidence-based point-of-care instruments can have a significant effect on unwarranted treatment variation.

Chronic obstructive pulmonary disease.

Chronic obstructive airways disease is a chronic, progressive disorder characterised by airways obstruction. The author discusses the management of patients with this condition, and examines the use of bronchodilator therapy, inhaled steroids, smoking cessation and pulmonary rehabilitation.

Therapy for respiratory tract infections caused by respiratory syncytial virus.

Respiratory syncytial virus (RSV) is the most common viral cause of lower respiratory tract infection (LRTI) in infancy and young children. No effective treatment for RSV lower respiratory tract infection (RSV-LRTI) exists. Ribavirin initially proved to be an effective anti-viral drug for RSV-LTRI. However, subsequently performed trials could not reproduce these positive results and, based on the current available evidence, there is no place for ribavirin in the routine treatment of RSV-LTRI. The use of nebulised bronchodilator therapy in RSV-LTRI has been subject of many trials, with conflicting results. Although the individual patient may have some short-term benefit from nebulised bronchodilators, there does not seem to be a sufficient scientific basis for the standard use of bronchodilator therapy in infants and children with RSV-LTRI. There is increasing evidence that RSV-LTRI is an immune-mediated disease and therefore corticosteroids may be an effective treatment. The results from efficacy trials have demonstrated that corticosteroids are not effective for patients with mild RSV infection. In contrast there are indications that it may be beneficial in patients with more severe RSV-LTRI. It has been demonstrated that in children with RSV infection the vitamin A concentration is inversely related to disease severity. The use of vitamin A in the treatment of patients with RSV-LTRI, however, proved not to be effective. Immunoprophylaxis with hyperimmune immunoglobulins and monoclonal antibody against the viral F-protein have been shown to be effective in the prevention of RSV-LRTI. From the results of the therapeutic efficacy trials, however, it can be discerned that immunoglobulins have no place in the treatment of RSV-LRTI. Although respiratory syncytial virus infections each year have a considerable socioeconomic impact, attempts to find an effective therapy have so far been quite unsuccessful. Anti-viral therapy with ribavirin has not been proven to be effective. Symptomatic therapy with bronchodilators may give only short-term relief of symptoms in some individual patients, but has no effect on hospitalisation rates, or duration of hospitalisation. The beneficial effect of corticosteroids in patients with mild respiratory syncytial virus infection is very disappointing, however, there are indications that there might be an effect in patients with more severe infection. So far no beneficial therapeutic effect has been demonstrated with immune globulins.

Oral Glucocorticosteroid-Sparing Effect of Budesonide Administered by Turbuhaler: A Double-blind, Placebo-Controlled Study in Adults With Moderate-to-Severe Chronic Asthma

To determine the ability of budesonide via an inhaler (Pulmicort Turbuhaler; Astra Draco AB) to replace oral glucocorticosteroids (GCSs) in adult subjects with moderate-to-severe asthma. Double-blind, randomized, and placebo-controlled study, with parallel groups. Multicenter study in outpatient setting. Eighty men and 79 women, aged 20 to 69 years, with moderate-to-severe asthma and a mean FEV1 of 58.3% predicted normal. All subjects were receiving oral GCS treatment and 79% of subjects were also receiving inhaled beclomethasone dipropionate (BDP). The mean daily doses of prednisone at baseline, including converted dose of BDP, for the placebo, budesonide 400 microg, and budesonide 800 microg, respectively, were 19.7 mg, 19.5 mg, and 18.7 mg. After a 2-week baseline period, subjects entered a 20-week treatment period, during which the oral dose of prednisone was reduced by forced down-titration at 2-weekly intervals. Subjects receiving 400 microg or 800 microg bid of budesonide achieved a significantly greater reduction (82.9% and 79.0% respectively) in oral GCS dose compared with placebo-treated subjects (27%; p<0.001). Two thirds of the subjects receiving budesonide were able to achieve sustained oral corticosteroid cessation, compared with 8% in the placebo group. Additionally, both doses of budesonide resulted in significant improvement in results of pulmonary function tests and asthma symptoms scores, and a significant decrease in the use of bronchodilator therapy. The mean plasma cortisol levels before and after adrenocorticotropic hormone stimulation increased most toward the normal range in the budesonide-treated groups compared with placebo-treated subjects. Budesonide administered via Turbuhaler has a significant oral GCS-sparing capacity with maintained or improved asthma control in adult subjects with moderate-to-severe asthma.

Use of bronchodilator therapy in cystic fibrosis.

Use of bronchodilator therapy in cystic fibrosis.

Managing symptoms and exacerbations in pediatric asthma

International guidelines indicate that the primary goals of asthma treatment are minimizing symptoms and preventing exacerbations. Symptoms last for short periods of time (minutes or hours) and usually disappear either spontaneously or with the use of bronchodilator therapy. Exacerbations last for 1 or more days and need more extensive bronchodilator therapy with the possible addition of a course of oral corticosteroids. Particularly in children, because of their active life style, exercise-induced symptoms may interfere with normal daily life, and nocturnal symptoms may cause severe sleep disturbance. Although the avoidance of triggers that provoke symptoms and exacerbations is advocated in the guidelines, this is not a practical option as it is extremely difficult for asthmatic children to lead a normal life and yet avoid exercise. Long-term use of medication is therefore necessary to achieve the treatment goals. Inhaled corticosteroids have been shown to be the most effective drugs for reducing asthma symptoms and exacerbations. However, most children will not be free of symptoms during corticosteroid therapy and intermittent use of bronchodilator therapy is required. Cessation of inhaled corticosteroid therapy, even after several years of use, is likely to result in a reoccurrence of asthma symptoms. Long-acting beta 2-agonists, such as salmeterol and formoterol, are now available as additional therapy to inhaled corticosteroids in patients who remain symptomatic despite at least a moderate dose of inhaled corticosteroid. Two recent studies in adults revealed addition of salmeterol superior to increasing inhaled corticosteroid dose. So far, no data in children are available, but theoretically it might be attractive to add a long-acting beta 2-agonist to on-going therapy for children who remain symptomatic, especially at nighttime, despite the use of inhaled corticosteroids. There is no place for the use of long-acting beta 2-agonists as monotherapy in pediatric patients.

Assessment of the continued supervision and asthma management knowledge of patients possessing home nebulizers

This paper describes the results of a questionnaire survey on some aspects of nebulizer use, nebulizer instruction, and features relating to the recognition and management of deteriorating asthma. The study population consisted of 90 children with home nebulizers attending a paediatric asthma clinic, and 200 asthmatic children and 200 asthmatic adults whose nebulizers had been purchased directly from a manufacturer in the U.K. The results suggest that follow-up supervision of the patients who bought their own nebulizers occurred in only approximately 25% of cases. Written information focusing on the management of symptoms was also lacking. Peak flow meters were being under-used. Although the majority (77–100%) of patients were aware of the ‘4 h rule’ for repeat use of bronchodilator therapy at home, there was still some confusion about the acceptable time interval and action to be taken should the dose be required more frequently. Very few (32%) in the nationwide adult group had a crisis action plan should the nebulizer fail to produce relief. This paper recommends that a simple treatment and crisis plan should be included with the purchased nebulizer, highlighting the key areas to be discussed by the patients with the doctor or other medical professionals. Such a package may prevent the occasional disaster that can occur with unsupervised nebulized bronchodilator usage.