Use Of Bronchodilators Research Articles

Inhaled Corticosteroid Exposure in Hospitalized Infants with Bronchopulmonary Dysplasia.

The objective of this paper was to determine inhaled corticosteroid (IC) use in infants with bronchopulmonary dysplasia (BPD), define the interhospital variation of IC administration to infants with BPD, and compare clinical, demographic, and hospital factors associated with IC use. Using the Pediatric Health Information System database, a retrospective multicenter cohort of 4,551 infants born at <32 weeks of gestation with developing BPD was studied. The clinical, demographic, and hospital characteristics of infants exposed and not exposed to ICs were compared. IC use varied markedly between hospitals, ranging from 0 to 66% of infants with BPD exposed to ICs. Increased annual BPD census was not associated with IC use. In total, 25% (1,144 out of 4,551) of patients with BPD and 43% (536 out of 1,244) of those with severe BPD received ICs. Increased IC exposure was associated with lower birth weight and gestational age, days on respiratory support, need for positive pressure ventilation at 36-week postmenstrual age, need for tracheostomy, and increased use of systemic steroids, bronchodilators, and diuretics. IC exposure is common in infants with BPD, with substantial interhospital variability. IC use was associated with more severe disease. Hospital experience did not account for the wide variability in IC use by the hospital. Further research into the effects of ICs use is urgently needed to help guide their use in this vulnerable population. · The risks and benefits of IC use in infants with BPD are incompletely understood.. · IC use is common in infants with BPD (25%) and severe BPD (43%) varies widely by hospital (0-66% of patients with BPD received an IC).. · Hospital experience did not account for the wide interhospital variation in IC use..

Prediction of treatment nonadherence among older adults with chronic obstructive pulmonary disease using Medicare real-world data.

BACKGROUND: Suboptimal maintenance medication (MM) adherence remains a clinical problem among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To inform risk-based personalized decision-making, this study sought to develop and validate prediction models of nonadherence to COPD MMs for Medicare beneficiaries. METHODS: This was a retrospective cohort study of beneficiaries aged 65 years and older with COPD and inhaled MMs. Nonadherence (proportion of days covered < 0.8) was measured in 12 months following the first MM fill after COPD diagnosis. Logistic and least absolute shrinkage selector operator regressions were implemented, and area under the receiver operating characteristic curve (AUROC) evaluated model accuracy, as well as positive predictive values and negative predictive values. Our models evaluated different sets of predictors for two cohorts: those with an MM prescription before COPD diagnosis (prevalent users) and those without (new users). RESULTS: Among 16,157 prevalent and 40,279 new users of MMs, 11,271 (69.8%) and 34,009 (84.4%), respectively, were nonadherent. The best-performing logistic models achieved AUROCs of 0.8714 and 0.881, positive predictive values of 0.881 and 0.881, and negative predictive values of 0.559 and 0.578, respectively, for prevalent and new users. The least absolute shrinkage selector operator models had similar accuracy. Models with baseline-only predictors had average performance (AUROC < 0.72). The most important predictors were initial MM adherence, short-acting bronchodilator use, and asthma. CONCLUSIONS: To our knowledge, this study is the first to develop predictive models of nonadherence to COPD MMs. Generated models achieved good discrimination and underlined the importance of early adherence. Well-performed models can be useful for care decision-making and interventions to improve COPD medication adherence after the first critical few months following a treatment episode. DISCLOSURES: All authors declared no conflicts of interest.

Clinical Trial of Losartan for Pulmonary Emphysema: Pulmonary Trials Cooperative Losartan Effects on Emphysema Progression Clinical Trial.

Rationale: There are no pharmacologic agents that modify emphysema progression in patients with chronic obstructive pulmonary disease (COPD). Objectives: To evaluate the efficacy of losartan, an angiotensin receptor blocker, to reduce emphysema progression. Methods: The trial was a multicenter, randomized, placebo-controlled trial conducted between May 2017 and January 2021. Eligible participants were aged ⩾40 years, had moderate to severe airflow obstruction, ⩾10 pack-years of smoking, mild-moderate emphysema on high-resolution computed tomography, and no medical indication for or intolerance of angiotensin receptor blockers. Treatment with losartan 100 mg daily or matching placebo (1:1) was randomly assigned. The primary outcome was emphysema progression on high-resolution computed tomography over 48 weeks. Secondary outcomes included the St George's Respiratory Questionnaire, the modified Medical Research Council dyspnea scale, the COPD Assessment Test, and the Physical Function-Short Form 20a. Measurements and Main Results: A total of 220 participants were enrolled; 58% were men, 19% were African American, and 24% were current smokers. The medians (interquartile ranges) for age were 65 (61-73) years and 48 (36-59) for percent predicted FEV1 after bronchodilator use. The mean (95% confidence interval) percentage emphysema progression was 1.35% (0.67-2.03) in the losartan group versus 0.66% (0.09-1.23) in the placebo group (P = NS). Conclusions: Losartan did not prevent emphysema progression in people with COPD with mild-moderate emphysema. Clinical trial registered with www.clinicaltrials.gov (NCT02696564).

Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives

IntroductionIn the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. Material and methodsA quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. Results1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6–55.8%) in 2012 to 7.8% (95% CI: 5.7%–10.5%) in 2018 (P < .001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%–16.3%) to 0.2% (95% CI: 0–1.1%) (P < .001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72 h. ConclusionsThe systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.

Risk factors and medical resource utilization in US adults hospitalized with influenza or respiratory syncytial virus in the Hospitalized Acute Respiratory Tract Infection study.

BackgroundInfluenza and respiratory syncytial virus (RSV) are associated with substantial morbidity and mortality in the United States. We assessed risk factors for severe disease and medical resource utilization (MRU) among US adults hospitalized with influenza or RSV in the Hospitalized Acute Respiratory Tract Infection (HARTI) study.MethodsHARTI was a prospective global (40 centers, 12 countries) epidemiological study of adults hospitalized with acute respiratory tract infections conducted across the 2017–2019 epidemic seasons. Patients with confirmed influenza or RSV were followed up to 3 months post‐discharge. Baseline characteristics, prevalence of core risk factors (CRFs) for severe disease (age ≥65 years, chronic heart or renal disease, chronic obstructive pulmonary disease, or asthma), and MRU were summarized descriptively.ResultsThe US cohort included 280 influenza‐positive and 120 RSV‐positive patients. RSV patients were older (mean: 63.1 vs. 59.7 years) and a higher proportion had CRFs (87.5% vs. 81.4%). Among those with CRFs (influenza, n = 153; RSV, n = 99), RSV patients required longer hospitalizations (median length of stay: 4.5 days) and a greater proportion (79.8%) required oxygen supplementation during hospitalization compared with influenza patients (4.0 days and 59.5%, respectively). At 3 months post‐discharge, a greater proportion of RSV patients with CRFs reported use of antibiotics, antitussives, bronchodilators, and inhaled and systemic steroids versus those with influenza and CRFs. Many patients with CRFs reported hospital readmission at 3 months post‐discharge (RSV: 13.4%; influenza: 11.9%).ConclusionsMRU during and post‐hospitalization due to RSV in adults is similar to or greater than that of influenza. Enhanced RSV surveillance and preventive and therapeutic interventions are needed.

Something Is Changing in Viral Infant Bronchiolitis Approach.

Acute Viral Bronchiolitis is one of the leading causes of hospitalization in the first 12–24 months of life. International guidelines on the management of bronchiolitis broadly agree in recommending a minimal therapeutic approach, not recommending the use of bronchodilators. Guidelines, generally, consider bronchiolitis as a “unique disease” and this runs the risk of not administering therapy in some patients who could benefit from the use of bronchodilators, for instance, in those who will develop asthma later in their life and face first episode in the age of bronchiolitis. Today, there is growing evidence that bronchiolitis is not a single illness but can have different “endotypes” and “phenotypes,” based on age, personal or family history of atopy, etiology, and pathophysiological mechanism. There is evidence that some phenotypes of bronchiolitis are more strongly associated with asthma features and are linked to higher risk for asthma development. In these populations, possible use of bronchodilators might have a better impact. Age seems to be the main feature to suggest a good response to a bronchodilator-trial, because, among children > 6 months old with bronchiolitis, the presence of a subset of patients with virus-induced wheezing or the first episode of asthma is more likely. While waiting for new research to define the relationship between therapeutic options and different phenotypes, a bronchodilator-trial (using short-acting β2 agonists with metered-dose inhalers and valved holding chambers) seems appropriate in every child with bronchiolitis and age > 6 months.

Pharmacologic Ascorbic Acid as Early Therapy for Hospitalized Patients with COVID-19: A Randomized Clinical Trial.

Despite the widespread availability of effective vaccines, new cases of infection with severe acute respiratory syndrome coronavirus-2, the cause of coronavirus disease 2019 (COVID-19), remain a concern in the settings of vaccine hesitancy and vaccine breakthrough. In this randomized, controlled, phase 2 trial, we hypothesized that high-dose ascorbic acid delivered intravenously to achieve pharmacologic concentrations may target the high viral phase of COVID-19 and thus improve early clinical outcomes. Sixty-six patients admitted with COVID-19 and requiring supplemental oxygen were randomized to receive either escalating doses of intravenous ascorbic acid plus standard of care or standard of care alone. The demographic and clinical characteristics were well-balanced between the two study arms. The primary outcome evaluated in this study was clinical improvement at 72 h after randomization. While the primary outcome was not achieved, point estimates for the composite outcome and its individual components of decreased use of supplemental oxygen, decreased use of bronchodilators, and the time to discharge were all favorable for the treatment arm. Possible favorable effects of ascorbic acid were most apparent during the first 72 h of hospitalization, although these effects disappeared over the course of the entire hospitalization. Future larger trials of intravenous ascorbic acid should be based on our current understanding of COVID-19 with a focus on the potential early benefits of ascorbic in hospitalized patients.

Lifetime cannabis exposure and small airway function in a population-based cohort study.

Background and objectiveThe long-term effects of cannabis on small airway function remain unclear. We investigated associations between cannabis use and small airway function in a general population sample.MethodsCannabis use was ascertained at multiple ages from age 18 to 45 years and quantified as joint-years among 895 participants in the Dunedin Multidisciplinary Health and Development Study. Small airway function at ages 38 and 45 years was measured using impulse oscillometry (IOS) before and after inhalation of salbutamol. Analyses used multiple linear regression adjusting for tobacco use, body mass index and height. Longitudinal analyses of cannabis use between 38 and 45 years also adjusted for IOS at age 38 years.ResultsAssociations between lifetime cannabis joint-years and IOS differed between men and women: in women, cannabis use was associated with pre-bronchodilator resistance at 5 Hz (R5) and 20 Hz (R20), reactance at 5 Hz, area of reactance and resonant frequency, and marginally associated with the difference between R5 and R20. Cannabis use was only statistically significantly associated with pre-bronchodilator resonant frequency in men. Cannabis use between the ages of 38 and 45 years was associated with a similar pattern of changes in IOS measures. After salbutamol, cannabis use was only statistically significantly associated with R5 and R20 among women and none of the IOS measures among men.ConclusionsCannabis use is associated with small airway dysfunction at age 45 years, indicating an increase in peripheral airway resistance and reactance. These associations were greater and mostly only statistically significant among women. Associations were weaker and mostly nonsignificant after bronchodilator use, suggesting that cannabis-induced changes in small airways may be at least partially reversible.

Adolescents’ practical knowledge of asthma self-management and experiences in the context of acute asthma: a qualitative content analysis

Objective To characterize adolescents’ practical knowledge of asthma self-management and experiences during acute asthma episodes, and compare practical knowledge between minority and non-minority groups. Methods We conducted a secondary analysis using a qualitative descriptive design of textual data collected from 126 adolescents that participated in a randomized controlled trial of an asthma self-management program. Directed content analysis was conducted using four constructs of asthma self-management including symptom prevention, symptom monitoring, acute symptom management, and symptom communication. Results Most of the adolescents knew how to prevent exercised-induced bronchoconstriction, but had limited understanding about how to assess and monitor the severity of acute symptoms, appropriately use bronchodilators, seek timely medical help, and communicate acute symptoms to caregivers or healthcare providers during a slow-onset and rapid-onset asthma attack. More minority participants monitored asthma using peak expiratory flow than non-minority participants, who often relied on symptom-based monitoring. Minority adolescents more frequently mentioned bronchodilator use to manage asthma attacks, while non-minority adolescents often reported use of complementary and alternative approaches. Minority youth mentioned accessing healthcare services for acute episodes more often than their non-minority counterparts. Minority participants mentioned communicating acute symptoms to their providers, or family members less frequently than non-minority youth. Conclusions Adolescents have insufficient practical knowledge about ways to prevent and manage acute asthma. Periodic assessment of learning needs related to asthma attacks should be considered a routine part of clinical visits for adolescents to provide targeted information support to address their identified needs.

Explainable Machine Learning Model for Predicting First-Time Acute Exacerbation in Patients with Chronic Obstructive Pulmonary Disease.

Background: The study developed accurate explainable machine learning (ML) models for predicting first-time acute exacerbation of chronic obstructive pulmonary disease (COPD, AECOPD) at an individual level. Methods: We conducted a retrospective case–control study. A total of 606 patients with COPD were screened for eligibility using registry data from the COPD Pay-for-Performance Program (COPD P4P program) database at Changhua Christian Hospital between January 2017 and December 2019. Recursive feature elimination technology was used to select the optimal subset of features for predicting the occurrence of AECOPD. We developed four ML models to predict first-time AECOPD, and the highest-performing model was applied. Finally, an explainable approach based on ML and the SHapley Additive exPlanations (SHAP) and a local explanation method were used to evaluate the risk of AECOPD and to generate individual explanations of the model’s decisions. Results: The gradient boosting machine (GBM) and support vector machine (SVM) models exhibited superior discrimination ability (area under curve [AUC] = 0.833 [95% confidence interval (CI) 0.745–0.921] and AUC = 0.836 [95% CI 0.757–0.915], respectively). The decision curve analysis indicated that the GBM model exhibited a higher net benefit in distinguishing patients at high risk for AECOPD when the threshold probability was <0.55. The COPD Assessment Test (CAT) and the symptom of wheezing were the two most important features and exhibited the highest SHAP values, followed by monocyte count and white blood cell (WBC) count, coughing, red blood cell (RBC) count, breathing rate, oral long-acting bronchodilator use, chronic pulmonary disease (CPD), systolic blood pressure (SBP), and others. Higher CAT score; monocyte, WBC, and RBC counts; BMI; diastolic blood pressure (DBP); neutrophil-to-lymphocyte ratio; and eosinophil and lymphocyte counts were associated with AECOPD. The presence of symptoms (wheezing, dyspnea, coughing), chronic disease (CPD, congestive heart failure [CHF], sleep disorders, and pneumonia), and use of COPD medications (triple-therapy long-acting bronchodilators, short-acting bronchodilators, oral long-acting bronchodilators, and antibiotics) were also positively associated with AECOPD. A high breathing rate, heart rate, or systolic blood pressure and methylxanthine use were negatively correlated with AECOPD. Conclusions: The ML model was able to accurately assess the risk of AECOPD. The ML model combined with SHAP and the local explanation method were able to provide interpretable and visual explanations of individualized risk predictions, which may assist clinical physicians in understanding the effects of key features in the model and the model’s decision-making process.

Clinical Evaluation of Exertional Dyspnea in Adult Pectus Excavatum Patients

Abstract: Evaluation of patients with pectus excavatum has primarily been focused and, especially the pediatric population who undergoes surgical correction of sternal defects mainly for cosmetic reasons combined with exercise-limiting symptoms. The extent of cardiopulmonary improvement in this population based on cardiac imaging, pulmonary function testing, and cardiopulmonary exercise testing may be highly variable. There is no current consensus on the limitations of cardiopulmonary impairment or potential improvement from surgical repair in pediatric patients. Limited data have been published in the medical literature on the evaluation of adults with pectus excavatum who may also present with a variety of clinical symptoms. Adult patients with exercise limitation and pectus excavatum may present with exertional dyspnea, chest discomfort, palpitations/tachycardia, exercise-induced wheezing, and use of bronchodilators for asthma-like symptoms. While numerous published review articles outline clinical evaluation and surgical treatment for younger patients, comprehensive evaluation for these adult patients has not been fully elucidated. There is no current consensus on the underlying cause of cardiopulmonary impairment in adult patients or their potential improvement from surgical repair. This review focuses on the recommended evaluation of adult patients to discern the potential cardiopulmonary limitations to exercise due to pectus excavatum, especially in physically fit adults, such as active-duty military personnel. Two illustrative cases are presented to describe the complexity of the evaluation for adult patients and the potential need for surgical correction.

The impact of the COVID‐19 pandemic on respiratory morbidity during infancy: A birth‐cohort study

To evaluate the incidence of wheezing and overall respiratory morbidity in healthy infants born during the first peak of the coronavirus disease-2019 (COVID-19) pandemic, compared with infants born during the preceding year. This was a single-center retrospective birth cohort study to compare a cohort of children born between February and March 2020 (COVID-19 group) to a control group of children born between February and March 2019 (pre-COVID-19 group). At 1 year of age, we collected respiratory data using parental and telephone questionnaires. wheezing incidence and/or bronchodilator use. recurrent wheezing, emergency-room visits, hospital admissions, pneumonia diagnosis, and admissions due to lower-respiratory-tract-infections (LRTI). We included the following covariate risk factors in the logistic regression models; atopy, daycare attendance, breastmilk feeding, parental smoking, C-section, siblings, and gestational age. We enrolled 588 infants, 294 in each group (48% males). Demographic, perinatal, and atopic characteristics were similar between the groups. Compared to the pre-COVID-19 group, infants born during the COVID-19 period were significantly less likely to report wheezing and/or bronchodilator use (adjusted-odds ratio [OR], 0.4; 95% confidence interval [CI] 0.28-0.59), systemic steroid use, (adjusted-OR, 0.47; 95% CI 0.24-0.91), emergency-room visits (adjusted-OR, 0.36; 95% CI 0.17-0.72), LRTI admissions (adjusted-OR, 0.2; 95% CI 0.05-0.74), or pneumonia diagnosis (adjusted-OR, 0.22; 95% CI 0.09-0.53). This study investigated wheezing and respiratory morbidity over the first year of the COVID-19 pandemic in infants born during the first peak of COVID-19. The study demonstrated a significant decrease in most aspects of respiratory morbidity. A longitudinal follow-up study to explore the subsequent impact of these findings is warranted.

L’ uso precoce dei broncodilatatori nella bronchiolite non ne modifica gli esiti

Early use of bronchodilators in Bronchiolitis doesn’t change outcomes A large retrospective multicenter study (446,696 emergency room visits of children with bronchiolitis) conducted in 3rd-level hospitals in the USA confirms that early use of bronchodilators doesn’t change outcomes, it doesn’t change the rate of hospitalization and return to the Emergency Department, it doesn’t reduce the percentage of invasive and non-invasive ventilation or hospitalization in Intensive Care Unit. The indication not to use this therapy, suggested by the AAP Guidelines and partially by an Italian consensus, does not yet seem part of the therapeutic habits of all Italian pediatrics.

Impact of chronic obstructive pulmonary disease on one-year outcome after Transcatheter Aortic Valve Replacement

Chronic obstructive pulmonary disease (COPD) patients are at increased risk of complications post surgical aortic valve replacement. We sought to assess the prognostic impact of COPD in patients undergoing transcatheter aortic valve replacement (TAVR). This is an observational single-center retrospective study involving all patients who underwent TAVR for severe aortic stenosis from 2009 to 2019. The existence of COPD was defined as the presence of lung symptoms requiring long-term use of bronchodilators or steroids, and its severity was assessed according to GOLD classification. Propensity score matching was performed. The main endpoint consisted of the one-year composite endpoint of all-cause mortality, stroke, or hospitalizations for valve-related symptoms or worsening heart failure. A total of 412 patients (mean age 79.6 ± 7.8 years, mean STS score 5.3 ± 3.6) were included. COPD was found in 115 patients (27.9%): stage 1 (n = 61, 53%), stage 2 (n = 28, 24.4%), stage 3 (n = 22, 19.1%) and stage 4 (n = 4, 3.5%). COPD patients were younger (P = 0.007) with a higher STS score (P = 0.024) in comparison with no COPD patients. Matching on the propensity score resulted in a data set of 102 matched pairs. COPD was associated with increased length of stay (LOS) post TAVR (median 3 [IQI 3–7] vs. 2 [IQI 1–5]; P = 0.007). COPD patients had lower survival than no COPD patients (88.1% vs. 95.5%; P = 0.048) while no difference was found in terms of one-year survival free from stroke and rehospitalization. A trend toward lower survival free from the composite endpoint was observed in COPD patients (81.5% vs. 90.5%; P = 0.076). Symptoms improvement was similar between COPD and no COPD patients (improvement ≥ 1 NYHA class: 85.1% vs. 83.3%; P = 0.766) (Fig. 1). COPD could result in longer LOS, lower survival and worse cardiovascular outcome at one year following TAVR. Very few patients with severe GOLD 4 were included in this study.

The role and place of bronchodilative and anti-inflammatory therapy for chronic obstructive pulmonary disease in patients with newly detected respiratory tuberculosis

Introduction. The relevance of the problem of managing patients with concomitant infectious and non-infectious pathology is beyond doubt, a third of patients suffering from tuberculosis have COPD as a comorbidity, which re-quires adequate therapy to improve the prognosis of the patient’s treatment as a whole. Objective: to evaluate the effectiveness of various options for bronchodilatory and anti-inflammatory therapy in patients with newly diag-nosed pulmonary tuberculosis secondary to COPD. Ma-terials and methods. A simple prospective comparative study included 210 patients divided into 3 groups: 124 pa-tients with TB+COPD; 46 patients with drug-susceptible TB (TB DS)+COPD; 40 patients with multidrug-resistant TB+COPD. The selection of treatment regimens was car-ried out with an assessment of the best efficiency, includ-ing inhaled glucocorticosteroid in combination with a long-acting β2-adrenergic agonist (IGCS/LABA) into the treatment regimens in the intensive phase of the course of TB. Duration of the follow-up is 6–9 months with assess-ment of X-ray pattern, bacterial shedding and smear neg-ativity as criteria for curing TB. Results. In patients with TB+COPD, the best effect of minimizing the severity of broncho-obstructive syndrome (reduction of dyspnea ac-cording to mMRC and CAT test) was obtained during ther-apy with a combination drug (long-acting anticholinergic drug and long-acting β2-agonist (LAAC/LABA) with good tolerance. In patients with TB DS+COPD, positive dynam-ics in the reduction of the severity of cough, dyspnea, CAT test was obtained in the ICS group in comparison with patients taking short-acting anticholinergic drugs (SDA). For patients with MDR+TB COPD, ICS/LABA showed the optimal effect on the severity of COPD symptoms. Against the background of taking IGCS/LABA in both groups, there was an increase in the number of patients achiev-ing smear negativity, cessation of bacterial shedding and closure of decay cavities, in comparison with the CAAC group, without any side effects. Conclusion. Adequate correction of broncho-obstructive syndrome in patients with COPD, including the use of bronchodilators (LABA) and anti-inflammatory drugs (IGCS) in the intensive phase of treatment of newly diagnosed pulmonary TB due to the main and additional effects of drugs, can improve the effectiveness of tuberculosis therapy

Pharmacoeconomic Analysis of Inhalation Drugs Availability Used in COPD Treatment

Relevance of the study and the presence of gaps in existing knowledge on topic. The use of inhalation bronchodilators and glucocorticosteroids (GCS) improves the functional parameters of the lungs in patients with chronic obstructive pulmonary disease (COPD), as well as reduces the number of middle and severe exacerbations. There are a large number of inhalation drugs in the modern Russian pharmaceutical market, which are both monocomponent and combinations of two and three drugs. Often, original and generic drugs have different costs and are not always economically or physically available to different population segments. Thus, the aim of this study was to conduct a comparative pharmacoeconomic analysis of inhalation bronchodilators and anti-inflammatory drugs to determine the level of economic availability. Materials and Methods. Drugs from the group of adrenomimetics for inhalational use (ATC code R03A), anticholinolytic and GCS for inhalation used in the COPD treatment (ATC code R03B) were analyzed. Information about the price of drugs is obtained from the state register of maximum selling prices and the Internet resource "Apteka.ru". To evaluate the availability of the analyzed groups of drugs, solvency adequacy coefficients (Ca.s) and price liquidity indicators (Cliq) were calculated. Results . The most available among the GCS was beclomethasone in form of a metered-dose inhalator (MDI) 50 mcg (Cliq = 52%; Ca.s = 0.338%), among short-acting emergency bronchodilators, salbutamol in MDI form 100 mcg (Cliq= 58%; Ca.s = 0.156%) was the most available. Greater availability was found for domestic drug manufacturers (95% CI: 0.690 - 1,000; p = 0.007), however, the opposite data were obtained for several drugs. Conclusions . The obtained results show a heterogeneous structure among the levels of inhalation drugs availability used in COPD treatment. Taking into account the wide range of drug products, in order to inform medical and pharmaceutical workers in a timely way, it is advisable to systematically study these drug groups using pharmacoeconomic analysis methods.

Development of MDS-Based Predication Model for COPD Severity in Nursing Home Residents.

Assessing chronic obstructive pulmonary disease (COPD) severity is challenging in nursing home (NH) residents due to incomplete symptom assessments and exacerbation history. The objective of this study was to predict COPD severity in NH residents using the Minimum Data Set (MDS), a clinical assessment of functional capabilities and health needs. A cohort analysis of prospectively collected longitudinal data was conducted. Residents from geographically varied Medicare-certified NHs with age ≥60 years, COPD diagnosis, and ≥6 months NH residence at enrollment were included. Residents with severe cognitive impairment were excluded. Demographic characteristics, medical history, and MDS variables were extracted from medical records. The care provider-completed COPD Assessment Test (CAT) and COPD exacerbation history were used to categorize residents by Global Initiative for Chronic Lung Disease (GOLD) A to D groups. Multivariate multinomial logit models mapped the MDS to GOLD A to D groups with stepwise selection of variables. Nursing home residents (N = 175) were 64% women and had a mean age of 77.9 years. Among residents, GOLD B was most common (A = 13.1%; B = 44.0%; C = 5.7%; D = 37.1%). Any long-acting bronchodilator (LABD) use and any dyspnea were significant predictors of GOLD A to D groups. The predicted MDS-GOLD group (A = 6.9%; B = 52.6%; C = 4.6%; D = 36.0%) showed good model fit (correctly predicted = 60.6%). Nursing home residents may underuse group-recommended LABD treatment (no LABD: B = 53.2%; C = 80.0%; D = 40.0%). The MDS, completed routinely for US NH residents, could potentially be used to estimate COPD severity. Predicted COPD severity with additional validation could provide a map to evidence-based treatment guidelines and may help to individualize treatment pathways for NH residents.

Rationale and Clinical Use of Bronchodilators in Adults with Bronchiectasis.

Currently, there is much controversy surrounding the therapeutic approach to pulmonary function abnormalities in patients with bronchiectasis and, consequently, whether and when to use bronchodilators in these patients. National and international guidelines on the treatment of bronchiectasis in adults do not recommend the routine use of bronchodilators because there is no evidence that a significant response to a bronchodilator or the presence or hyperresponsiveness of the airway are good predictors of future effective clinical response. However, some guidelines recommend them in the presence of airway obstruction and/or special conditions, which vary according to the guideline in question, although there are no recommendations on optimal dosing and bronchodilator treatment combined with or without inhaled corticosteroids. Nonetheless, in contrast with guideline recommendations, bronchodilators are overused in real-world patients with bronchiectasis even in the absence of airway obstruction, as demonstrated by analysis of national and international registries. This overuse can be explained by the awareness of the existence of a solid pharmacological rationale that supports the use of bronchodilators in the presence of chronic airway obstruction independent of its aetiology. We performed a systematic review of the literature and were able to verify that there are no randomised controlled trials (apart from a small study with methodological limitations and a very recent trial involving a not-very-large number of patients), or any long-term observational studies on the short- or long-term effect of bronchodilators in patients with bronchiectasis. Therefore, we believe that it is essential and even urgent to evaluate the effects of bronchodilators in these patients with appropriately designed studies.

Mid-term results of vascular ring surgery.

Vascular rings cause respiratory symptoms in children. Treatment consists of surgical division; however, data regarding mid-term results are scarce. The purpose of this study was to evaluate clinical results of vascular ring surgery. Retrospective chart review of consecutive patients who underwent vascular ring surgery. Mid-term follow-up consisted of clinic visits and telephone questionnaire over a 1-year period sampling at five points in time. Follow-up of 85 patients who underwent vascular rings surgery revealed significant symptomatic improvement within 6 months. In total, 50% were symptomatic to some degree at their last documented clinic visit complaining of stridor (36.8%), cough (34.2%), wheezing (10.5%), dyspnoea on exertion (10.5%), or recurrent respiratory infections (23.7%). By telephone questionnaires, 83% described a significant improvement in respiratory symptoms, 63.4% had some residual symptoms, 36.6% stridor, 38.8% chronic cough, 32.4% bronchodilator use,18.3% had at least one episode of pneumonia per year, 31% of children had dyspnoea or respiratory limitation, and 12.7% while doing physical activities. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. Surgical division of vascular rings results in significant clinical improvement within 1 year; nevertheless, some patients remain symptomatic to some degree. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. Further evaluation is warranted to assess the nature of residual symptoms and explore whether anatomical causes can be identified leading to surgical modifications.

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