Budesonide facilitates weaning from mechanical ventilation in difficult-to-wean very severe COPD patients: Association with inflammatory mediators and cells

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

Acinetobacter baumannii among Patients Receiving Glucocorticoid Aerosol Therapy during Invasive Mechanical Ventilation, China

Acinetobacter baumannii is a nosocomial pathogen associated with severe illness and death. Glucocorticoid aerosol is a common inhalation therapy in patients receiving invasive mechanical ventilation. We conducted a prospective cohort study to analyze the association between glucocorticoid aerosol therapy and A. baumannii isolation from ventilator patients in China. Of 497 enrolled patients, 262 (52.7%) received glucocorticoid aerosol, and A. baumannii was isolated from 159 (32.0%). Glucocorticoid aerosol therapy was an independent risk factor for A. baumannii isolation (hazard ratio 1.5, 95% CI 1.02-2.28; p = 0.038). Patients receiving glucocorticoid aerosol had a higher cumulative hazard for A. baumannii isolation and analysis showed that glucocorticoid aerosol therapy increased A. baumannii isolation in most subpopulations. Glucocorticoid aerosol was not a direct risk factor for 30-day mortality, but A. baumannii isolation was independently associated with 30-day mortality in ventilator patients. Physicians should consider potential A. baumannii infection when prescribing glucocorticoid aerosol therapy.

Sequential treatment of severe pneumonia with respiratory failure and its influence on respiratory mechanical parameters and hemodynamics

BACKGROUND

The pathophysiological characteristics of severe pneumonia complicated by respiratory failure comprise pulmonary parenchymal changes leading to ventilation imbalance, alveolar capillary injury, pulmonary edema, refractory hypoxemia, and reduced lung compliance. Prolonged hypoxia can cause acid-base balance disorder, peripheral circulatory failure, blood-pressure reduction, arrhythmia, and other adverse consequences.

AIM

To investigate sequential mechanical ventilation’s effect on severe pneumonia complicated by respiratory failure.

METHODS

We selected 108 patients with severe pneumonia complicated by respiratory failure who underwent mechanical ventilation between January 2018 and September 2020 at the Luhe Hospital’s Intensive Care Unit and divided them into sequential and regular groups according to a randomized trial, with each group comprising 54 patients. The sequential group received invasive and non-invasive sequential mechanical ventilation, whereas the regular group received invasive mechanical ventilation. Blood-gas parameters, hemodynamic parameters, respiratory mechanical parameters, inflammatory factors, and treatment outcomes were compared between the two groups before and after mechanical-ventilation treatment.

RESULTS

The arterial oxygen partial pressure and stroke volume variation values of the sequential group at 24, 48, and 72 h of treatment were higher than those of the conventional group (P < 0.05). The carbon dioxide partial pressure value of the sequential group at 72 h of treatment and the Raw value of the treatment group at 24 and 48 h were lower than those of the conventional group (P < 0.05). The pH value of the sequential group at 24 and 72 h of treatment, the central venous pressure value of the treatment at 24 h, and the Cst value of the treatment at 24 and 48 h were higher than those of the conventional group (P < 0.05). The tidal volume in the sequential group at 24 h of treatment was higher than that in the conventional group (P < 0.05), the measured values of interleukin-6 and tumor necrosis factor-α in the sequential group at 72 h of treatment were lower than those in the conventional group (P < 0.05), and the total time of mechanical ventilation in the sequential group was shorter than that in the conventional group, with a statistically significant difference (P < 0.05).

CONCLUSION

Treating severe pneumonia complicated by respiratory failure with sequential mechanical ventilation is more effective in improving respiratory system compliance, reducing inflammatory response, maintaining hemodynamic stability, and improving patient blood-gas levels; however, from this study’s perspective, it cannot reduce patient mortality.

To Wean or Not to Wean: A Practical Patient Focused Guide to Ventilator Weaning

Since the inception of critical care medicine and artificial ventilation, literature and research on weaning has transformed daily patient care in intensive care units (ICU). As our knowledge of mechanical ventilation (MV) improved, so did the need to study patient-ventilator interactions and weaning predictors. Randomized trials have evaluated the use of protocol-based weaning (vs. usual care) to study the duration of MV in ICUs, different techniques to conduct spontaneous breathing trials (SBT), and strategies to eventually extubate a patient whose initial SBT failed. Despite considerable milestones in the management of multiple diseases contributing to reversible respiratory failure, in the application of early rehabilitative interventions to preserve muscle integrity, and in ventilator technology that mitigates against ventilator injury and dyssynchrony, major barriers to successful liberation from MV persist. This review provides a broad encompassing view of weaning classification, causes of weaning failure, and evidence behind weaning predictors and weaning modes.

Engineered mucoadhesive microparticles of formoterol/budesonide for pulmonary administration

In the present study, a multi-component system comprised of dipalmitylphospatidylcholine (DPPC), Chitosan, Lactose, and L-Leucine was developed for pulmonary delivery. Microparticles were engineered by the spray drying process and the selection of the critical parameters was performed by applying experimental design. The microcarriers with the appropriate size and yield were co-formulated with two active pharmaceutical ingredients (APIs), namely, Formoterol fumarate and Budesonide, and they were further investigated. All formulations exhibited spherical shape, appropriate aerodynamic performance, satisfying entrapment efficiency, and drug load. Their physicochemical properties were evaluated using Scanning Electron Microscopy (SEM), Fourier Transform Infrared Spectroscopy (FT-IR), and Differential Scanning Calorimetry (DSC). The aerodynamic particle size characterization was determined using an eight-stage Andersen cascade impactor, whereas the release of the actives was monitored in vitro in simulated lung fluid. Additional evaluation of the microparticles' mucoadhesive properties was performed by ζ-potential measurements and ex vivo mucoadhesion study applying a falling liquid film method using porcine lung tissue. Cytotoxicity and cellular uptake studies in Calu-3 lung epithelial cell line were conducted to further investigate the safety and efficacy of the developed formulations.

Clinical effects of lentinan combined with budesonide inhalation in treating acute exacerbation of chronic obstructive pulmonary disease under mechanical ventilation

In the present study, the clinical efficacy of the immune modulator lentinan combined with inhalation of the corticosteroid budesonide in treating acute exacerbation of chronic obstructive pulmonary disease (AECOPD) under mechanical ventilation was assessed. A total of 72 cases of AECOPD treated at Shanghai Jiao Tong University Affiliated Sixth People's Hospital (Shanghai, China) between June 2016 and September 2017 were enrolled. The AECOPD patients were randomly divided into an experimental group (n=36) and a control group (n=36). All of the patients received ventilator support and endotracheal intubation was performed. The experimental group was orally administered lentinan and budesonide was administered via atomization inhalation through a Y-tube and the control group received only budesonide via Y-tube. After the treatment, airway pressure, the time of mechanical ventilation and the time of stay at the intensive care unit for the experimental group were significantly lower than those for the control group (P<0.001). The plasma levels of adiponectin, D-dimer, interleukin-17 and high-sensitivity C-reactive protein, as well as the pressure of CO₂ in the experimental group were significantly lower than those in control group (P<0.001). Furthermore, the partial O₂ pressure in the experimental group was significantly higher than that in the control group (P<0.001). After the combined treatment, the proportions of CD3⁺ and CD4⁺T-cells in the blood were elevated, while the proportion of CD8⁺T-cells was decreased, compared with those in the experimental group at baseline or the control group post-treatment. In conclusion, the strategy of lentinan treatment combined with budesonide inhalation for AECOPD patients under mechanical ventilation demonstrated improved clinical efficacy compared with budesonide alone. (Chinese Clinical Trial Registry no. ChiCTR1800019088).