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Regard L, Lazureanu PC, Pascal B, Laurichesse G, Rolland-Debord C. [Efficacy and toxicity of short-course corticosteroid therapy in chronic bronchial diseases]. Rev Mal Respir 2024:S0761-8425(24)00273-0. [PMID: 39389905 DOI: 10.1016/j.rmr.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 08/28/2024] [Indexed: 10/12/2024]
Abstract
Chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) are characterized by airway inflammation. While corticosteroids (CS) are frequently prescribed during exacerbations of these conditions, their repeated use is associated with numerous side effects. The aim of this review is to synthesize the recent literature on the indications, benefits, and risks of short-term CS therapy for these two diseases. French guidelines recommend short-term CS as a first-line treatment during asthma exacerbation (0,5 to 1mg/kg/day, not exceeding 60mg/day, for at least 5 to 7 days) or as a second-line treatment for COPD exacerbation (5 days, 30 to 40mg/day). However, these recommendations are not without limitations; they are primarily based on studies conducted in hospital settings, raising questions about the generalizability of their results to primary care, and as they employ a "one size fits all" strategy, they do not take into account the phenotypic heterogeneity of different patients. Moreover, repeated short-term CS courses generate side effects that even at low doses can appear early in young asthma patients, and they can exacerbate pre-existing comorbidities in COPD patients. The concept of a threshold dose should be employed in routine practice in view of accurately assessing the risk of side effects. In the near future, it will be important to consider recently published data supporting the use of predictive biomarkers for responses to CS, particularly in COPD cases.
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Affiliation(s)
- L Regard
- Service de pneumologie, Hôpital Cochin, AP-HP centre, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Unité INSERM U1016, Institut Cochin, Université Paris Cité, Paris, France
| | - P C Lazureanu
- Service de pneumologie, CHU de Clermont-Ferrand, université Clermont-Auvergne, 53, rue Montalembert, 63000 Clermont-Ferrand, France
| | - B Pascal
- Service de pneumologie, CHU de Clermont-Ferrand, université Clermont-Auvergne, 53, rue Montalembert, 63000 Clermont-Ferrand, France; Fédération des maladies allergiques d'Auvergne-Auvall, CHU de Clermont-Ferrand, université Clermont-Auvergne, 53, rue Montalembert, 63000 Clermont-Ferrand, France
| | - G Laurichesse
- Service de pneumologie, CHU de Clermont-Ferrand, université Clermont-Auvergne, 53, rue Montalembert, 63000 Clermont-Ferrand, France
| | - C Rolland-Debord
- Service de pneumologie, CHU de Clermont-Ferrand, université Clermont-Auvergne, 53, rue Montalembert, 63000 Clermont-Ferrand, France.
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Ramgopal S, Naik VV, Komukai S, Owusu-Ansah S, Crowe RP, Okubo M, Martin-Gill C. The association of prehospital systemic corticosteroids with emergency department and in-hospital outcomes for patients with asthma exacerbations. Acad Emerg Med 2024; 31:675-687. [PMID: 38456349 DOI: 10.1111/acem.14890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Timely administration of systemic corticosteroids is a cornerstone of asthma exacerbation treatment, yet little is known regarding potential benefits of prehospital administration by emergency medical services (EMS) clinicians. We examined factors associated with prehospital corticosteroid administration with hospitalization and hospital length of stay (LOS). METHODS We performed a retrospective study of EMS encounters for patients 2-50 years of age with suspected asthma exacerbation from a national data set. We evaluated factors associated with systemic corticosteroid administration using generalized estimating equations. We performed propensity matching based on service level, age, encounter duration, vital signs, and treatments to evaluate the association of prehospital corticosteroid administration with hospitalization and LOS using weighted logistic regression. We evaluated the association of prehospital corticosteroid administration with admission using Bayesian models. RESULTS Of 15,834 encounters, 4731 (29.9%) received prehospital systemic corticosteroids. Administration of corticosteroids was associated with older age; sex; urbanicity; advanced life support provider; vital sign instability; increasing doses of albuterol; and provision of ipratropium bromide, magnesium, epinephrine, and supplementary oxygen. Within the matched sample, prehospital corticosteroids were not associated with hospitalization (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.73-1.01) or LOS (multiplier 0.76, 95% CI 0.56-1.05). Administration of corticosteroids was associated with lower odds of admission and shorter LOS in longer EMS encounters (>34 min), lower admission odds in patients with documented wheezing, and shorter LOS among patients treated with albuterol. In a Bayesian model with noninformative priors, the OR for admission among encounters given corticosteroids was 0.86 (95% credible interval 0.77-0.96). CONCLUSIONS Prehospital systemic corticosteroid administration was not associated with hospitalization or LOS in the overall cohort of asthma patients treated by EMS, though they had a lower probability of admission within Bayesian models. Improved outcomes were noted among subgroups of longer EMS encounters, documented wheezing, and receipt of albuterol.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vishal V Naik
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sylvia Owusu-Ansah
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Kramer AW, Erlich J, Yaphockun K, Roderick D, Farkas K, Bryl AW, Pade KH. Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients. Pediatr Qual Saf 2024; 9:e738. [PMID: 38868756 PMCID: PMC11167218 DOI: 10.1097/pq9.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months. Methods We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time. Results From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate. Conclusions Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.
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Management of Life-Threatening Asthma. Chest 2022; 162:747-756. [DOI: 10.1016/j.chest.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022] Open
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Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology 2021; 26:1112-1130. [PMID: 34587348 PMCID: PMC9291960 DOI: 10.1111/resp.14147] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.
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Affiliation(s)
- John Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, Curtin University, Perth, Western Australia, Australia
| | - Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Medical Centre, Melbourne, Victoria, Australia
| | - John Gornall
- Centre of Excellence in Severe Asthma, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Pharmacy School, The University of Sydney AND Quality Use of Respiratory Medicines Group, The Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - John Harrington
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Trudy Hopkins
- South Eastern Sydney Health Department, Sydney, New South Wales, Australia
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health and University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- The University of Queensland, Diamantina Institute AND Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia.,John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy & Immunology, Monash University and Medical Centre, Melbourne, Victoria, Australia
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Doymaz S, Ahmed YE, Francois D, Pinto R, Gist R, Steinberg M, Giambruno C. Methylprednisolone, dexamethasone or hydrocortisone for acute severe pediatric asthma: does it matter? J Asthma 2021; 59:590-596. [PMID: 33380248 DOI: 10.1080/02770903.2020.1870130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Various intravenous (IV) corticosteroids are available for acute severe asthma (ASA) treatment. The choice of IV corticosteroids varies broadly and depends on institution, country, or physician preferences. In this study, we compared the efficacy of IV methylprednisolone, hydrocortisone and dexamethasone in ASA treatment during pediatric intensive care unit (PICU) admission. METHODS The study was a prospective randomized clinical trial. We enrolled patients of 1-21 years after they were admitted to the PICU requiring continuous beta-2 agonist treatment. Patients were randomized into three groups: Group A: IV Methylprednisolone, Group B: IV Hydrocortisone and Group C: IV Dexamethasone. The primary outcomes measured were durations of beta-2 agonist continuous nebulization treatment. Secondary outcomes, included PICU and hospital length of stay (LOS), pediatric asthma severity score (PASS), need for mechanical ventilation and maximum dose of beta-2 agonist treatment. RESULTS 61 patients were included in the analysis. 22 patients recruited in Group A, 20 in group B and 19 group C. Median durations of beta-2-agonist treatment were 23 h (QR 16-38) for methylprednisolone, 27 h (QR 16-40) for hydrocortisone, and 32 h (QR 16-48) for dexamethasone (p = 0.90). There was no difference in PICU LOS, hospital LOS, PASS score, B2 agonist maximum dose, or need for ventilation support. CONCLUSIONS The use of IV methylprednisolone, hydrocortisone, and dexamethasone have equivalent efficacy when used at the appropriate doses. Studies with larger cohorts are needed to compare the effectiveness of IV corticosteroids in the management of ASA in the PICU setting.
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Affiliation(s)
- Sule Doymaz
- Department of Pediatrics, Pediatric Critical Care Unit, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Youssef E Ahmed
- Department of Pediatrics, Pediatric Critical Care Unit, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Densley Francois
- Department of Pediatrics, Neonatal Intensive Care Unit, Presbyterian Hospital/Morgan Stanley Children's Hospital, New York, NY, USA
| | - Rohit Pinto
- Department of Pediatrics, Pediatric Critical Care Unit, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ramon Gist
- Department of Pediatrics, Pediatric Critical Care Unit, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Miriam Steinberg
- Department of Pediatrics, Pediatric Critical Care Unit, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Clara Giambruno
- Department of Pediatrics, Pediatric Critical Care Unit, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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7
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Checa J, Aran JM. Airway Redox Homeostasis and Inflammation Gone Awry: From Molecular Pathogenesis to Emerging Therapeutics in Respiratory Pathology. Int J Mol Sci 2020; 21:E9317. [PMID: 33297418 PMCID: PMC7731288 DOI: 10.3390/ijms21239317] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
As aerobic organisms, we are continuously and throughout our lifetime subjected to an oxidizing atmosphere and, most often, to environmental threats. The lung is the internal organ most highly exposed to this milieu. Therefore, it has evolved to confront both oxidative stress induced by reactive oxygen species (ROS) and a variety of pollutants, pathogens, and allergens that promote inflammation and can harm the airways to different degrees. Indeed, an excess of ROS, generated intrinsically or from external sources, can imprint direct damage to key structural cell components (nucleic acids, sugars, lipids, and proteins) and indirectly perturb ROS-mediated signaling in lung epithelia, impairing its homeostasis. These early events complemented with efficient recognition of pathogen- or damage-associated recognition patterns by the airway resident cells alert the immune system, which mounts an inflammatory response to remove the hazards, including collateral dead cells and cellular debris, in an attempt to return to homeostatic conditions. Thus, any major or chronic dysregulation of the redox balance, the air-liquid interface, or defects in epithelial proteins impairing mucociliary clearance or other defense systems may lead to airway damage. Here, we review our understanding of the key role of oxidative stress and inflammation in respiratory pathology, and extensively report current and future trends in antioxidant and anti-inflammatory treatments focusing on the following major acute and chronic lung diseases: acute lung injury/respiratory distress syndrome, asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, and cystic fibrosis.
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Affiliation(s)
| | - Josep M. Aran
- Immune-Inflammatory Processes and Gene Therapeutics Group, IDIBELL, L’Hospitalet de Llobregat, 08908 Barcelona, Spain;
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8
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Lucia D, Cain J, Porter A, Sagar M, Blazovic S, Finley L, Mallett L. Pediatric asthma pathway in the emergency room. Proc (Bayl Univ Med Cent) 2020; 34:40-43. [PMID: 33456142 DOI: 10.1080/08998280.2020.1801110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Asthma is one of the leading causes of hospital admission in the pediatric population. Standardization of asthma management guidelines for patients admitted to the emergency department has been suggested to improve care delivery and patient outcomes. Utilizing a multidisciplinary asthma task force at a single academic medical center, we sought to determine if a protocol-driven approach to implementation of care for patients with asthma could improve patient outcomes by reducing wait times for administration of steroids. A prospective cohort study examined the use of a standardized asthma pathway over a 2-year period compared to historical controls. Pathway use significantly decreased time to corticosteroid administration (45 vs. 29 min [year 1] and 20 min [year 2]; P < 0.0001). By implementing this standard of care at pediatric emergency departments, time to treatment can be decreased, therefore improving the morbidity and mortality of pediatric patients with asthma nationwide.
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Affiliation(s)
- Dominic Lucia
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - James Cain
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Ashlee Porter
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Malvika Sagar
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Sarah Blazovic
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Leland Finley
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Lea Mallett
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
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9
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Liang Y, Wang D, Hua D, Liao H, Chen R. Short-term oral corticosteroids for initial treatment of moderate-to-severe persistent asthma: A double-blind, randomized, placebo-controlled trial. Respir Med 2020; 172:106126. [PMID: 32911138 DOI: 10.1016/j.rmed.2020.106126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate that on the basis of ICS-LABA treatment, whether or not adding on short course of oral corticosteroid could increase the rate of asthma control. METHODOLOGY This was a double blind, randomized controlled study. Patients with moderate to severe persistent asthma who are maintenance treatment naïve were recruited from the out-patients clinic. All patients included in the study received ICS-LABA as initial treatment. Two weeks oral corticosteroid or placebo were added on at the beginning of treatment. All the subjects were followed-up by daily measurement of PEF and asthma diary for 12 week and spirometry at 4 weeks and 12 weeks. RESULTS 13 cases were randomized to Corticosteroid group (M/F: 9/4, age: 45.0 ± 5.0 yrs), 11 to Placebo group (M/F: 4/7, age: 35.7 ± 9.6yrs). After treatment, significant improvement in ACT、ACQ、AQLQ、FEV1、FEV1% were observed in both groups as compared with baseline data (all P < 0.05). However, there were no significant difference between two groups in the improvement of ACT、ACQ、AQLQ、FEV1、FEV1% (all P > 0.05). After 4 weeks of treatment, total control was achieved in 3 (30.8%) in corticosteroid group and 2 (18.2%) in placebo group; Partial control was achieved in 7 (61.5%)in corticosteroid group and in 7 (63.6%) in placebo group. There was no significant difference in control rates between two groups (X2 = 0.919, P = 0.632). Similar findings were observed after 12 weeks of treatment. CONCLUSION In maintenance treatment naïve moderate to severe persistent asthma, ICS-LABA therapy was adequate initial treatment for achieving asthma control in majority of the patients. Add on short course of oral corticosteroid provided no significant clinical benefit.
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Affiliation(s)
- Yihua Liang
- Department of Respiratory Medicine, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, China
| | - Dexi Wang
- Department of Respiratory Medicine, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, China
| | - Dongming Hua
- Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University (National Clinical Research Center for Respiratory Diseases), Guangzhou, China
| | - Hua Liao
- Guangzhou Overseas Chinese Hospital, China
| | - Rongchang Chen
- Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University (National Clinical Research Center for Respiratory Diseases), Guangzhou, China.
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Park JY, Chu GE, Park S, Park C, Aryal S, Kang WJ, Cho WG, Key J. Therapeutic Efficacy of Curcumin Enhanced by Microscale Discoidal Polymeric Particles in a Murine Asthma Model. Pharmaceutics 2020; 12:pharmaceutics12080739. [PMID: 32781576 PMCID: PMC7463530 DOI: 10.3390/pharmaceutics12080739] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/01/2020] [Accepted: 08/03/2020] [Indexed: 01/18/2023] Open
Abstract
Curcumin is considered a potential anti-asthmatic agent owing to its anti-inflammatory properties. The objective of the present study was to prepare curcumin-containing poly(lactic-co-glycolic acid)-based microscale discoidal polymeric particles (Cur-PLGA-DPPs) and evaluate their anti-asthmatic properties using a murine asthma model. Cur-PLGA-DPPs were prepared using a top-down fabrication method. The prepared Cur-PLGA-DPPs had a mean particle size of 2.5 ± 0.4 μm and a zeta potential value of −34.6 ± 4.8 mV. Ex vivo biodistribution results showed that the Cur-PLGA-DPPs mainly accumulated in the lungs and liver after intravenous injection. Treatment with Cur-PLGA-DPPs effectively suppressed the infiltration of inflammatory cells in bronchoalveolar lavage fluid, and reduced bronchial wall thickening and goblet-cell hyperplasia compared to those in the phosphate-buffered-saline-treated control group. No significant changes in hematology and blood biochemistry parameters were observed after treatment with Cur-PLGA-DPPs. At equal curcumin concentrations, treatment with Cur-PLGA-DPPs exhibited better therapeutic efficacy than treatment with free curcumin. Our results suggest that the microscale Cur-PLGA-DPPs can be potentially used as a lung-targeted asthma therapy.
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Affiliation(s)
- Jun Young Park
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.Y.P.); (W.J.K.)
| | - Ga Eul Chu
- Department of Anatomy, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea;
| | - Sanghyo Park
- Department of Biomedical Engineering, Yonsei University, Gangwon-do, Wonju 26493, Korea; (S.P.); (C.P.); (S.A.)
| | - Chaewon Park
- Department of Biomedical Engineering, Yonsei University, Gangwon-do, Wonju 26493, Korea; (S.P.); (C.P.); (S.A.)
| | - Susmita Aryal
- Department of Biomedical Engineering, Yonsei University, Gangwon-do, Wonju 26493, Korea; (S.P.); (C.P.); (S.A.)
| | - Won Jun Kang
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.Y.P.); (W.J.K.)
| | - Won Gil Cho
- Department of Anatomy, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea;
- Correspondence: (W.G.C.); (J.K.); Tel.: +82 337602857 (J.K.)
| | - Jaehong Key
- Department of Biomedical Engineering, Yonsei University, Gangwon-do, Wonju 26493, Korea; (S.P.); (C.P.); (S.A.)
- Correspondence: (W.G.C.); (J.K.); Tel.: +82 337602857 (J.K.)
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Long B, Lentz S, Koyfman A, Gottlieb M. Evaluation and management of the critically ill adult asthmatic in the emergency department setting. Am J Emerg Med 2020; 44:441-451. [PMID: 32222313 DOI: 10.1016/j.ajem.2020.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management. OBJECTIVE This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma. DISCUSSION It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission. CONCLUSIONS This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, United States
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12
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Henriquez AR, Snow SJ, Schladweiler MC, Miller CN, Dye JA, Ledbetter AD, Richards JE, Hargrove MM, Williams WC, Kodavanti UP. Beta-2 Adrenergic and Glucocorticoid Receptor Agonists Modulate Ozone-Induced Pulmonary Protein Leakage and Inflammation in Healthy and Adrenalectomized Rats. Toxicol Sci 2019; 166:288-305. [PMID: 30379318 DOI: 10.1093/toxsci/kfy198] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We have shown that acute ozone inhalation activates sympathetic-adrenal-medullary and hypothalamus-pituitary-adrenal stress axes, and adrenalectomy (AD) inhibits ozone-induced lung injury and inflammation. Therefore, we hypothesized that stress hormone receptor agonists (β2 adrenergic-β2AR and glucocorticoid-GR) will restore the ozone injury phenotype in AD, while exacerbating effects in sham-surgery (SH) rats. Male Wistar Kyoto rats that underwent SH or AD were treated with vehicles (saline + corn oil) or β2AR agonist clenbuterol (CLEN, 0.2 mg/kg, i.p.) + GR agonist dexamethasone (DEX, 2 mg/kg, s.c.) for 1 day and immediately prior to each day of exposure to filtered air or ozone (0.8 ppm, 4 h/day for 1 or 2 days). Ozone-induced increases in PenH and peak-expiratory flow were exacerbated in CLEN+DEX-treated SH and AD rats. CLEN+DEX affected breath waveform in all rats. Ozone exposure in vehicle-treated SH rats increased bronchoalveolar lavage fluid (BALF) protein, N-acetyl glucosaminidase activity (macrophage activation), neutrophils, and lung cytokine expression while reducing circulating lymphocyte subpopulations. AD reduced these ozone effects in vehicle-treated rats. At the doses used herein, CLEN+DEX treatment reversed the protection offered by AD and exacerbated most ozone-induced lung effects while diminishing circulating lymphocytes. CLEN+DEX in air-exposed SH rats also induced marked protein leakage and reduced circulating lymphocytes but did not increase BALF neutrophils. In conclusion, circulating stress hormones and their receptors mediate ozone-induced vascular leakage and inflammatory cell trafficking to the lung. Those receiving β2AR and GR agonists for chronic pulmonary diseases, or with increased circulating stress hormones due to psychosocial stresses, might have altered sensitivity to air pollution.
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Affiliation(s)
- Andres R Henriquez
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina 27599
| | - Samantha J Snow
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Mette C Schladweiler
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Colette N Miller
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Janice A Dye
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Allen D Ledbetter
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Judy E Richards
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Marie M Hargrove
- Oak Ridge Institute for Science and Education, Research Triangle Park, North Carolina 27709
| | - Wanda C Williams
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Urmila P Kodavanti
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
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Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management. J Clin Med 2019; 8:jcm8091283. [PMID: 31443563 PMCID: PMC6780340 DOI: 10.3390/jcm8091283] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.
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14
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Menzella F, Latorre M, Ruggiero P, Bagnasco D, Heffler E. Reduction of oral corticosteroids in patients with severe eosinophilic asthma treated with Benralizumab: could it represent a marker of treatment efficacy? Expert Opin Biol Ther 2019; 19:601-606. [PMID: 31033373 DOI: 10.1080/14712598.2019.1613367] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Subjects with severe Th2-high endotype usually respond to oral corticosteroids (OCS). However, they often require high dosages with incremental side effects and health-care costs. The advent of biological therapies provides an effective strategy to improve asthma control, as well as reduce OCS use. Various molecules have been developed, each targeting different pathways. We analyzed the two anti-IL-5 strategies, benralizumab and mepolizumab, based on pivotal trials (RCTs), mechanisms of action and their possible role on the steroid-sparing effect. Areas covered: This review analyzes the data from the benralizumab and mepolizumab RCTs, focusing on the advantages of each drug on clinical efficacy and the steroid-sparing effect. Expert opinion: Benralizumab may represent a promising therapeutic option in the treatment of eosinophilic asthma, due to its mechanism of action, which rapidly allows a reduction in the eosinophils' number, and a greater steroid-sparing effect.
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Affiliation(s)
- Francesco Menzella
- a Department of Medical Specialties, Pneumology Unit , Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia-IRCCS , Reggio Emilia , Italy
| | - Manuela Latorre
- b Department of Surgery, Medicine, Molecular Biology and Critical Care , University of Pisa , Pisa , Italy
| | - Patrizia Ruggiero
- a Department of Medical Specialties, Pneumology Unit , Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia-IRCCS , Reggio Emilia , Italy
| | - Diego Bagnasco
- c Allergy & Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Enrico Heffler
- d Personalized Medicine, Asthma and Allergy , Humanitas Research Hospital , Rozzano , Italy
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15
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Phungpanya C, Chaipuang A, Machan T, Watla-iad K, Thongpoon C, Suwantong O. Synthesis of prednisolone molecularly imprinted polymer nanoparticles by precipitation polymerization. POLYM ADVAN TECHNOL 2018. [DOI: 10.1002/pat.4428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Chalida Phungpanya
- School of Science; Mae Fah Luang University; Chiang Rai 57100 Thailand
- Center of Chemical Innovation for Sustainability; Mae Fah Luang University; Chiang Rai 57100 Thailand
| | - Angkana Chaipuang
- School of Science; Mae Fah Luang University; Chiang Rai 57100 Thailand
- Center of Chemical Innovation for Sustainability; Mae Fah Luang University; Chiang Rai 57100 Thailand
| | - Theeraphan Machan
- School of Science; Mae Fah Luang University; Chiang Rai 57100 Thailand
- Center of Chemical Innovation for Sustainability; Mae Fah Luang University; Chiang Rai 57100 Thailand
| | - Kanchana Watla-iad
- School of Science; Mae Fah Luang University; Chiang Rai 57100 Thailand
- Center of Chemical Innovation for Sustainability; Mae Fah Luang University; Chiang Rai 57100 Thailand
| | - Chalermporn Thongpoon
- Program of Chemistry, Faculty of Science and Technology; Pibulsongkram Rajabhat University; Phitsanulok 65000 Thailand
| | - Orawan Suwantong
- School of Science; Mae Fah Luang University; Chiang Rai 57100 Thailand
- Center of Chemical Innovation for Sustainability; Mae Fah Luang University; Chiang Rai 57100 Thailand
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16
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Castillo JR, Peters SP, Busse WW. Asthma Exacerbations: Pathogenesis, Prevention, and Treatment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:918-927. [PMID: 28689842 PMCID: PMC5950727 DOI: 10.1016/j.jaip.2017.05.001] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/27/2017] [Accepted: 05/08/2017] [Indexed: 11/25/2022]
Abstract
Guideline-based management of asthma focuses on disease severity and choosing the appropriate medical therapy to control symptoms and reduce the risk of exacerbations. However, irrespective of asthma severity and often despite optimal medical therapy, patients may experience acute exacerbations of symptoms and a loss of disease control. Asthma exacerbations are most commonly triggered by viral respiratory infections, particularly with human rhinovirus. Given the importance of these events to asthma morbidity and health care costs, we will review common inciting factors for asthma exacerbations and approaches to prevent and treat these events.
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Affiliation(s)
- Jamee R Castillo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stephen P Peters
- Wake Forest School of Medicine, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - William W Busse
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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17
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Melbye H, Al-Ani S, Spigt M. Drop in lung function during asthma and COPD exacerbations - can it be assessed without spirometry? Int J Chron Obstruct Pulmon Dis 2016; 11:3145-3152. [PMID: 27994453 PMCID: PMC5153253 DOI: 10.2147/copd.s123315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND When assessing patients with exacerbation of asthma or COPD, it may be useful to know the drop in forced expiratory volume in 1 second (FEV1) compared with stable state, in particular when considering treatment with oral corticosteroids. The objective of the study was to identify indicators of drop in FEV1 during exacerbations. METHODS In this prospective multicenter study from primary care, patients diagnosed with asthma or COPD were examined at stable state and during exacerbations the following year. Symptoms, chest findings, and pulse oximetry were recorded, and spirometry was performed. A fixed drop in FEV1 (10% and ≥200 mL) and percentage change in FEV1 were outcomes when possible indicators were evaluated. RESULTS Three hundred and eighty patients attended baseline examination, and 88 with a subsequent exacerbation were included in the analysis. Thirty (34%) had a significant drop in FEV1 (10% and 200 mL). Increased wheezing was the only symptom associated with this drop with a likelihood ratio of 6.4 (95% confidence interval, 1.9-21.7). Crackles and any new auscultation finding were also associated with a significant drop in FEV1, as was a ≥2% drop in oxygen saturation (SpO2) to ≤92% in the subgroup diagnosed with COPD. Very bothersome wheezing and severe decrease in SpO2 were also very strong predictors of change in FEV1 in linear regression adjusted for age, gender, and baseline FEV1% predicted. CONCLUSION Increased wheezing, as experienced by the patient, and a decreased SpO2 value strongly indicated a drop in lung function during asthma and COPD exacerbations and should probably be taken into account when treatment with oral corticosteroids is considered.
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Affiliation(s)
- Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, UIT The Arctic University of Norway, Tromsø, Norway
| | - Salwan Al-Ani
- General Practice Research Unit, Department of Community Medicine, UIT The Arctic University of Norway, Tromsø, Norway
| | - Mark Spigt
- General Practice Research Unit, Department of Community Medicine, UIT The Arctic University of Norway, Tromsø, Norway; Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands
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18
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Deshpande DR, Martinez FD. The dilemma of systemic steroids in preschool children with recurrent wheezing exacerbations. Pediatr Pulmonol 2016; 51:775-7. [PMID: 27158816 DOI: 10.1002/ppul.23465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 01/19/2023]
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19
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Jamieson KC, Warner SM, Leigh R, Proud D. Rhinovirus in the Pathogenesis and Clinical Course of Asthma. Chest 2016; 148:1508-1516. [PMID: 26270739 DOI: 10.1378/chest.15-1335] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
In healthy individuals, human rhinovirus (HRV) infections are the major cause of the common cold. These are generally uncomplicated infections except for occasional cases of otitis media or sinusitis. In individuals with asthma, however, HRV infections can have a major impact on disease development and progression. HRV-induced wheezing illnesses in early life are a significant risk factor for subsequent development of asthma, and growing evidence supports a role of recurrent HRV infections in the development and progression of several aspects of airway remodeling in asthma. In addition, HRV infections are one of the most common triggers for acute exacerbations of asthma, which represent a major burden to health-care systems around the world. None of the currently prescribed medications for asthma are effective in preventing or reversing asthma development and airway remodeling or are ideal for treating HRV-induced exacerbations of asthma. Thus, a better understanding of the role of HRV in asthma is important if we are to develop more effective therapies. In the past decade, we have gained new insights into the role of HRV infections in the development and progression of airway remodeling as well as a new appreciation for the proinflammatory and host defense responses to HRV infections that may help to regulate susceptibility to asthma exacerbations. This article reviews the current understanding of the role HRV infections play in the pathogenesis of asthma and identifies possible avenues to new therapeutic strategies for limiting the effects of HRV infections in asthma.
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Affiliation(s)
- Kyla C Jamieson
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephanie M Warner
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Richard Leigh
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Proud
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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20
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Raherison C, Bourdin A, Bonniaud P, Deslée G, Garcia G, Leroyer C, Taillé C, De Blic J, Dubus JC, Tillié-Leblond I, Chanez P. Updated guidelines (2015) for management and monitoring of adult and adolescent asthmatic patients (from 12 years and older) of the Société de Pneumologie de Langue Française (SPLF) (Full length text). Rev Mal Respir 2016; 33:279-325. [PMID: 27147308 DOI: 10.1016/j.rmr.2016.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C Raherison
- Inserm U1219, ISPED, service des maladies respiratoires, pôle cardio-thoracique, CHU de Bordeaux, université de Bordeaux, 33000 Bordeaux, France.
| | - A Bourdin
- Inserm U1046, département de pneumologie et addictologie, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, université Montpellier 1, 34000 Montpellier, France
| | - P Bonniaud
- Inserm U866, service de pneumologie et soins intensifs respiratoires, CHU de Bourgogne, université de Bourgogne, 21079 Dijon, France
| | - G Deslée
- Service de pneumologie, CHU Maison-Blanche, université de Reims - Champagne-Ardennes, 51000 Reims, France
| | - G Garcia
- Inserm, UMRS 999, service de pneumologie, département hospitalo-universitaire (DHU) thorax innovation, hôpital de Bicêtre, Centre national de référence de l'hypertension pulmonaire sévère, faculté de médecine, université Paris-Sud, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - C Leroyer
- Département de médecine interne et de pneumologie, CHU de la Cavale-Blanche, université de Bretagne Occidentale, 29000 Brest, France
| | - C Taillé
- Service de pneumologie, département hospitalo-universitaire FIRE, centre de compétence des maladies pulmonaires rares, hôpital Bichat, université Paris-Diderot, AP-HP, 75018 Paris, France
| | - J De Blic
- Service de pneumologie et allergologie pédiatriques, hôpital Necker-Enfants-Malades, 75743 Paris, France
| | - J-C Dubus
- Unité de pneumologie et médecine infantile, hôpital Nord, 13000 Marseille, France
| | - I Tillié-Leblond
- Service de pneumo-allergologie, CHRU de Lille, 59000 Lille, France
| | - P Chanez
- UMR 7333 Inserm U 1067, service de pneumologie, hôpital Nord, université Aix Marseille, AP-HM, 13000 Marseille, France
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21
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Abstract
Respiratory emergencies are 1 of the most common reasons parents seek evaluation for the their children in the emergency department (ED) each year, and respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients. Whereas many respiratory illnesses are mild and self-limiting, others are life threatening and require prompt diagnosis and management. Therefore, it is imperative that emergency clinicians be able to promptly recognize and manage these illnesses. This article reviews ED diagnosis and management of foreign body aspiration, asthma exacerbation, epiglottitis, bronchiolitis, community-acquired pneumonia, and pertussis.
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22
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Beigelman A, Bacharier LB. Management of Preschool Children with Recurrent Wheezing: Lessons from the NHLBI's Asthma Research Networks. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2016; 4:1-8; quiz 9-10. [PMID: 26772922 PMCID: PMC4715860 DOI: 10.1016/j.jaip.2015.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
Recurrent wheezing in the preschool children is a common clinical problem, often associated with significant morbidity related to acute episodes. The management of these children has been complicated by a paucity of high-quality clinical trials in this age group. To fill this knowledge gap, National Heart, Lung, and Blood Institute's asthma research networks have performed a series of clinical trials in an effort to provide practitioners with guidance on appropriate management strategies. These studies establish daily inhaled corticosteroid (ICS) therapy in toddlers at high risk for subsequent asthma as an effective approach for the prevention of exacerbations and symptom reduction, but without evidence of disease-modifying properties. Additional studies have confirmed substantial heterogeneity in ICS response, in terms of both efficacy and effect on linear growth. Treatment with intermittent high-dose ICS was demonstrated to be an alternative approach to daily low-dose ICS for preventing severe exacerbations in toddlers with intermittent but significant wheeze and a positive modified asthma predictive index. This review details the findings and clinical implications derived from these studies, discuss the utility of biomarkers and the role of oral corticosteroids during acute exacerbations, and summarizes ongoing clinical trials in this age group.
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Affiliation(s)
- Avraham Beigelman
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
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Leigh R, Proud D. Virus-induced modulation of lower airway diseases: pathogenesis and pharmacologic approaches to treatment. Pharmacol Ther 2014; 148:185-98. [PMID: 25550230 PMCID: PMC7173263 DOI: 10.1016/j.pharmthera.2014.12.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 02/08/2023]
Abstract
Uncomplicated upper respiratory viral infections are the most common cause of days lost from work and school and exert a major economic burden. In susceptible individuals, however, common respiratory viruses, particularly human rhinoviruses, also can have a major impact on diseases that involve the lower airways, including asthma, chronic obstructive pulmonary diseases (COPD) and cystic fibrosis (CF). Respiratory virus-induced wheezing illnesses in early life are a significant risk factor for the subsequent development of asthma, and virus infections may also play a role in the development and progression of airway remodeling in asthma. It is clear that upper respiratory tract virus infections can spread to the lower airway and trigger acute attacks of asthma, COPD or CF. These exacerbations can be life-threatening, and exert an enormous burden on health care systems. In recent years we have gained new insights into the mechanisms by which respiratory viruses may induce acute exacerbations of lower airway diseases, as well as into host defense pathways that may regulate the outcomes to viral infections. In the current article we review the role of viruses in lower airway diseases, including our current understanding on pathways by which they may cause remodeling and trigger acute exacerbations. We also review the efficacy of current and emerging therapies used to treat these lower airway diseases on the outcomes due to viral infection, and discuss alternative therapeutic approaches for the management of virus-induced airway inflammation.
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Affiliation(s)
- Richard Leigh
- Airway Inflammation Research Group, Snyder Institute for Chronic Diseases and Department of Medicine, University of Calgary Faculty of Medicine, Calgary, Canada; Airway Inflammation Research Group, Snyder Institute for Chronic Diseases and Department of Physiology & Pharmacology, University of Calgary Faculty of Medicine, Calgary, Canada
| | - David Proud
- Airway Inflammation Research Group, Snyder Institute for Chronic Diseases and Department of Physiology & Pharmacology, University of Calgary Faculty of Medicine, Calgary, Canada.
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24
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Alangari AA. Corticosteroids in the treatment of acute asthma. Ann Thorac Med 2014; 9:187-92. [PMID: 25276236 PMCID: PMC4166064 DOI: 10.4103/1817-1737.140120] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 03/10/2014] [Indexed: 01/25/2023] Open
Abstract
Asthma is a prevalent chronic disease of the respiratory system and acute asthma exacerbations are among the most common causes of presentation to the emergency department (ED) and admission to hospital particularly in children. Bronchial airways inflammation is the most prominent pathological feature of asthma. Inhaled corticosteroids (ICS), through their anti-inflammatory effects have been the mainstay of treatment of asthma for many years. Systemic and ICS are also used in the treatment of acute asthma exacerbations. Several international asthma management guidelines recommend the use of systemic corticosteroids in the management of moderate to severe acute asthma early upon presentation to the ED. On the other hand, ICS use in the management acute asthma has been studied in different contexts with encouraging results in some and negative in others. This review sheds some light on the role of systemic and ICS in the management of acute asthma and discusses the current evidence behind their different ways of application particularly in relation to new developments in the field.
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Affiliation(s)
- Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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25
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Vézina K, Chauhan BF, Ducharme FM. Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital. Cochrane Database Syst Rev 2014; 2014:CD010283. [PMID: 25080126 PMCID: PMC10772940 DOI: 10.1002/14651858.cd010283.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Inhaled anticholinergics given in addition to β2-agonists are effective in reducing hospital admissions in children presenting to the emergency department with a moderate to severe asthma exacerbation. It seems logical to assume a similar beneficial effect in children hospitalised for an acute asthma exacerbation. OBJECTIVES To assess the efficacy and safety of anticholinergics added to β2-agonists as inhaled or nebulised therapy in children hospitalised for an acute asthma exacerbation. To investigate the characteristics of patients or therapy, if any, that would influence the magnitude of response attributable to the addition of anticholinergics. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO and through handsearching of respiratory journals and meeting abstracts. The search is current to November 2013. SELECTION CRITERIA Randomised trials comparing the combination of inhaled or nebulised anticholinergics and short-acting β2-agonists versus short-acting β2-agonists alone in children one to 18 years of age hospitalised for an acute asthma exacerbation were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the methodological quality of trials and extracted data; disagreement was resolved by consensus or with the input of a third review author, when needed. Primary outcomes were duration of hospital stay and serious adverse events. Secondary outcomes included admission and duration of stay in the intensive care unit (ICU), ventilation assistance, time to short-acting β2-agonists spaced at four hours or longer, supplemental asthma therapy, duration of supplemental oxygen, change from baseline in asthma severity, relapse after discharge, adverse health effects and withdrawals. MAIN RESULTS Seven randomised trials were included, four of which reported usable data on 472 children with asthma one to 18 years of age who were admitted to paediatric wards. No trials included patients admitted to the ICU. The anticholinergic used, ipratropium bromide 250 μg, was given every one to eight hours over a period from four hours to the entire length of the hospital stay. Two of four trials (50%) contributing data were deemed of high methodological quality. The addition of anticholinergics to β2-agonists showed no evidence of effect on the duration of hospital admission (mean difference (MD) -0.28 hours, 95% confidence interval (CI) -5.07 to 4.52, 3 studies, 327 participants, moderate quality evidence) and no serious or non-serious adverse events were reported in any included trials. As a result of the similarity of trials, we could not explore the influence of age, admission site, intensity of anticholinergic treatment and co-interventions on primary outcomes. No statistically significant group difference was noted in other secondary outcomes, including the need for supplemental asthma therapy, time to short-acting β2-agonists spaced at four hours or longer, asthma clinical scores, lung function and overall withdrawals for any reason. AUTHORS' CONCLUSIONS In children hospitalised for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulised anticholinergics were added to short-acting β2-agonists. No adverse health effects were reported, yet the small number of trials combined with inadequate reporting prevent firm reassurance regarding the safety of anticholinergics. In the absence of trials conducted in ICUs, no conclusion can be drawn regarding children with impending respiratory failure. These findings support current national and international recommendations indicating that healthcare practitioners should refrain from using anticholinergics in children hospitalised for acute asthma.
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Affiliation(s)
- Kevin Vézina
- CHU Sainte‐JustineDepartment of PediatricsMontrealQCCanada
| | - Bhupendrasinh F Chauhan
- Research Centre, CHU Sainte‐JustineClinical Research Unit on Childhood Asthma3175, Cote Sainte‐CatherineMontrealQCCanada
| | - Francine M Ducharme
- University of MontrealDepartment of PaediatricsMontrealQCCanada
- CHU Sainte‐JustineResearch CentreMontrealCanada
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26
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Beigelman A, Bacharier LB. Infection-induced wheezing in young children. J Allergy Clin Immunol 2014; 133:603-4. [PMID: 24636478 DOI: 10.1016/j.jaci.2013.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/26/2013] [Accepted: 12/04/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo.
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27
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Abstract
Critical asthma syndrome represents the most severe subset of asthma exacerbations, and the critical asthma syndrome is an umbrella term for life-threatening asthma, status asthmaticus, and near-fatal asthma. According to the 2007 National Asthma Education and Prevention Program guidelines, a life-threatening asthma exacerbation is marked by an inability to speak, a reduced peak expiratory flow rate of <25 % of a patient's personal best, and a failed response to frequent bronchodilator administration and intravenous steroids. Almost all critical asthma syndrome cases require emergency care, and most cases require hospitalization, often in an intensive care unit. Among asthmatics, those with the critical asthma syndrome are difficult to manage and there is little room for error. Patients with the critical asthma syndrome are prone to complications, they utilize immense resources, and they incite anxiety in many care providers. Managing this syndrome is anything but routine, and it requires attention, alacrity, and accuracy. The specific management strategies of adults with the critical asthma syndrome in the hospital with a focus on intensive care are discussed. Topics include the initial assessment for critical illness, initial ventilation management, hemodynamic issues, novel diagnostic tools and interventions, and common pitfalls. We highlight the use of critical care ultrasound, and we provide practical guidelines on how to manage deteriorating patients such as those with pneumothoraces. When standard asthma management fails, we provide experience-driven recommendations coupled with available evidence to guide the care team through advanced treatment. Though we do not discuss medications in detail, we highlight recent advances.
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Affiliation(s)
- Michael Schivo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis, 4150 V Street, PSSB 3400, Sacramento, CA, 95817, USA,
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Redman E, Powell C. Question 1: Prednisolone or dexamethasone for acute exacerbations of asthma: do they have similar efficacy in the management of exacerbations of childhood asthma? Arch Dis Child 2013; 98:916-9. [PMID: 24123403 DOI: 10.1136/archdischild-2013-304937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Elisabeth Redman
- Department of Child Health, Noah's Ark Children's Hospital for Wales, Cardiff University, , Cardiff, Wales, UK
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Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing? J Allergy Clin Immunol 2013; 131:1518-25. [PMID: 23498594 DOI: 10.1016/j.jaci.2013.01.034] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 01/22/2013] [Accepted: 01/25/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Oral corticosteroids (OCSs) are recommended for severe wheezing episodes in children. However, limited evidence supports this intervention in preschool children with outpatient wheezing illnesses. OBJECTIVE We sought to investigate whether OCSs reduce symptom scores during acute lower respiratory tract illnesses (LRTIs) in preschool children with recurrent wheeze. METHODS We performed post hoc and replication analyses in 2 outpatient cohorts of children aged 1 to 5 years with episodic wheezing participating in clinical trials. We compared symptom scores during LRTIs that were or were not treated with OCSs, adjusting for differences in disease and episode severity covariates. We stratified episodes by severity by using a propensity model. The primary outcome was the area under the curve (AUC) of total symptom scores among the more severe episodes. RESULTS Two hundred fifteen participants from the Acute Intervention Management Strategies trial experienced 798 acute LRTIs, 112 of which were defined as severe based on propensity scores. The AUCs of total symptom scores did not differ between the episodes that were (n = 70) and were not (n = 42) treated with OCSs (P = .46) nor was there an OCS treatment effect on individual symptom scores. Similar analyses of the Maintenance Versus Intermittent Inhaled Corticosteroids in Wheezing Toddlers trial, involving 278 participants with 133 severe LRTIs, confirmed the above findings (P = .46 for AUC of total symptoms score comparison). CONCLUSION In 2 separate cohorts of preschool children with episodic wheezing, OCS treatment during clinically significant LRTIs did not reduce symptom severity during acute LRTIs, despite asthma controller medication use during most episodes. These findings need to be confirmed in a prospective randomized controlled trial.
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Adams JY, Sutter ME, Albertson TE. The patient with asthma in the emergency department. Clin Rev Allergy Immunol 2013; 43:14-29. [PMID: 21597902 DOI: 10.1007/s12016-011-8273-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma is a highly prevalent disease that presents commonly to the emergency department (ED) in acute exacerbation. Recent asthma treatment guidelines have added content dedicated to the management of acute exacerbations. Effective management of an exacerbation requires rapid assessment of severity through physical examination, measurement of peak expiratory flow rate, and response to initial treatment. Most therapies are directed at alleviating bronchospasm and decreasing airway inflammation. While inhaled short-acting beta-agonists, systemic corticosteroids, and supplemental oxygen are the initial and often only therapies required for patients with mild moderate exacerbations, high-dose beta agonists and inhaled anti-cholinergics should also be given to patients with severe exacerbations. Adjunctive therapy with intravenous magnesium and Heliox-driven nebulization of bronchodilators should be considered for patients presenting with severe and very severe exacerbations. Early recognition and appropriate management of respiratory failure are required to mitigate the risk of complications including death. Disposition should be determined based on serial assessments of the response to therapy over the first 4 h in the ED. Patients stable for discharge should receive medications, asthma education including a written asthma action plan, and should have follow-up scheduled for them by ED staff. Rapid implementation of evidence-based, multi-disciplinary care is required to ensure the best possible outcomes for this potentially treatable disease.
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Affiliation(s)
- Jason Y Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California Davis Medical Center, 4150 V Street, Sacramento, CA 95817, USA.
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31
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Mourad ST, Elganady AA, Mohamed EE, Elgammal AM. Assessment of the effect of implementation of global initiatives for asthma (GINA) guidelines in the outcome of asthma exacerbation in the emergency department. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.
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Affiliation(s)
- Joseph Choi
- McGill University FRCP Emergency Medicine Residency Program, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.62, Montreal, Quebec, Canada H3A 1A1.
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33
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Wang XF, Hong JG. Management of severe asthma exacerbation in children. World J Pediatr 2011; 7:293-301. [PMID: 22015722 DOI: 10.1007/s12519-011-0325-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 03/28/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND Asthma is a common disease in children and acute severe asthma exacerbation can be life-threatening. This article aims to review recent advances in understanding of risk factors, pathophysiology, diagnosis and treatment of severe asthma exacerbation in children. DATA SOURCES Articles concerning severe asthma exacerbation in children were retrieved from PubMed. Literatures were searched with MeSH words "asthma", "children", "severe asthma exacerbation" and relevant cross references. RESULTS Severe asthma exacerbation in children requires aggressive treatments with β2-agonists, anticholinergics, and corticosteroids. Early initiation of inhaled β-agonists and systemic use of steroids are recommended. Other agents such as magnesium and aminophylline have some therapeutic benefits. When intubation and mechanical ventilation are needed, low tidal volume, controlled hypoventilation with lower-than-traditional respiratory rates and permissive hypercapnia can be applied. CONCLUSIONS Researchers should continue to detect the risk factors, pathophysiology, diagnosis and treatment of severe asthma exacerbation in children. More studies especially randomized controlled trials are required to evaluate the efficacy and safety of standard and new therapies.
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Affiliation(s)
- Xiao-Fang Wang
- Department of Pediatrics, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai 200080, China
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34
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Managing pediatric asthma exacerbations in the ED. Am J Nurs 2011; 111:48-53. [PMID: 21270585 DOI: 10.1097/01.naj.0000394293.78448.2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kravitz J, Dominici P, Ufberg J, Fisher J, Giraldo P. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Ann Emerg Med 2011; 58:200-4. [PMID: 21334098 DOI: 10.1016/j.annemergmed.2011.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 01/05/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone. METHODS We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up. RESULTS Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval -7% to 11%, P=.67). CONCLUSION In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.
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Affiliation(s)
- Joel Kravitz
- Department of Emergency Medicine, Community Medical Center, St. Barnabas Health System, Toms River, NJ 08755, USA.
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36
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Ducharme FM, Ochs HD, Resendes S, Zhang X, Mazer BD. A Short Burst of Oral Corticosteroid for Children with Acute Asthma: Is There an Impact on Immunity? PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010. [DOI: 10.1089/ped.2010.0041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Francine M. Ducharme
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
- Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Hans D. Ochs
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Sandy Resendes
- Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Xun Zhang
- Research Institute, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Bruce D. Mazer
- Service of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
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Lin JL, Bonnichsen MH, Nogeh EU, Raftery MJ, Thomas PS. Proteomics in detection and monitoring of asthma and smoking-related lung diseases. Expert Rev Proteomics 2010; 7:361-72. [PMID: 20536308 DOI: 10.1586/epr.10.9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Asthma, chronic obstructive pulmonary disease (COPD) and lung cancer cause extensive mortality and morbidity worldwide. However, the current state-of-the-art diagnosis and management schemes of these diseases are suboptimal as the incidence of asthma has risen by 250% over the last two decades and the 5-year mortality rate of lung cancer remains at 88%. Proteomic analysis is at the frontier of medical research and demonstrates tremendous potential in the early detection, diagnosis and staging, as well as providing novel therapeutic targets for improved management of smoking-related lung diseases. Advances in analytical tools, such as 2D gel electrophoresis, mass spectrometry, protein arrays and improved bioinformatics, allow sensitive and specific biomarker/protein profile discoveries and the infusion of new knowledge towards the molecular basis of lung diseases and their progression. Significant hurdles still stand between these laboratory findings and their applications in clinical practice. One of the challenges is the difficulty in the selection of samples that provide scope into the specific disease entity. Induced sputum, bronchoalveolar lavage, exhaled breath and exhaled breath condensate are methods of sampling airway and lung fluids that can serve as a window to assess the microenvironment of the lungs. With better study design standardization and the implementation of novel technologies to reach the optimal research standard, there is enough reason be optimistic about the future of proteomic research and its clinical implications.
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Affiliation(s)
- Jiun-Lih Lin
- Faculty of Medicine, University of New South Wales, Sydney, Australia
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Ducharme FM, Zemek RL, Chalut D, McGillivray D, Noya FJD, Resendes S, Khomenko L, Rouleau R, Zhang X. Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control. Am J Respir Crit Care Med 2010; 183:195-203. [PMID: 20802165 DOI: 10.1164/rccm.201001-0115oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial. OBJECTIVES We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department. METHODS We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control. MEASUREMENTS AND MAIN RESULTS Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes. CONCLUSIONS Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).
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Affiliation(s)
- Stephen C Lazarus
- Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143-0111, USA.
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40
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Abstract
Proteomic approaches have already been successfully implemented in areas such as cancer research. Surprisingly, only a few proteomics analyses have been published reporting on the protein profiles associated with asthma. Although proteomics has its limitations and experimental challenges, it can successfully contribute to the understanding of a complex disease such as asthma. We have reviewed the current literature that has reported the use of proteomic techniques to identify proteins that may contribute to altered lung function in asthma. Only a few of these studies have used proteomic techniques on human tissues associated with asthma, while most research has been performed with animal models of asthma. Proteomic applications have been used as a complimentary technique to verify the suspected candidate proteins involved in asthma. In addition, novel proteins have been identified as potential therapeutic targets. Future collaboration between the different scientific disciplines using proteomic studies of animal models of asthma and confirmation of these findings in human tissues will significantly contribute to the understanding of the etiology of asthma and lead to the development of new therapeutic strategies for this highly prevalent disease.
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Affiliation(s)
- Annette Osei-Kumah
- Discipline of Obstetrics and Gynaecology, School of Paediatrics and Reproductive Health, University of Adelaide, SA 5005, Australia.
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41
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Camargo CA, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. J Emerg Med 2009; 37:S6-S17. [PMID: 19683665 DOI: 10.1016/j.jemermed.2009.06.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Carlos A Camargo
- Department of Emergency Medicine and Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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42
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Krishnan JA, Nowak R, Davis SQ, Schatz M. Anti-inflammatory treatment after discharge home from the emergency department in adults with acute asthma. J Emerg Med 2009; 37:S35-41. [PMID: 19683663 DOI: 10.1016/j.jemermed.2009.06.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jerry A Krishnan
- Asthma and COPD Center, Department of Medicine, and Department of Health Studies, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA.
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43
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Hung GR. Principles of managing children with asthma in the emergency department. Paediatr Child Health 2007; 12:479-481. [PMID: 19030412 DOI: 10.1093/pch/12.6.479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2007] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION: Paediatric asthma exacerbations comprise a significant portion of emergency department (ED) visits and hospitalizations. Recognition of diagnostic symptoms and signs, and timely use of appropriate medications may reduce the need of hospitalizations and the impact of this disease on the lives of children and their families. OBJECTIVE: To review the pathophysiology of asthma, the current recommendations for conventional medical treatment in the ED, the controversies surrounding adjunct therapies, and the importance of discharge planning and follow-up. CONCLUSIONS: Paediatric asthma exacerbations may be successfully treated in the ED with the use of appropriate inhaled and systemic medications.
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Affiliation(s)
- Geoffrey R Hung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia
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44
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A model protocol for emergency medical services management of asthma exacerbations. PREHOSP EMERG CARE 2007; 10:418-29. [PMID: 16997769 DOI: 10.1080/10903120600884814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Emergency medical services (EMS) is an important part of the continuum of asthma management. The magnitude of the EMS responsibility is very large, with millions of patients with asthma treated each year by EMS personnel. In response to inconsistencies between the 1997 National Asthma Education and Prevention Program asthma guidelines and a variety of existing EMS protocols on the management of asthma exacerbations, the Centers for Disease Control and Prevention convened a workgroup in 2004 to discuss the various opportunities and challenges ahead. At the meeting, and over the ensuing year, the workgroup created a model protocol that was derived from the National Asthma Education and Prevention Program guidelines. The model protocol is available in both text and algorithm format and offers guidance for EMS systems to develop and implement treatment protocols in their local areas. The workgroup recommendations emphasize flexibility, simplicity, and low-risk practices. By integrating these recommendations into existing protocols, we believe that EMS systems could improve prehospital care for patients with asthma. Demonstration projects are needed to carefully examine the implementation process and the actual impact of the model protocol on various outcomes. The workgroup also encourages more research on EMS management of asthma exacerbations. In the meantime, improved collaboration between EMS and national asthma organizations is an immediate priority and will continue to advance future discussions on how to improve asthma management in the prehospital setting. The workgroup hopes that state and local EMS systems will see the value of the model protocol and encourage its use.
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Blake K. Review of guidelines and the literature in the treatment of acute bronchospasm in asthma. Pharmacotherapy 2007; 26:148S-55S. [PMID: 16945061 DOI: 10.1592/phco.26.9part2.148s] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Asthma is a common chronic condition that disproportionately affects persons younger than 45 years. Asthma exacerbations can be sudden and severe, requiring treatment in the emergency department or hospitalization. Children younger than 15 years are 2-4 times more likely to have asthma as the first-listed hospital discharge diagnosis compared with those in other age groups. An estimated 12.8 million missed school days and 24.5 million lost work days due to asthma occurred in 2003. Drugs used in the treatment of acute asthma include inhaled beta(2)-agonists, oral corticosteroids, and inhaled anticholinergics. Levalbuterol was evaluated in several recent trials for treatment of asthma in the emergency department, for its effect in improving pulmonary function and on hospitalization rate. Theophylline, intravenous beta(2)-agonists, intravenous magnesium sulfate, and inhaled anesthetics have not been proven useful in the emergency management of asthma. The effectiveness of inhalation devices is dependent on age, cooperation of the patient, and technique.
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Affiliation(s)
- Kathryn Blake
- Center for Clinical Pediatric Pharmacology Research, Nemours Children's Clinic, Jacksonville, Florida 32247, USA
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Volovitz B. Inhaled budesonide in the management of acute worsenings and exacerbations of asthma: a review of the evidence. Respir Med 2006; 101:685-95. [PMID: 17125984 DOI: 10.1016/j.rmed.2006.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Revised: 08/21/2006] [Accepted: 10/06/2006] [Indexed: 11/24/2022]
Abstract
The use of systemic corticosteroids, together with bronchodilators and oxygen therapy, has become established for the management of acute asthma. These agents are undoubtedly effective, but are also associated with problems such as metabolic adverse effects. Inhaled corticosteroids (ICS) offer potential benefit in the acute setting because they are delivered directly to the airways. They are also likely to reduce systemic exposure, which would lead in turn to reductions in rates of unwanted systemic effects. In order to evaluate the role of budesonide in the management of acute asthma exacerbations we conducted a review of the literature and critically evaluated the rationale for the use of ICS in general in this setting. Trials in adults and children requiring treatment for acute exacerbation of asthma have shown clinical and/or spirometric benefit for budesonide when delivered via nebulizer, dry powder inhaler, or aerosol in the emergency department, hospital and follow-up settings. The efficacy seems to benefit from high doses given repeatedly during the initial phase of an acute exacerbation. These acute effects are likely to be linked to the drug's distinctive pharmacokinetic and pharmacodynamic profile. The current evidence base revealed encouraging results regarding the efficacy of the ICS budesonide in patients with wheeze and acute worsening of asthma. Future studies should focus on the efficacy of these agents in more severe asthma worsenings.
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Affiliation(s)
- Benjamin Volovitz
- Paediatric Asthma Clinic and Asthma Research Laboratories, Schneider Children's Medical Center, 14 Kaplan Street, Petach Tikva, 49202 Israel.
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47
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Vondracek SF, Hemstreet BA. Is there an optimal corticosteroid regimen for the management of an acute exacerbation of chronic obstructive pulmonary disease? Pharmacotherapy 2006; 26:522-32. [PMID: 16553512 DOI: 10.1592/phco.26.4.522] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Systemic corticosteroids are standard of care for the management of an acute exacerbation of chronic obstructive pulmonary disease (COPD). Several prospective, randomized trials demonstrated modest improvements in patient outcomes when short courses of systemic corticosteroids were used. However, the most appropriate dosage regimen remains controversial, as the corticosteroid regimens used in these trials differed greatly, and no studies have directly compared medium-, high-, and low-dose regimens. In addition, data are lacking on the safety, efficacy, and appropriate dosing of systemic corticosteroids in women and in patients with an acute exacerbation of COPD and concomitant pneumonia or severe respiratory failure. Systemic corticosteroid use is associated with several adverse effects that are dose and/or duration dependent. Evidence suggests that higher dose corticosteroid regimens may place patients at increased short-term and long-term risk, without additional clinical benefit. Tapering of systemic corticosteroid regimens, although a common practice, is unnecessary in most circumstances. The risk for hypothalamic-pituitary-adrenal-axis suppression is negligible when low-dose, short-course corticosteroid regimens are used, and no evidence exists to suggest that abruptly stopping a low-dose steroid regimen will increase the risk of disease relapse. Still, no studies have directly compared tapered and non-tapered regimens in patients with an acute exacerbation of COPD. Consistent with clinical guideline recommendations, safety and efficacy data support the use of low-dose corticosteroid regimens such as prednisone 40 mg orally once/day for 10-14 days in most patients with an acute exacerbation of COPD. Further studies are needed to clarify the optimal systemic corticosteroid regimen for an acute exacerbation of COPD.
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Affiliation(s)
- Sheryl F Vondracek
- Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80262, USA.
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Abstract
Acute exacerbations of asthma may represent reactions to airway irritants or failures of chronic treatment. The costs to both the patient and society are high. Exacerbations often are frightening episodes that can cause significant morbidity and sometimes death. The emergency department (ED) visits and hospitalizations often required lead to significant health care expenses. Thus, preventing and optimizing management of acute exacerbations is critical. Corticosteroids are a cornerstone of asthma therapy. They have been shown to lower admission rates and reduce risk of relapse. This article provides an overview of the role of corticosteroids (including betamethasone, dexamethasone, methylprednisolone, and prednisolone) in the management of acute asthma exacerbations, with an aim toward effective decision making about the choice of therapy.
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Affiliation(s)
- Stanley B Fiel
- Department of Medicine, Morristown Memorial Hospital, Morristown, New Jersey, USA.
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49
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Vondracek SF, Hemstreet BA. Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm 2006; 63:645-52. [PMID: 16554288 DOI: 10.2146/ajhp050316] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The use of systemic corticosteroids for the management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) was studied. METHODS Medical charts of patients admitted to the hospital between July 2002 and November 2003 with a primary diagnosis of AECOPD were retrospectively reviewed. The primary objective was to characterize the drug, dosage, route, frequency, and duration of systemic corticosteroids prescribed for the management of AECOPD. The secondary objective was to compare the mean length of stay (LOS) and 30-day relapse rate between patients who received lower and higher dosages of corticosteroids. RESULTS One hundred forty-five admissions (123 patients) for AECOPD (mean +/- S.D. age, 65 +/- 11 years) were evaluated. Higher dosages of systemic corticosteroids (>80 mg of prednisone equivalent [PE] per day) were prescribed for 51% and i.v. therapy for 56% of admissions. The mean +/- S.D. total systemic corticosteroid exposure during hospitalization for all admissions was 759 +/- 971 mg of PE (mean +/- S.D. daily exposure = 134 +/- 111 mg of PE per day). The mean LOS was significantly longer for the higher-dosage group than for the lower-dosage group (6.1 versus 4.2 days, p = 0.0004). A tapered regimen was prescribed for 79% of discharges. Twenty-seven percent of the discharges with routine follow-up care had a relapse of disease within 30 days. CONCLUSION This retrospective observational study confirmed a wide variability in the dosages of systemic corticosteroids for the inpatient management of AECOPD, including the use of higher dosages and tapered regimens. Prospective randomized studies are needed to determine the most effective regimen of systemic corticosteroids in patients with AECOPD.
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Affiliation(s)
- Sheryl F Vondracek
- Department of Clinical Pharmacy, University of Colorado Health Sciences Center, 4200 E. Ninth Avenue, Denver, CO 80262, USA.
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Joye F, Marion F, Broche C, Plaisance P, Guitteny S. [Management of severe acute asthma in adults]. Presse Med 2005; 34:1375-83. [PMID: 16292191 DOI: 10.1016/s0755-4982(05)84195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Any life-threatening episode of asthma requires early pre-hospital specialized medical management by emergency medical crews. Gravity depends on both clinical criteria and a peak expiratory flow rate (PEFR) more than 30% below either the level predicted by the reference graph or the patient's reference value. Initial treatment combines continuous nebulizations containing a beta2-agonist and ipratropium bromide, with oxygen administration and intravenous corticosteroid bolus. Recommended as second-line treatment in the absence of adequate response are: intravenous magnesium sulphate and continuous-perfusion beta2-agonists (electric syringe), or, in the case of shock, epinephrine. If mechanical ventilation is required, its settings should aim for low tidal volumes, low frequency, and increased expiratory time.
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Affiliation(s)
- F Joye
- Service Samu 11 - Smurs - SAU - Cesu 11, Centre Hospitalier Antoine Gayraud, Carcassonne.
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