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Borsi SH, Shoushtari MH, Raji H, Nezhad HH, Mal-Amir MD. The Efficacy of Daily Administration of Nebulized Heparin on the Prevention of Endotracheal Tube Blockage in Patients With Pneumonia. Cureus 2024; 16:e53244. [PMID: 38425613 PMCID: PMC10903965 DOI: 10.7759/cureus.53244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE Nosocomial infections pose a significant public health concern, impacting over 100 million people worldwide annually. Within this research, we investigated heparin nebulization through the endotracheal tube and its effect on preventing blockage due to clots and mucus plugs compared to normal saline. METHODS A double-blind clinical experiment was done on a cohort of 40 pneumonia patients who were intubated and hospitalized in the intensive care unit (ICU) at Imam Khomeini Hospital in Ahvaz, Iran. The individuals were randomly assigned to two groups of 20 patients using a random allocation technique. The initial cohort was administered 5000 IU of heparin diluted in 4 ccs of 0.9% normal saline every eight hours via a nebulizer through a tracheal tube. In contrast, the second cohort was given 5 ccs of normal saline as a nebulizer through a tracheal tube. The study compared the incidence of tracheal tube obstruction caused by mucus plug or clot, the occurrence of patient hypoxia resulting in emergency tracheal tube replacement, and the frequency of emergency tracheal tube suction due to partial obstruction caused by mucus plug in both the heparin and saline groups. RESULTS According to our data, the number of patients in the heparin group who could avoid the need for emergency tracheal tube replacement owing to blockage was more significant than in the ordinary saline group (P=0.013). Heparin was significantly correlated with the number of times emergency suction was required to remove a tracheal tube occlusion (P=0.01). Heparin had no significant effect on coagulation factors (international normalized ratio [INR], platelet [PLT], and partial thromboplastin time [PTT]), Acute Physiology and Chronic Health Evaluation (APACHE) score, pneumonia severity index (PSI), saturation of patients, or tracheal tube secretions. There was no statistically significant difference in total time spent in the intensive care unit (P=0.91). CONCLUSIONS Further studies are suggested to determine the effect of heparin nebulization on preventing endotracheal tube obstruction due to clots and mucus plugs in intubated ICU patients.
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Affiliation(s)
- Seyed Hamid Borsi
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Maryam Haddadzadeh Shoushtari
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Hanieh Raji
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Hooshmand Hosseini Nezhad
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Mehrdad Dargahi Mal-Amir
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
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Zhang Y, Li Q, Sun C, Gu Y, Qi Z, Li J. The effect of nebulized heparin on clinical outcomes in mechanically ventilated patients: a meta-analysis and review of the literature. J Int Med Res 2023; 51:3000605231201340. [PMID: 37815327 PMCID: PMC10566280 DOI: 10.1177/03000605231201340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/29/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To determine the relationship between use of nebulized heparin and clinical outcomes in mechanically ventilated patients. METHODS The Medline, Embase, Web of Science, Cochrane Library, and PubMed databases were searched for relevant randomized controlled trials (RCTs), published between database inception and May 2022. Primary outcomes were intensive care unit (ICU) length of stay and in-hospital mortality; secondary outcomes included duration of mechanical ventilation, ventilator-free days (VFDs) in 28 days, and length of hospitalization. The study protocol was registered on PROSPERO (registration No: CRD42022345533). RESULTS A total of eight RCTs (651 patients) were included. Nebulized heparin was associated with reduced ICU length of stay (six studies; mean difference [MD] -1.10, 95% confidence interval [CI] -1.87, -0.33, I2 = 76%), reduced duration of mechanical ventilation (two studies; MD -2.63, 95% CI -3.68, -1.58, I2 = 92%) and increased VFDs in 28 days (two studies; MD 4.22, 95% CI 1.10, 7.35, I2 = 18%), without increased incidence of adverse events, such as bleeding; but was not associated with a reduction in length of hospitalization (three studies; MD -1.00, 95% CI -2.90, -0.90, I2 = 0%) or in-hospital mortality (five studies; odds ratio 1.10, 95% CI 0.69, 1.77, I2 = 0%). CONCLUSION Nebulized heparin reduces ICU length of stay and duration of mechanical ventilation in mechanically ventilated patients, but has no effect on length of hospitalization or mortality.
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Affiliation(s)
- Yi Zhang
- Department of Respiratory and Critical Care Medicine, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Qiankun Li
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Changan Sun
- Intensive Care Unit, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Yue Gu
- Department of Respiratory and Critical Care Medicine, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Zhijiang Qi
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China; National Centre for Respiratory Medicine, Beijing, China
| | - Jun Li
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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3
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Ashmawy R, Zaki A, Baess A, El Sayed I. Efficacy and safety of inhaled heparin in asthmatic and chronic obstructive pulmonary disease patients: a systematic review and a meta-analysis. Sci Rep 2023; 13:13326. [PMID: 37587208 PMCID: PMC10432425 DOI: 10.1038/s41598-023-40489-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/10/2023] [Indexed: 08/18/2023] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are prevalent chronic respiratory disorders that cause significant morbidity and mortality. Some studies evaluated the use of inhaled unfractionated heparin (UFH) in the treatment of asthma and COPD. We aimed to synthesize the available evidence for the efficacy and safety of inhaled heparin in improving lung functions among asthmatic and COPD patients. A comprehensive search was performed using Pubmed, Embase, EBSCO, Scopus, Web of Science, Cochrane CENTRAL, WHO Clinical trials, clinicaltrials.gov, Iranian Clinical trials, Google Scholar, Research Gate, ProQuest Thesis, OVID, and medRxiv databases. Two independent reviewers included all pertinent articles according to PRISMA guidelines, and extract data independently. The two reviewers checked the quality of studies using the ROB2 tool. To determine the pooled effect estimate of the efficacy and safety of inhaled heparin, a meta-analysis was carried out using the R programming language. Publication bias was evaluated using Egger's regression test. The heterogeneity was explained using a meta-regression, and the quality of evidence was assessed by the GRADE approach. Twenty-six studies with a total of 581 patients were included in the qualitative analysis and 16 in the meta-analysis. The primary outcome was treatment success (improvement of lung function) that was measured by standardized mean differences (SMD) of the forced expiratory volume per second (FEV1) either per ml or percentage. Heparin has a large effect on both FEV1% and FEV1 ml when compared to the control group (SMD 2.7, 95% CI 1.00; 4.39; GRADE high, SMD 2.12, 95% CI - 1.49; 5.72: GRADE moderate, respectively). Secondary outcomes are other lung functions improving parameters such as PC20 (SMD 0.91, 95% CI - 0.15; 1.96). Meta-regression and subgroup analysis show that heparin type, dose, year of publication, study design, and quality of studies had a substantial effect. Regarding safety, inhaled heparin showed a good coagulation profile and mild tolerable side effects. Inhaled heparin showed improvement in lung functions either alone or when added to standard care. More large parallel RCTs are needed including COPD patients, children, and other types, and stages of asthmatic patients.
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Affiliation(s)
- Rasha Ashmawy
- Department of Clinical Research, Maamora Chest Hospital, MoHP, Alexandria, Egypt
| | - Adel Zaki
- Department of Biomedical Informatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Ayman Baess
- Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Iman El Sayed
- Department of Biomedical Informatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt.
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4
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Shute JK. Heparin, Low Molecular Weight Heparin, and Non-Anticoagulant Derivatives for the Treatment of Inflammatory Lung Disease. Pharmaceuticals (Basel) 2023; 16:ph16040584. [PMID: 37111341 PMCID: PMC10141002 DOI: 10.3390/ph16040584] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Unfractionated heparin has multiple pharmacological activities beyond anticoagulation. These anti-inflammatory, anti-microbial, and mucoactive activities are shared in part by low molecular weight and non-anticoagulant heparin derivatives. Anti-inflammatory activities include inhibition of chemokine activity and cytokine synthesis, inhibitory effects on the mechanisms of adhesion and diapedesis involved in neutrophil recruitment, inhibition of heparanase activity, inhibition of the proteases of the coagulation and complement cascades, inhibition of neutrophil elastase activity, neutralisation of toxic basic histones, and inhibition of HMGB1 activity. This review considers the potential for heparin and its derivatives to treat inflammatory lung disease, including COVID-19, ALI, ARDS, cystic fibrosis, asthma, and COPD via the inhaled route.
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Affiliation(s)
- Janis Kay Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth PO1 2UP, UK
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5
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Ntiamoah P, Mukhopadhyay S, Ghosh S, Mehta AC. Recycling plastic: diagnosis and management of plastic bronchitis among adults. Eur Respir Rev 2021; 30:30/161/210096. [PMID: 34407979 DOI: 10.1183/16000617.0096-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/26/2021] [Indexed: 11/05/2022] Open
Abstract
Plastic bronchitis is a rare, underdiagnosed and potentially fatal condition. It is characterised by the formation and expectoration of branching gelatinous plugs that assume the shape of the airways. These airway plugs differ from the allergic mucin that characterises allergic bronchopulmonary aspergillosis and mucoid impaction of the bronchi. Plastic bronchitis is most often encountered in the paediatric population following corrective cardiac surgery, such as the Fontan procedure. It also occurs in adults. Plastic bronchitis in adults is rare, heterogeneous in its aetiology, and can lead to respiratory distress or even life-threatening airway obstruction. Plastic bronchitis in adulthood should not be overlooked, particularly in patients with chronic inflammatory lung diseases. This review presents current understanding of the presentation, aetiology, pathogenesis, pathology and management of plastic bronchitis in adults.
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Affiliation(s)
- Prince Ntiamoah
- Dept of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Subha Ghosh
- Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Atul C Mehta
- Dept of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
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6
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Conzelmann C, Müller JA, Perkhofer L, Sparrer KM, Zelikin AN, Münch J, Kleger A. Inhaled and systemic heparin as a repurposed direct antiviral drug for prevention and treatment of COVID-19. Clin Med (Lond) 2020; 20:e218-e221. [PMID: 32863274 PMCID: PMC7687307 DOI: 10.7861/clinmed.2020-0351] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Here, we advocate a highly favourable opportunity for the treatment of COVID-19 disease by repurposing a long-serving medical agent with an excellent history of clinical use, namely heparin. Heparin is best known as an anticoagulant, but it also exhibits direct antiviral activity against many enveloped viruses and has anti-inflammatory activity. The high incidence of thromboembolic events in COVID-19 patients suggests that coagulopathy plays an important role in the SARS-CoV-2 pathogenesis. This already makes heparin a unique, potentially curative agent that can be used immediately to help resolve the ongoing crisis associated with SARS-CoV-2 infection and COVID-19 disease. We demonstrate here in vitro that heparin does indeed inhibit SARS-CoV-2 infection. The three concurrent modes of activity of heparin (antiviral, anticoagulant and anti-inflammatory) against SARS-CoV-2/COVID-19 form a unique therapeutic combination. Thus, repurposing of heparin to fight SARS-CoV-2 and COVID-19 appears to be a powerful, readily available measure to address the current pandemic.
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Affiliation(s)
- Carina Conzelmann
- Institute of Molecular Virology, Ulm University Medical Centre, Ulm, Germany
- *equal contributions
| | - Janis A Müller
- Institute of Molecular Virology, Ulm University Medical Centre, Ulm, Germany
- *equal contributions
| | - Lukas Perkhofer
- Department of Internal Medicine, Ulm University Hospital, Ulm, Germany
| | | | - Alexander N Zelikin
- Department of Chemistry and iNano Interdisciplinary Nanoscience Centre, Aarhus University, Aarhus, Denmark
- #equal contribution and joint supervision
| | - Jan Münch
- Institute of Molecular Virology, Ulm University Medical Centre, Ulm, Germany
| | - Alexander Kleger
- Department of Internal Medicine, Ulm University Hospital, Ulm, Germany
- #equal contribution and joint supervision
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7
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van Haren FMP, Page C, Laffey JG, Artigas A, Camprubi-Rimblas M, Nunes Q, Smith R, Shute J, Carroll M, Tree J, Carroll M, Singh D, Wilkinson T, Dixon B. Nebulised heparin as a treatment for COVID-19: scientific rationale and a call for randomised evidence. Crit Care 2020; 24:454. [PMID: 32698853 PMCID: PMC7374660 DOI: 10.1186/s13054-020-03148-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 12/16/2022] Open
Abstract
Nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale and warrants urgent investigation of its therapeutic potential, for COVID-19-induced acute respiratory distress syndrome (ARDS). COVID-19 ARDS displays the typical features of diffuse alveolar damage with extensive pulmonary coagulation activation resulting in fibrin deposition in the microvasculature and formation of hyaline membranes in the air sacs. Patients infected with SARS-CoV-2 who manifest severe disease have high levels of inflammatory cytokines in plasma and bronchoalveolar lavage fluid and significant coagulopathy. There is a strong association between the extent of the coagulopathy and poor clinical outcomes.The anti-coagulant actions of nebulised UFH limit fibrin deposition and microvascular thrombosis. Trials in patients with acute lung injury and related conditions found inhaled UFH reduced pulmonary dead space, coagulation activation, microvascular thrombosis and clinical deterioration, resulting in increased time free of ventilatory support. In addition, UFH has anti-inflammatory, mucolytic and anti-viral properties and, specifically, has been shown to inactivate the SARS-CoV-2 virus and prevent its entry into mammalian cells, thereby inhibiting pulmonary infection by SARS-CoV-2. Furthermore, clinical studies have shown that inhaled UFH safely improves outcomes in other inflammatory respiratory diseases and also acts as an effective mucolytic in sputum-producing respiratory patients. UFH is widely available and inexpensive, which may make this treatment also accessible for low- and middle-income countries.These potentially important therapeutic properties of nebulised UFH underline the need for expedited large-scale clinical trials to test its potential to reduce mortality in COVID-19 patients.
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Affiliation(s)
- Frank M P van Haren
- Australian National University, Medical School, Canberra, Australia.
- Intensive Care Unit, the Canberra Hospital, Canberra, Australia.
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Antonio Artigas
- Critical Center, Corporació Sanitaria Parc Tauli , CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - Marta Camprubi-Rimblas
- Institut d'Investigació I Innovació Parc Tauli (I3PT), CIBER de Enfermedades Respiratorias, Sabadell, Spain
| | - Quentin Nunes
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Roger Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Janis Shute
- School of Pharmacy and Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - Mary Carroll
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Julia Tree
- National Infection Service, Public Health England, Porton Down, UK
| | - Miles Carroll
- National Infection Service, Public Health England, Porton Down, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Barry Dixon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
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8
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Guo B, Bai Y, Ma Y, Liu C, Wang S, Zhao R, Dong J, Ji HL. Preclinical and clinical studies of smoke-inhalation-induced acute lung injury: update on both pathogenesis and innovative therapy. Ther Adv Respir Dis 2019; 13:1753466619847901. [PMID: 31068086 PMCID: PMC6515845 DOI: 10.1177/1753466619847901] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Smoke-inhalation-induced acute lung injury (SI-ALI) is a leading cause of morbidity and mortality in victims of fire tragedies. SI-ALI contributes to an estimated 30% of burn-caused patient deaths, and recently, more attention has been paid to the specific interventions for this devastating respiratory illness. In the last decade, much progress has been made in the understanding of SI-ALI patho-mechanisms and in the development of new therapeutic strategies in both preclinical and clinical studies. This article reviews the recent progress in the treatment of SI-ALI, based on pathophysiology, thermal damage, airway obstruction, the nuclear-factor kappa-B signaling pathway, and oxidative stress. Preclinical therapeutic strategies include use of mesenchymal stem cells, hydrogen sulfide, peroxynitrite decomposition catalysts, and proton-pump inhibitors. Clinical interventions include high-frequency percussive ventilation, perfluorohexane, inhaled anticoagulants, and nebulized epinephrine. The animal model, dose, clinical application, and pharmacology of these medications are summarized. Future directions and further needs for developing innovative therapies are discussed.
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Affiliation(s)
- Bingxin Guo
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Yichun Bai
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Yana Ma
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Cong Liu
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Song Wang
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Runzhen Zhao
- Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Jiaxing Dong
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Hong-Long Ji
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler, Tyler, TX, USA
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9
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Shute JK, Puxeddu E, Calzetta L. Therapeutic use of heparin and derivatives beyond anticoagulation in patients with bronchial asthma or COPD. Curr Opin Pharmacol 2018; 40:39-45. [PMID: 29455115 DOI: 10.1016/j.coph.2018.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/23/2018] [Accepted: 01/25/2018] [Indexed: 02/06/2023]
Abstract
In this review, we identify potential targets for the therapeutic effects of heparin in asthma and chronic obstructive pulmonary disease (COPD), consider the safety and delivery modalities of this therapeutic approach. Specifically, we point to the anti-inflammatory, antioxidant and mucolytic effects of unfractionated heparin with potential to modify disease progression in COPD and asthma when administered via the inhaled route. Inhaled heparin may represent an effective add-on therapy in COPD and asthma patient groups, especially when taking into consideration the relative deficiency in endogenous heparin reported in asthma patients.
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Affiliation(s)
- Janis K Shute
- Institute of Biological and Biomedical Sciences, University of Portsmouth, UK.
| | - Ermanno Puxeddu
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Luigino Calzetta
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
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10
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Shute JK, Calzetta L, Cardaci V, di Toro S, Page CP, Cazzola M. Inhaled nebulised unfractionated heparin improves lung function in moderate to very severe COPD: A pilot study. Pulm Pharmacol Ther 2017; 48:88-96. [PMID: 28986203 DOI: 10.1016/j.pupt.2017.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/28/2017] [Accepted: 10/01/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND COPD is an inflammatory airway disease characterised by progressive airflow limitation and air trapping, leading to lung hyperinflation and exercise limitation. Acute worsening of symptoms, including dyspnea, cough and sputum production, occurs during exacerbations which are associated with significantly reduced health related quality of life, and increased morbidity and mortality. Chronic bronchial mucus production and productive cough are risk factors for exacerbations. Medicines targeting bronchoconstriction and airway inflammation are the current mainstays of COPD therapy. However, there is growing concern with an increased risk of pneumonia in patients with COPD receiving regular inhaled corticosteroids and there is therefore a need to find safer alternative treatments. Previous studies have indicated that inhalation of unfractionated heparin (UFH) treats local inflammation, mucus hypersecretion and lung injury, without systemic anticoagulation, and is safe. Therefore, our primary objective was to demonstrate that inhaled UFH significantly improves lung function (FEV1) over 21 days of treatment in patients with COPD receiving pulmonary rehabilitation and that UFH provides a novel, safe and effective way of treating this complex disease. METHODS Forty patients with moderate to very severe COPD admitted to the IRCCS San Raffaele Pisana Hospital for 21 days pulmonary rehabilitation were randomised to receive nebulised inhaled UFH (75,000 or 150,000 IU BID) or placebo for 21 days. All patients also received nebulised salbutamol (1 mg) and beclomethasone dipropionate (400 μg) BID over the same period. Lung function was measured at day 0, 7, 14 and 21 of treatment and at a follow-up visit 7 days post-treatment. Exercise capacity (6MWT) and dyspnoea (Borg score) were measured before and after treatment. In pre-clinical studies, the ability of basic proteins found in COPD sputum to neutralise the anticoagulant activity of heparin was determined using the AMAX heparin assay kit. MAIN RESULTS At both doses, UFH significantly increased FVC following 7 days of treatment and 150,000 IU BID significantly increased FEV1 (+249 ± 69 ml compared with placebo) at this time, an effect maintained to the 28 day follow-up. Clinically significant improvement in exercise capacity and dyspnoea were seen after 21 days of treatment with both doses of UFH. There were no serious adverse events or effects on systemic coagulation. Pre-clinical studies demonstrated that the basic proteins lactoferrin, platelet factor-4 (PF-4), IL-8 and polyarginine, as a model of the eosinophil cationic protein (ECP), found in COPD sputum neutralise the anticoagulant activity of heparin. CONCLUSION Inhaled nebulised UFH is safe and provides additional clinical benefit for patients with moderate to very severe COPD through effects that are independent of its anticoagulant activity.
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Affiliation(s)
- Janis K Shute
- Institute of Biological and Biomedical Sciences, University of Portsmouth, UK.
| | - Luigino Calzetta
- Department of Systems Medicine, University of Rome Tor Vergata, Italy.
| | | | | | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, King's College, London, UK.
| | - Mario Cazzola
- Department of Systems Medicine, University of Rome Tor Vergata, Italy.
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11
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Robin E, Guieu LV, Le Boedec K. Recurrent Obstructive Fibrinous Tracheal Pseudomembranes in a Young English Bulldog. J Vet Intern Med 2017; 31:550-555. [PMID: 28224661 PMCID: PMC5354013 DOI: 10.1111/jvim.14650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/04/2016] [Accepted: 12/06/2016] [Indexed: 11/30/2022] Open
Abstract
Endotracheal intubation is a common procedure, rarely associated with life-threatening complications (e.g., tracheal rupture, necrosis, foreign body). A 1.5-year-old English Bulldog was presented for respiratory distress, with increased respiratory efforts and stridor, 2 days after endotracheal intubation. Cervical and thoracic radiographs disclosed a severe narrowing of the tracheal lumen associated with an intraluminal soft-tissue structure at the thoracic inlet. Tracheoscopy confirmed the presence of an obstructive fibrinous tracheal pseudomembrane (OFTP) creating a 1-way valve obstruction. Removal of the OFTP dramatically improved the dog's respiratory function, but the lesion reformed twice despite corticosteroid and antibiotic therapy PO, warranting repeated endoscopic removal of the OFTP. No additional recurrences were observed after treatment with inhaled heparin and N-acetylcysteine q4h. No respiratory signs were reported 9 months after discharge. Postintubation OFTP has been reported rarely in humans and never described in dogs. Unexplained signs of upper airway obstruction shortly after endotracheal intubation should prompt consideration of OFTP in dogs, even if intubation was uneventful. Unlike its counterpart in humans, OFTP in dogs can reoccur after endoscopic removal, warranting repeated endoscopic extraction. A combination of corticosteroid therapy PO and heparin and N-acetylcysteine inhalation q4h may be attempted if recurrence is observed.
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Affiliation(s)
- E Robin
- Internal Medicine Unit, CHV Fregis, Arcueil, France
| | - L V Guieu
- Emergency and Critical Care Unit, CHV Fregis, Arcueil, France
| | - K Le Boedec
- Internal Medicine Unit, CHV Fregis, Arcueil, France
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12
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Pulsipher A, Qin X, Thomas AJ, Prestwich GD, Oottamasathien S, Alt JA. Prevention of sinonasal inflammation by a synthetic glycosaminoglycan. Int Forum Allergy Rhinol 2016; 7:177-184. [PMID: 27863138 DOI: 10.1002/alr.21865] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/12/2016] [Accepted: 09/22/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Glycosaminoglycans (GAGs) are polysaccharides that are distributed on respiratory epithelial cells, endothelial cells, and submucosal glands. Uniquely positioned, certain GAGs exhibit anti-inflammatory properties in respiratory diseases and serve important roles in repairing mucosal surfaces and modulating mucociliary clearance. We hypothesized that topical administration of a synthetic GAG (GM-0111) would prevent sinonasal inflammation in a mouse model of rhinosinusitis (RS). METHODS To test our hypothesis, C57BL/6 mice were intranasally administered fluorescent GM-0111, and sinonasal tissues were examined for coating and penetration ability. To test therapeutic feasibility, mice (n = 6) were given GM-0111 or hyaluronic acid (HA; 800 μg dose) prior to inducing RS with inflammatory molecule LL-37 (115 μg dose). After 24 hours, sinonasal tissues were harvested for histological and biochemical analysis of inflammatory markers (inflammatory cell infiltration, lamina propria [LP] thickening, and neutrophil enzyme myeloperoxidase [MPO]) and cell death. RESULTS GM-0111 was observed within sinonasal tissues 1 hour and 24 hours after intranasal administration, indicating rapid and effective coating and penetration. GM-0111 prevented sinonasal tissues from developing inflammatory changes, with significant reductions in mast cell infiltration (p < 0.05), LP thickening (p < 0.001), and MPO levels (p < 0.01) when compared to tissues treated with LL-37 and those pretreated with HA. GM-0111 reduced cell death within sinonasal tissues in contrast to LL-37-treated tissues. CONCLUSION We report a new synthetic GAG (GM-0111) that uniformly coats and penetrates into the sinonasal mucosa to prevent sinonasal inflammation and cell death in a mouse model of RS.
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Affiliation(s)
- Abigail Pulsipher
- Division of Head and Neck Surgery, Rhinology-Sinus and Skull Base Surgery Program, Department of Surgery; University of Utah School of Medicine, Salt Lake City, UT.,GlycoMira Therapeutics, Inc., Salt Lake City, UT
| | - Xuan Qin
- Division of Head and Neck Surgery, Rhinology-Sinus and Skull Base Surgery Program, Department of Surgery; University of Utah School of Medicine, Salt Lake City, UT
| | - Andrew J Thomas
- Division of Head and Neck Surgery, Rhinology-Sinus and Skull Base Surgery Program, Department of Surgery; University of Utah School of Medicine, Salt Lake City, UT
| | - Glenn D Prestwich
- Department of Medicinal Chemistry and Center for Therapeutic Biomaterials, Salt Lake City, UT.,GlycoMira Therapeutics, Inc., Salt Lake City, UT
| | - Siam Oottamasathien
- Department of Medicinal Chemistry and Center for Therapeutic Biomaterials, Salt Lake City, UT.,Division of Pediatric Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Jeremiah A Alt
- Division of Head and Neck Surgery, Rhinology-Sinus and Skull Base Surgery Program, Department of Surgery; University of Utah School of Medicine, Salt Lake City, UT.,Department of Medicinal Chemistry and Center for Therapeutic Biomaterials, Salt Lake City, UT
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Glas GJ, Serpa Neto A, Horn J, Cochran A, Dixon B, Elamin EM, Faraklas I, Dissanaike S, Miller AC, Schultz MJ. Nebulized heparin for patients under mechanical ventilation: an individual patient data meta-analysis. Ann Intensive Care 2016; 6:33. [PMID: 27083915 PMCID: PMC4833759 DOI: 10.1186/s13613-016-0138-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/29/2016] [Indexed: 01/08/2023] Open
Abstract
Pulmonary coagulopathy is a characteristic feature of lung injury including ventilator-induced lung injury. The aim of this individual patient data meta-analysis is to assess the effects of nebulized anticoagulants on outcome of ventilated intensive care unit (ICU) patients. A systematic search of PubMed (1966-2014), Scopus, EMBASE, and Web of Science was conducted to identify relevant publications. Studies evaluating nebulization of anticoagulants in ventilated patients were screened for inclusion, and corresponding authors of included studies were contacted to provide individual patient data. The primary endpoint was the number of ventilator-free days and alive at day 28. Secondary endpoints included hospital mortality, ICU- and hospital-free days at day 28, and lung injury scores at day seven. We constructed a propensity score-matched cohort for comparisons between patients treated with nebulized anticoagulants and controls. Data from five studies (one randomized controlled trial, one open label study, and three studies using historical controls) were included in the meta-analysis, compassing 286 patients. In all studies unfractionated heparin was used as anticoagulant. The number of ventilator-free days and alive at day 28 was higher in patients treated with nebulized heparin compared to patients in the control group (14 [IQR 0-23] vs. 6 [IQR 0-22]), though the difference did not reach statistical significance (P = 0.459). The number of ICU-free days and alive at day 28 was significantly higher, and the lung injury scores at day seven were significantly lower in patients treated with nebulized heparin. In the propensity score-matched analysis, there were no differences in any of the endpoints. This individual patient data meta-analysis provides no convincing evidence for benefit of heparin nebulization in intubated and ventilated ICU patients. The small patient numbers and methodological shortcomings of included studies underline the need for high-quality well-powered randomized controlled trials.
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Affiliation(s)
- Gerie J Glas
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Critical Care Medicine, Faculdade de Medicina do ABC, Santo André, Brazil.,Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, Santo André, Brazil
| | - Janneke Horn
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Amalia Cochran
- Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Barry Dixon
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Elamin M Elamin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, James A. Haley Veteran's Hospital, University of South Florida, Tampa, FL, USA
| | - Iris Faraklas
- Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Andrew C Miller
- Department of Critical Care Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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