A comparison of nebulized budesonide with oral prednisolone in the treatment of exacerbations of obstructive pulmonary disease

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

OBJECTIVE

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

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

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

RESULTS

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

CONCLUSION

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

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Redundant medication use during acute exacerbation of chronic obstructive pulmonary disease in hospitalized patients

Background Few clinical studies have evaluated redundant therapy during an exacerbation of chronic obstructive pulmonary disease in hospitalized patients, but clinical practice guidelines endorse this practice. Objective The aim of this study is to measure the frequency of redundant therapy and explore its association with clinical outcomes, adverse effects, and cost among adults hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Setting Six hospitals within an academic health system in the United States. Method A retrospective cohort study of adults with a principal diagnosis of acute exacerbation of chronic obstructive pulmonary disease between January 1, 2016 and March 31, 2016 was performed. Main outcome measure The primary outcome was the proportion of patients who received redundant therapy during inpatient management of acute exacerbation of chronic obstructive pulmonary disease. Results Overall, 137 patients were included and 99 (72.7%) received redundant medication therapy. Redundant therapy was not associated with significant differences in clinical outcomes such as median hospital length of stay, 30-day readmission, tachycardia, thrush, psychiatric symptoms or urinary retention in the univariate or multivariate analyses. The median medication acquisition cost per patient was nearly 11-fold higher among those receiving redundant medication therapy [$135.14 (49.21) vs 12.50 (17.02); p < 0.001]. After controlling for confounding variables using multivariate linear regression, the cost of redundant medication therapy was $50.20 higher on average (p < 0.001). Conclusion Redundant inhaled therapy for acute exacerbation of chronic obstructive pulmonary disease in the hospital setting was not associated with improved clinical outcomes or more adverse effects but did significantly increase medication cost. The findings of this study should be considered exploratory.

Optimization of Nebulized Budesonide in the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background

Clinical studies have suggested nebulized budesonide (NB) as an alternative to systemic corticosteroids for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, the optimal budesonide dose for AECOPD remains unclear.

Objectives

To compare the efficacy and safety of different doses of NB in the management of AECOPD.

Patients and Methods

A total of 321 AECOPD patients with moderate-to-severe exacerbation were randomly divided into three groups and treated with NB. The low dose group (L) was given 4 mg/day (n=95, 1 mg Q6h), while high-dose group 1 (H1, n=111, 2 mg Q6h) and high-dose group 2 (H2, n=115, 4 mg Q12h) were given 8 mg/day. Patients also received routine treatment including oxygen therapy, expectorant, nebulization bronchodilators, antibiotics, and fluid rehydration. The COPD assessment test (CAT), lung function, and artery blood gas were evaluated before and after 3 hrs and 5 days of treatment. In addition, hospital stay, frequency of acute exacerbations within 3 months of discharge, and adverse events during treatment were compared.

Results

H1 and H2 showed improved spirograms and CAT score faster than L. In H2, forced expiratory volume in 1 s (FEV₁%) at 3 hrs and FEV₁%, forced expiratory flow after 50% of the forced vital capacity has been exhaled (FEF_50%), mean forced expiratory flow between 25% and 75% of forced vital capacity (FEF_25-75%) and CAT score at 5 days were significantly improved compared to L. FEV₁% improved most in H2, moderately in H1, and least in L, with significant differences between groups at 5 days. No differences between groups were observed in adverse effects, hospital stay, and frequency of exacerbations within 3 months of discharge.

Conclusion

Compared to the conventional dose (4 mg/day), a high dose (8 mg/day) of NB improved pulmonary function and symptoms more effectively in the early treatment of AECOPD, especially when given as 4 mg twice daily.

Comparative efficacies of nebulized budesonide and systemic corticosteroids in the treatment of exacerbations of chronic obstructive pulmonary disease: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Corticosteroids are recommended by almost all international guidelines for the management of exacerbations of chronic obstructive pulmonary disease (COPD). Nevertheless, due to their side effects, there are still concerns regarding the use of systemic corticosteroids (SCs). The Global Initiative for Chronic Obstructive Lung Disease guideline states nebulized budesonide (NB) may be a suitable alternative to SCs for treating COPD exacerbations. We conducted this study to systematically compare the efficacies of NB and SCs by using a meta-analysis.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched from database inception to 10 October 2019. Our main end points were change in pulmonary function and blood gas analysis. Secondary end points were numbers of exacerbations and hyperglycaemia.

RESULTS AND DISCUSSION

Of 645 identified studies, 6 were eligible and were included in our analysis (N = 867 participants). Compared with SCs, NB was non-inferior on the change in FEV₁ %predicted at 24 hours, 48-72 hours and 5-7 days; FEV₁ at 5-7 days; FEV₁ /FVC at 7 days. For blood gas analysis, our meta-analysis indicated that PaO₂ , PaCO₂ at 24 hours, 48-72 hours and 7-10 days and SaO₂ at 24 hours and 7-10 days showed a non-significant difference in both groups, whereas the SaO₂ was significant higher in NB group at 48-72 hours after treatment. Hyperglycaemia was less frequent with NB (odds ratio, 0.1; 95% CI, 0.01-0.85; P = .04).

WHAT IS NEW AND CONCLUSION

Based on our meta-analysis, NB was not inferior to SCs when used in the treatment of COPD exacerbations. However, additional well-designed prospective studies are needed to identify the optimal dose of nebulized budesonide and the effects of nebulized budesonide in outpatients, or patients in ICU settings.

Use of glucocorticoids in patients with COPD exacerbations in China: a retrospective observational study

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are common in patients with underlying moderate to severe COPD and are associated with increased health and economic burden. International and Chinese guidelines recommend using glucocorticoids for the management of AECOPD because glucocorticoid therapy has been shown to benefit clinical outcomes. However, only scant data are available for current status of glucocorticoid therapy in hospitalized AECOPD patients in China. The aim of the study was to identify current use of glucocorticoids for the treatment of AECOPD in China.

METHODS

This retrospective, multicenter, noninterventional study evaluated the treatment pattern of AECOPD in patients hospitalized from January 2014 to September 2014 at 43 sites (41 tertiary hospitals and two secondary hospitals) in China. The endpoints of the study were the percentage of patients receiving glucocorticoids by different routes of administration, doses and duration, mortality, and the mean length of hospitalization.

RESULTS

A total of 4569 patients (90.17%) received glucocorticoids for AECOPD treatment. A combination of nebulized and systemic route was most frequently used (40.51%), followed by using nebulized route alone (38.00%), systemic route alone (15.45%), and inhaled route other than nebulization (6.04%). Furthermore, the most commonly prescribed glucocorticoids of the nebulized, intravenous, inhaled (other than nebulized) and oral route was budesonide (69.4%), methylprednisolone sodium succinate (45.31%), fluticasone propionate (19.54%), and prednisone acetate (11.90%), respectively. The in-hospital mortality rate was 1.24% and the mean length of hospitalization was 12.22 ± 6.20 days (± SD).

CONCLUSIONS

Our study was the first study of the treatment pattern of glucocorticoids in the management of hospitalized AECOPD patients in China. Data indicates that there is a gap in the implementation of international guidelines for the treatment of AECOPD in China. Further studies are warranted to clarify the appropriate glucocorticoids strategy for the management of AECOPD to determine the optimal route of administration, dose and duration, and resulting clinical outcomes.

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

INTRODUCTION

Mechanical ventilatory support is life-saving therapy for patients with respiratory failure in intensive care units (ICU) but is linked to ventilator-associated pneumonia and other nosocomial infections. Interventions that improve the efficiency of weaning from mechanical ventilation may improve patient outcomes.

OBJECTIVE

To determine whether inhaled budesonide decreases time-to-weaning in COPD stage 4 difficult-to-wean patients and reduces the release of pro-inflammatory cytokines in ICU patients.

MATERIALS AND METHODS

We recruited 55 difficult-to-wean COPD patients (Stage 4) within the ICU of the Masih Daneshvari Hospital. Subjects were randomly assigned to receive inhaled budesonide (0.5mg/day) or placebo (normal saline). Dynamic compliance and BAL cytokines were measured.

RESULTS

Budesonide significantly reduced the number of days on MV (days-to-weaning=4.6±1.6days) compared to that seen in the control group (7.2±2.7days, p=0.014). Dynamic compliance was significantly improved in the budesonide group on days 3 (p=0.018) and 5 (p=0.011) The levels of CXCL-8 and IL-6 diminished on days 3-5 after start of budesonide (p<0.05).

CONCLUSION

In COPD patients on MV, nebulized budesonide was associated with reduced BAL CXCL8 and IL-6 levels and neutrophil numbers as well as an improvement in ventilatory mechanics and facilitated weaning.

Comparative Efficacies of Inhaled Corticosteroids and Systemic Corticosteroids in Treatment of Chronic Obstructive Pulmonary Disease Exacerbations: A Systematic Review and Meta-Analysis

BACKGROUND

Corticosteroids play an important role in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations, and a global initiative has suggested the use of inhaled corticosteroids (ICSs) as an alternative to systemic corticosteroids (SCs). Here, we report results of a meta-analysis performed to systematically compare the efficacies of ICSs and SCs in the treatment of COPD exacerbations.

METHODS

PubMed, EMBASE, and the Cochrane databases were searched for relevant human clinical trials describing the use of ICSs compared with SCs in the treatment of COPD exacerbations. We compared the results of FEV1%pred and blood gas analyses that had been calculated. Weighted mean differences and fixed effects models were applied by using Revman 5.2.

RESULTS

Five original studies satisfied our inclusion criteria, and no significant heterogeneity was shown. Three studies evaluated the increase of FEV₁%pred after treatment for 7 days. There were three and four studies, respectively, that evaluated the increase of SaO₂ and PaO₂, and three reported the decrease of PaCO₂ at 24 hours control, 2-4 days control, and 7-10 days control. All the results showed that both ICSs and SCs were effective in the treatment of COPD exacerbations.

CONCLUSION

ICSs were not inferior to SCs when used in the treatment of COPD exacerbations.

Effects of nebulized high-dose budesonide on moderate-to-severe acute exacerbation of asthma in children: a randomized, double-blind, placebo-controlled study

BACKGROUND AND OBJECTIVE

The efficacy of inhaled corticosteroids (ICS) in asthma exacerbation are yet to be clarified. The aim of this study was to investigate the efficacy of nebulized ICS in children with moderate-to-severe acute exacerbation of asthma in an emergency room setting in order to elucidate the potential use of ICS as the first-line therapy in the management of acute exacerbation of asthma.

METHODS

This was a prospective, randomized, double-blind, placebo-controlled study. Paediatric patients with moderate-to-severe acute exacerbation of asthma in emergency room were randomized to receive nebulized salbutamol and ipratropium bromide, with the addition of nebulized high-dose budesonide (BUD group, n = 60) or normal saline (control group, n = 58), three doses in the first hour.

RESULTS

The improvement in forced expiratory volume in 1 s was similar in both groups at 0 h after three doses of nebulization, but there was significantly further improvement at 1 and 2 h in the BUD group (0.095 ± 0.062 L and 0.100 ± 0.120 L, respectively) compared with the control group (0.059 ± 0.082 L and 0.021 ± 0.128 L, respectively), P = 0.013 and 0.001, respectively. Complete remission rate was significantly higher (84.7% vs 46.3%, P = 0.004) and need for oral corticosteroids was significantly lower (16.9% vs 46.3%, P = 0.011) in BUD group than in control group.

CONCLUSION

On the basis of nebulized short-acting bronchodilators, addition of nebulized high-dose budesonide resulted in clinical improvement in children with moderate-to-severe acute exacerbation of asthma, suggesting that nebulized high-dose ICS can be used as first-line therapy for non-life-threatening acute exacerbation of asthma in children.

Two different dosages of nebulized steroid versus parenteral steroid in the management of COPD exacerbations: a randomized control trial

BACKGROUND

The study aimed to compare the efficacy and safety of nebulized steroid (NS) with systemic corticosteroids (SC) and to determine optimal NS dose in the treatment of patients with COPD exacerbations requiring hospitalization.

MATERIAL AND METHODS

The study was a randomized, parallel design trial. Eligible patients (n=86) were randomly allocated to 1 of the 3 treatment groups: parenteral corticosteroid (PS) (n=33), 4 mg (NB) (n=27), or 8 mg NB (n=26). Partial pressure of arterial oxygen (PaO2), carbon dioxide (PaCO2), pH, and oxygen saturation (SaO2) were evaluated at baseline, 24 h, 48 h, and discharge. Airway obstruction (forced vital capacity [FVC] and forced expiratory volume 1 s [FEV1]) was evaluated at admission and discharge.

RESULTS

There were no significant differences between the groups for all parameters at all time periods, except for higher FEV1 value in the 8-mg NB group at baseline. In groups, significant differences were determined for FVC, FEV1, PaO2, and SaO2 (p<0.001), but not for PaCO2 and pH, in comparison to their baseline values. As adverse events, hyperglycemia and oral moniliasis were observed in the PS group (n=4) and in the NB groups (n=5), respectively, and treatment change was required in 9 patients (2 patients in the PS group and 7 patients in the NB groups) (p=0.57).

CONCLUSIONS

Nebulized budesonide may be used as an alternative to SC because of its equal effectiveness and lesser systemic adverse effects. The choice of optimal dosage needs to be evaluated carefully because adverse effect and dropout rates varied according to dosage. However, there is a need for further studies including more severe cases and evaluating long-term outcomes or relapses comparing the 3 arms.

Inhaled steroids for acute asthma following emergency department discharge

BACKGROUND

Patients with acute asthma treated in the emergency department (ED) are frequently treated with inhaled beta(2)-agonists and systemic corticosteroids after discharge. The use of inhaled corticosteroids (ICS) following discharge may also be beneficial in improving patient outcomes after acute asthma.

OBJECTIVES

To determine the effectiveness of ICS on outcomes in the treatment of acute asthma following discharge from the ED. To quantify the effectiveness of ICS therapy on acute asthma following ED discharge, when used in addition to, or as a substitute for, systemic corticosteroids.

SEARCH METHODS

Controlled clinical trials (CCTs) were identified from the Cochrane Airways Review Group register, which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by handsearching of respiratory journals and conference proceedings. In addition, primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews and texts also were searched. The searches have been conducted up to September 2012

SELECTION CRITERIA

We included both randomised controlled trials (RCTs) and quasi-RCTs. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids. Two review authors independently assessed articles for potential relevance, final inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors, or confirmed by the study authors. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager software. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) or relative risks (RR) with 95% confidence intervals (CIs). Where appropriate, individual and pooled continuous outcomes were reported as mean differences (MD) or standardized mean differences (SMD) with 95% CIs. The primary analysis employed a fixed effect model and heterogeneity is reported using I-squared (I(2)) statistics.

MAIN RESULTS

Twelve trials were eligible for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus systemic corticosteroids versus oral corticosteroid therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to oral corticosteroid therapy in the trials. Relapses were reduced; however, this was not statistically significant with the addition of ICS therapy (OR 0.68; 95% CI 0.46 to 1.02; 3 studies; N = 909). In addition, no statistically significant differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores or adverse effects.Nine trials, involving a total of 1296 patients compared high-dose ICS therapy alone versus oral corticosteroid therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone versus oral corticosteroid therapy alone for relapse rates (OR 1.00; 95% CI 0.66 to 1.52; 4 studies; N = 684), admissions to hospital, or in the secondary outcomes of beta(2)-agonist use, symptoms or adverse events. However, the sample size was not adequate to exclude the possibility of either treatment being significantly inferior and people with severe asthma were excluded from these trials.

AUTHORS' CONCLUSIONS

There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard systemic corticosteroid therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as oral corticosteroid therapy when used in mild asthmatics upon ED discharge; however, the confidence intervals were too wide to be confident of equal effectiveness. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment following ED discharge. The review does not suggest any reason to stop usual treatment with ICS following ED discharge, even if a course of oral corticosteroids are prescribed.

Inhalation therapy in patients receiving mechanical ventilation: an update

Incremental gains in understanding the influence of various factors on aerosol delivery in concert with technological advancements over the past 2 decades have fueled an ever burgeoning literature on aerosol therapy during mechanical ventilation. In-line use of pressurized metered-dose inhalers (pMDIs) and nebulizers is influenced by a host of factors, some of which are unique to ventilator-supported patients. This article reviews the impact of various factors on aerosol delivery with pMDIs and nebulizers, and elucidates the correlation between in-vitro estimates and in-vivo measurement of aerosol deposition in the lung. Aerosolized bronchodilator therapy with pMDIs and nebulizers is commonly employed in intensive care units (ICUs), and bronchodilators are among the most frequently used therapies in mechanically ventilated patients. The use of inhaled bronchodilators is not restricted to mechanically ventilated patients with chronic obstructive pulmonary disease (COPD) and asthma, as they are routinely employed in other ventilator-dependent patients without confirmed airflow obstruction. The efficacy and safety of bronchodilator therapy has generated a great deal of interest in employing other inhaled therapies, such as surfactant, antibiotics, prostacyclins, diuretics, anticoagulants and mucoactive agents, among others, in attempts to improve outcomes in critically ill ICU patients receiving mechanical ventilation.

Il percorso diagnostico-assistenziale della broncopneumopatia cronica ostruttiva riacutizzata in Medicina Interna

Introduction

Chronic obstructive pulmonary disease (COPD) is the second leading cause of hospitalization in Internal Medicine departments in Italy and the fourth leading cause of death all over the word. By 2020, COPD will be the third leading cause of death and the fifth leading cause of disability. It is – along with chronic congestive heart failure – one of the most common causes of unscheduled hospital readmissions, and as such it represents a significant economic burden for the health-care system. Exacerbations of COPD are important events in the natural history of this prevalent condition.

Discussion

This review provides a comprehensive state-of-the-art look at prevention and management of COPD exacerbations. Treatment of these episodes has to be tailored to the severity of the clinical presentation. We now have a wide range of therapeutic available options, based on the results of clinical trials. Management of the acute event should include the necessary measures (mainly the administration of inhaled short-acting bronchodilators, inhaled or oral corticosteroids, and antibiotics), with or without oxygen and ventilator support.

Conclusions

To improve the management of COPD exacerbations, the focus of care must be shifted from the episodic acute complications to their systematic prevention. The management of COPD, which is often associated with multiple co-morbidities, is complex and requires a tailored, multifaceted and multidisciplinary approach. Integrated care for COPD also requires that patients be informed about their condition, that they participate actively in their care, and that they have easy access to the necessary health-care services.

Nebulized corticosteroids in the management of acute exacerbation of COPD

Acute exacerbations in chronic onstructive pulmonary disease (COPD) are common and systemic steroids play an important role in the management of these cases along with the bronchodilators. Nebulized budesonide is being used in the acute attacks of bronchial asthma either in children or in adults. But the role of nebulized steroids in acute exacerbation of COPD is not much studied in the literature. In this clinical review we have evaluated the role of nebulized corticosteroids in the management of acute exacerbation of COPD (AECOPD). Through Medline, Pubmed and Embase we analyzed the various studies that has been done to study the role of nebulized corticosteroids in the management of acute exacerbation of COPD. The key words used for the search criteria were: acute exacerbation, COPD, nebulized corticosteroids, budesonide, fluticasone. Only eight studies were found which had evaluated the role of nebulized corticosteroids in acute exacerbations of COPD. All these studies had used nebulized budesonide in AECOPD in different dosages, and had been compared with both either parental or oral steroids, and standard bronchodilator therapy. All the studies had found the clinical efficacy of nebulized budesonide to be of similar extent to that of either parental or oral steroids in AECOPD. Side effects profile of nebulized budesonide was minimal and acceptable as compared to systemic steroids. Nebulized budesonide may be an alternative to parental/oral prednisolone in the treatment of acute exacerbations of COPD but further studies should be done to evaluate its long-term impact on clinical outcomes after an initial episode of COPD exacerbation.

Steroids in acute exacerbations of chronic obstructive pulmonary disease: are nebulized and systemic forms comparable?

PURPOSE OF REVIEW

Systemic corticosteroids are strongly recommended in the treatment of exacerbations of chronic obstructive pulmonary disease (COPD). As COPD patients are usually elderly and are relatively immobile, side effects of systemic corticosteroids frequently outweigh their beneficial effects. On the contrary, nebulized corticosteroid solutions have a negligible systemic side-effect profile. In this review, as an alternative to systemic corticosteroids, the place of nebulized corticosteroids in exacerbation periods of COPD was summarized.

RECENT FINDINGS

The number of trials in the literature is increasing. Regarding the available data, high dose nebulized budesonide was found as effective as systemic corticosteroids in exacerbations of COPD. The side-effect profile, blood glucose level in particular, is better for nebulized budesonide.

SUMMARY

Findings from recent studies are giving a positive impression on the role of high dose nebulized budesonide in exacerbations of COPD. However, larger and statistically high powered trials testing different types of nebulized corticosteroid solutions with varying dosages are still lacking. Before recommending the routine use of nebulized corticosteroids in exacerbations, present findings need to be confirmed with further studies of high quality.

Anti-inflammatory effects of combined budesonide/formoterol in COPD exacerbations

Systemic corticosteroids and additional short-acting beta2-agonists are commonly used in exacerbations of chronic obstructive pulmonary disease (COPD). In this double-blind study, the combination of a high-dose inhaled corticosteroid with a rapid-onset long-acting beta2-agonist was evaluated in the treatment of out-patient COPD exacerbations. The primary aim was to compare 14-day treatment effects of budesonide/formoterol to placebo on sputum eosinophils and, secondarily, on other indices of inflammation, forced expiratory flow in one second (FEV(1)), symptoms, health status, and adverse events. Forty-five patients not using steroids (37 male, 21/24 current/ex smoker, median packyears 38, age 65 years, FEV(1) 61% predicted), experiencing a COPD exacerbation, were treated at home with budesonide/formoterol (320/9 microg 4 times daily), prednisolone (30 mg daily), or placebo for 14 days. Sputum eosinophils were significantly reduced by budesonide/formoterol (-57%) compared to placebo (+24%) (p = 0.01). Budesonide/formoterol reduced total symptom scores significantly (p = 0.01) compared to placebo. The increase in FEV(1) by 2 weeks of treatment with budesonide/formoterol (125 ml) was not significantly different from that of placebo (43 ml) (p = 0.07). Budesonide/ formoterol treatment did not suppress morning serum cortisol compared to placebo (-16%; p = 0.50). In conclusion, budesonide/formoterol reduces sputum eosinophils and improves symptoms in the treatment of out-patient COPD exacerbations.

The role of nebulized inhaled corticosteroid therapy in adult patients with asthma and chronic obstructive pulmonary disease

Conventional metered-dose inhalers and dry powder inhalers are used by most adult patients with asthma and chronic obstructive pulmonary disease who receive inhaled corticosteroid therapy. There are circumstances, however, in which nebulized inhaled corticosteroid delivery may provide greater clinical benefit to these patients. This review discusses the efficacy and safety of nebulized inhaled corticosteroid therapy in adult patients with asthma or chronic obstructive pulmonary disease for whom nebulized therapy may be preferable.

Oral corticosteroid-sparing effects of inhaled corticosteroids in the treatment of persistent and acute asthma

OBJECTIVE

To review the efficacy and safety of inhaled corticosteroids (ICSs) when used to reduce daily oral corticosteroid (OCS) requirements in patients with severe persistent asthma and periodic requirements in patients with acute asthma exacerbations.

DATA SOURCES

Clinical studies of the OCS-sparing effects of ICSs were located by searching MEDLINE databases from 1966 onward using the terms oral, steroid, and asthma in combination with the generic names for each marketed ICS.

STUDY SELECTION

Studies reporting on the use of ICSs to reduce OCS requirements in patients with persistent and acute asthma are included.

RESULTS

Clinical study results consistently show that ICSs significantly improve asthma control and reduce OCS requirements among adults, children, and infants with persistent asthma. A dose reduction or complete discontinuation of use of OCSs is possible in most patients without loss of asthma control. ICSs also can control asthma during acute asthma exacerbations and reduce the need for short courses of OCSs. With many ICSs, the reductions in OCS use are accompanied by recovery of hypothalamic-pituitary-adrenal axis function, indicating that the safety of asthma therapy is improved when OCS requirements are decreased with ICSs. Of the available ICSs that may reduce OCS needs, budesonide appears to be the most intensively studied.

CONCLUSIONS

ICSs can reduce OCS requirements in adults and children with persistent asthma and during acute asthma exacerbations. The reduced systemic corticosteroid activity associated with ICS treatment improves the overall safety of asthma therapy.

The effectiveness of high-dose inhaled budesonide therapy in the treatment of acute asthma exacerbations in children

BACKGROUND

International guidelines recommend the use of systemic steroids for the treatment of acute asthma attack if it has not been resolved within 24 to 36 hours of home management with regular beta2 mimetic inhalation. Such therapy for infrequent exacerbations is unlikely to have serious systemic effects. Unfortunately, many patients receiving frequent courses are potentially at risk for corticosteroid-induced side effects such as adrenal suppression, depression of linear growth, and osteoporosis.

OBJECTIVE

To decrease the use of frequent oral corticosteroid courses in children, this study was designed to evaluate the efficacy of high-dose inhaled steroids in comparison with oral steroids, in the therapy of acute asthma exacerbations in children.

METHODS

Sixty children who have experienced an acute exacerbation of asthma unresponsive to home management with regular use of inhaled beta2 mimetics, yet not severe enough to hospitalize, were randomized to be treated with either high-dose inhaled budesonide (1,600 microg daily) or oral methylprednisolone (1 mg/kg daily) plus medium-dose inhaled budesonide (800 microg daily, both in addition to inhaled terbutaline, 2,000 microg daily). Pre- and posttreatment pulmonary index scores, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC and forced expiratory flow 25% to 75% (FEF25%-75%) were evaluated.

RESULTS

The mean number of decrease in pulmonary index score was 2.61 +/- 1.12 in the high-dose budesonide-receiving group (group I) and 1.90 +/- 1.08 in the oral steroid-receiving group (group II). There was a statistically significant difference between the two groups, in favor of group I (P = .038). No statistically significant difference was detected between the two groups with respect to the increase in lung function test measurements (FEV1, FEV1/FVC, FEF25%-75%; P = .790, .959, .819, respectively).

CONCLUSIONS

Short-term high-dose budesonide therapy can be considered an alternative for children who are experiencing an acute asthma attack that is unresponsive to home management with regular use of an inhaled beta2 mimetic, yet who are not severe enough to hospitalize.

Budesonide Inhalation Suspension

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Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders

Budesonide, a topically active corticosteroid, has a broad spectrum of clinically significant local anti-inflammatory effects in patients with inflammatory lung diseases including persistent asthma. In infants and young children with persistent asthma, day- and night-time symptom scores, and the number of days in which beta2-agonist bronchodilators were required, were significantly lower during randomised, double-blind treatment with budesonide inhalation suspension 0.5 to 2 mg/day than placebo in 3 multicentre trials. Significantly fewer children discontinued therapy with budesonide inhalation suspension than with placebo because of worsening asthma symptoms in a study that included children who were receiving inhaled corticosteroids at baseline. Recent evidence indicates that budesonide inhalation suspension is significantly more effective than nebulised sodium cromoglycate in improving control of asthma in young children with persistent asthma. At a dosage of 2 mg/day, budesonide inhalation suspension significantly reduced the number of asthma exacerbations and requirements for systemic corticosteroids in preschool children with severe persistent asthma. In children with acute asthma or wheezing, the preparation was as effective as, or more effective than oral prednisolone in improving symptoms. In children with croup, single 2 or 4mg dosages of budesonide inhalation suspension were significantly more effective than placebo and as effective as oral dexamethasone 0.6 mg/kg or nebulised L-epinephrine (adrenaline) 4mg in alleviating croup symptoms and preventing or reducing the duration of hospitalisation. Early initiation of therapy with budesonide inhalation suspension 1 mg/day appears to reduce the need for mechanical ventilation and decrease overall corticosteroid usage in preterm very low birthweight infants at risk for chronic lung disease. In adults with persistent asthma, budesonide inhalation suspension < or =8 mg/day has been compared with inhaled budesonide 1.6 mg/day and fluticasone propionate 2 mg/day administered by metered dose inhaler. Greater improvements in asthma control occurred in patients during treatment with budesonide inhalation suspension than with budesonide via metered dose inhaler, whereas fluticasone propionate produced greater increases in morning peak expiratory flow rates than nebulised budesonide. Several small studies suggest that the preparation has an oral corticosteroid-sparing effect in adults with persistent asthma and that it may be as effective as oral corticosteroids during acute exacerbations of asthma or chronic obstructive pulmonary disease. The frequency of adverse events was similar in children receiving budesonide inhalation suspension 0.25 to 2 mg/day or placebo in 12-week studies. During treatment with budesonide inhalation suspension 0.5 to 1 mg/day in 3 nonblind 52-week studies, growth velocity in children was generally unaffected; however, a small but statistically significant decrease in growth velocity was detected in children who were not using inhaled corticosteroids prior to the introduction of budesonide inhalation suspension. Hypothalamic-pituitary-adrenal axis function was not affected by short (12 weeks) or long (52 weeks) term treatment with nebulised budesonide. In conclusion, budesonide inhalation suspension is the most widely available nebulised corticosteroid, and in the US is the only inhaled corticosteroid indicated in children aged > or =1 year with persistent asthma. The preparation is suitable for use in infants, children and adults with persistent asthma and in infants and children with croup.

Inhaled budesonide for the treatment of acute wheezing and dyspnea in children up to 24 months old receiving intravenous hydrocortisone

BACKGROUND

Inhaled corticosteroids are highly effective in the treatment of asthma at all ages, and their use in younger children is increasing. There are no data currently available on the treatment of infants with acute wheeze and dyspnea with nebulized budesonide.

OBJECTIVE

Our purpose was to assess the clinical effect of nebulized budesonide in infants with acute wheeze and dyspnea.

METHODS

A prospective study was performed comparing the addition of nebulized budesonide 0.25 mg every 6 hours (group A, n = 32) and nebulized ipratropium bromide 0.1 mg every 6 hours (group B, n = 39) with the normal treatment regimen with intravenous fluid, hydrocortisone, and nebulized fenoterol. A clinical score was made at admission and every 12 hours. The score included wheezing and costal retraction (0-6) and respiratory rate (counts per minute).

RESULTS

Seventy-one infants aged 3 to 24 months were studied (42 boys). A statistically significant reduction was seen in clinical score and respiratory rate in both groups 12 hours after admission. The children who received budesonide improved significantly faster than the children who received ipratropium bromide, and the hospitalization period was significantly lower in the budesonide group (66.4 hours) compared with the ipratropium bromide group (93 hours) (P <.01). Three patients from the budesonide group and 2 from the ipratropium bromide group were readmitted within the first 4 weeks.

CONCLUSION

Treatment of infants with acute wheeze with nebulized budesonide is associated with faster clinical improvement and reduction in hospital stay period.

Inhaled steroids in acute asthma following emergency department discharge

BACKGROUND

Patients with acute asthma treated in the emergency department are frequently treated with inhaled beta-agonists and corticosteroids (CS) after discharge. The use of inhaled CS (ICS) following discharge may also be beneficial in acute asthma.

OBJECTIVES

To determine the effect of inhaled corticosteroids (ICS) on outcomes in the treatment of acute asthma following discharge from the emergency department (ED).

SEARCH STRATEGY

Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by hand searching of 20 respiratory journals. In addition, abstracts from conferences were searched; primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews, and texts also were searched.

SELECTION CRITERIA

Only RCTs or quasi RCTs were eligible for inclusion. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids (CS). Two reviewers independently assessed articles for potential relevance, final inclusion, and methodological quality - to "expand" the search. We didn't include any in the end)

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers if the authors were unable to verify the validity of information. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager 4.0.4.

MAIN RESULTS

Ten trials were selected for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus CS Vs CS therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to CS therapy in the trials. Relapses were reduced, but not significantly, with the addition of ICS therapy (OR: 0.68; 95% CI: 0.46 to 1.02). As well, no differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores, or adverse effects. Seven trials, involving a total of 1204 patients, compared high-dose ICS therapy alone Vs CS therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone and CS therapy alone for relapse rates (OR: 1.00; 95% CI: 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to confidently exclude the possibility of either treatment being significantly inferior, and severe asthmatics were excluded from these trials.

REVIEWER'S CONCLUSIONS

There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard CS therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics upon ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment in the ED or following ED discharge.