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Ittiporn S, Prajongdee K. Adherence to the asthma pathway, including pre-triage bronchodilator history, reduces hospitalizations. J Asthma 2024; 61:238-248. [PMID: 37737546 DOI: 10.1080/02770903.2023.2263090] [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: 06/08/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023]
Abstract
Objective: To determine if adherence to an asthma treatment pathway is associated with a decrease in hospitalizations.Methods: A prospective cohort design was conducted of Thai children aged 2-15 years who visited the emergency department with severe asthma exacerbations, defined as a Buddhasothorn Asthma Severity Score ≥ 8. Patients who received systemic corticosteroids and nebulized short-acting beta-2 agonists combined with ipratropium bromides were classified as the adherence group. The timing of steroid and bronchodilator administration, length of hospital stay, and hospitalization rate were examined in relation to adherence to the asthma pathway. Multivariable logistic regression models and adjusted odds ratios were used to assess associations.Results: A total of 118 episodes of asthma exacerbations (EAEs) from 59 participants were included. Patients who adhered to the pathway had a significantly higher rate of systemic corticosteroid administration within 1 h of arrival at triage (88.6% vs. 41.9%, adjusted Odds Ratio: aOR 10.21; 95%CI 3.52-29.62). A higher proportion of the patients who adhered to the pathway also received inhaled ipratropium bromide ≥ 2 doses within 1 h of arrival at triage (72.7% vs. 12.2%, aOR 23.51; 95%CI 7.73-71.54) and it was administered significantly faster by 31 min (5 min vs. 36 min, p < 0.001) compared to non-adherence group. The hospitalization rate was significantly lower by almost half of EAEs for adherence group (36.4% vs. 63.5%, aOR 0.41; 95%CI 0.18-0.93).Conclusions: Accurate assessment of severity and adherence to the clinical pathway can reduce hospitalization in pediatric patients with severe asthma exacerbations.
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Affiliation(s)
- Suttipong Ittiporn
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Buddhasothorn Hospital, Chachoengsao, Thailand
- Academic Medical Center of Collaborative Project to Increase Production of Rural Doctor, Ministry of Public Health, Bangkok, Thailand
| | - Kanlaya Prajongdee
- Division of Nursing Services, Department of Pediatrics, Buddhasothorn Hospital, Chachoengsao, Thailand
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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Santamaria F, Ziello C, Lorello P, Bouchè C, Borrelli M. Update on Long-Acting Anticholinergics in Children and Adolescents With Difficult and Severe Asthma. Front Pediatr 2022; 10:896865. [PMID: 35928684 PMCID: PMC9343620 DOI: 10.3389/fped.2022.896865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Tiotropium bromide is the only long-acting muscarinic antagonist (LAMA) approved for treatment of patients aged ≥6 years old who have symptoms of uncontrolled asthma. Results from several clinical trials have found that once-daily inhaled tiotropium bromide is safe and efficacious in 6- to 17-year-olds with symptomatic asthma despite treatment with inhaled corticosteroids, with or without other medications. There are still few available studies investigating the impact of tiotropium bromide treatment in preschool children with suboptimal control. In this narrative review, we summarize the pharmacological effects of the LAMA tiotropium bromide, provide an overview about current asthma studies at different pediatric ages, and describe future research needs.
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Affiliation(s)
- Francesca Santamaria
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Carla Ziello
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Paola Lorello
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Cristina Bouchè
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Melissa Borrelli
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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Guo L, Wang L, Wang Z, Wei L, Ding L, Kong Y, Liu Z, Tian Y, Yang F, Sun L. Evaluation of the effectiveness and safety of cupping therapy in the treatment of asthma: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27518. [PMID: 34731141 PMCID: PMC8519211 DOI: 10.1097/md.0000000000027518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Asthma is one of the most common chronic airway diseases and is characterized by wheezing, dyspnea, chest tightness, and coughing. These symptoms reduce the patient's quality of life and limit physical activity in daily life. However, there is no systematic review of the efficacy of cupping therapy in the treatment of asthma. To evaluate the efficacy and safety of cupping in the treatment of asthma, we conducted a systematic review and meta-analysis of published randomized clinical trials of cupping in the treatment of asthma. METHODS We will search the following Chinese and English databases: China National Knowledge Infrastructure, China Science and Periodical Database, Wanfang Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library. All of the above electronic databases will be searched from inception to August 22, 2021. In addition, we will manually search for conference papers, ongoing experiments, and internal reports to supplement the studies retrieved via electronic search. We will use the Review Manager 5.4 provided by Cochrane Collaboration Network for statistical analysis. RESULTS The study will prove the effectiveness and safety of cupping in the treatment of asthma. CONCLUSION We plan to submit this systematic review to a peer-reviewed journal. INPLASY REGISTRATION NUMBER INPLASY202180104.
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Affiliation(s)
- Lei Guo
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
| | - Lie Wang
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
- Affiliated Hospital of Changchun University of Chinese Medicine, 1478 Gongnong Road, Changchun City, Jilin Province, China
| | - Zhongtian Wang
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
| | - Lina Wei
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
- Affiliated Hospital of Changchun University of Chinese Medicine, 1478 Gongnong Road, Changchun City, Jilin Province, China
| | - Lizhong Ding
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
- Affiliated Hospital of Changchun University of Chinese Medicine, 1478 Gongnong Road, Changchun City, Jilin Province, China
| | - Yibu Kong
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
- Affiliated Hospital of Changchun University of Chinese Medicine, 1478 Gongnong Road, Changchun City, Jilin Province, China
| | - Zhimei Liu
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
- Affiliated Hospital of Changchun University of Chinese Medicine, 1478 Gongnong Road, Changchun City, Jilin Province, China
| | - Ye Tian
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
| | - Fushuang Yang
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
| | - Liping Sun
- Changchun University of Chinese Medicine, 1035 Boshuo Road, Changchun City, Jilin Province, China
- Affiliated Hospital of Changchun University of Chinese Medicine, 1478 Gongnong Road, Changchun City, Jilin Province, China
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6
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Xu H, Tong L, Gao P, Hu Y, Wang H, Chen Z, Fang L. Combination of ipratropium bromide and salbutamol in children and adolescents with asthma: A meta-analysis. PLoS One 2021; 16:e0237620. [PMID: 33621253 PMCID: PMC7901745 DOI: 10.1371/journal.pone.0237620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND A combination of ipratropium bromide (IB) and salbutamol is commonly used to treat asthma in children and adolescents; however, there has been a lack of consistency in its usage in clinical practice. OBJECTIVE To evaluate the efficacy and safety of IB + salbutamol in the treatment of asthma in children and adolescents. METHODS The MEDLINE, Embase, and Cochrane Library as well as other Chinese biomedical databases (including China Biological Medicine Database, Chinese National Knowledge Infrastructure, Chongqing VIP, and Wanfang Chinese language bibliographic database) were systematically searched from the earliest record date to September 2020 for randomized controlled trials in children and adolescents (≤18 years) with asthma who received IB + salbutamol or salbutamol alone. The primary outcomes included hospital admission and adverse events. A random effects model with a 95% confidence interval (CI) was used. Subgroup analysis was performed according to age, severity of asthma, and co-interventions with other asthma controllers. This study was registered with PROSPERO. RESULTS Of the 1061 studies that were identified, 55 met the inclusion criteria and involved 6396 participants. IB + salbutamol significantly reduced the risk of hospital admission compared with salbutamol alone (risk ratio [RR] 0.79; 95% CI 0.66-0.95; p = 0.01; I2 = 40%). Subgroup analysis only showed significant difference in the risk of hospital admission in participants with severe asthma exacerbation (RR 0.73; 95% CI 0.60-0.88; p = 0.0009; I2 = 4%) and moderate-to-severe exacerbation (RR 0.69; 95% CI 0.50-0.96; p = 0.03; I2 = 3%). There were no significant differences in the risk of adverse events between IB + salbutamol group and salbutamol alone group (RR 1.77; 95% CI 0.63-4.98). CONCLUSION IB + salbutamol may be more effective than salbutamol alone for the treatment of asthma in children and adolescents, especially in those with severe and moderate to severe asthma exacerbation. The very low to high quality of evidence indicated that future well-designed double-blind RCTs with large sample are needed for research on evaluating the effectiveness of IB + salbutamol treatment for asthma in children and adolescents.
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Affiliation(s)
- Hongzhen Xu
- Department of Pulmonology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Lin Tong
- Department of Pulmonology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Peng Gao
- Department of Pharmacy, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Yan Hu
- Department of Pharmacy, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Huijuan Wang
- Department of Pharmacy, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Zhimin Chen
- Department of Pulmonology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Luo Fang
- Department of Pharmacy, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
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Lin J, Xing B, Chen P, Huang M, Zhou X, Wu C, Yang D, Yin K, Cai S, Cheng X, Hao C, Wang C, Liu C. Chinese expert consensus-based guideline on assessment and management of asthma exacerbation. J Thorac Dis 2019; 11:4918-4935. [PMID: 32030208 DOI: 10.21037/jtd.2019.12.67] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Jiangtao Lin
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Bin Xing
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Ping Chen
- Department of Respiratory Medicine, General Hospital of Shenyang Military Region, Shenyang 110015, China
| | - Mao Huang
- Department of Respiratory Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xin Zhou
- Department of Respiratory Medicine, First People's Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Changgui Wu
- Department of Respiratory Medicine, Xijing Hospital of Fourth Military Medical University, Xi'an 710032, China
| | - Dong Yang
- Department of Respiratory Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Kaisheng Yin
- Department of Respiratory Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Shaoxi Cai
- Department of Respiratory Medicine, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China
| | - Xiaoming Cheng
- Department of Respiratory Medicine, Xinqiao Hospital of Third Military Medical University, Chongqing 400037, China
| | - Chuangli Hao
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Suzhou 215000, China
| | - Changzheng Wang
- Department of Respiratory Medicine, Xinqiao Hospital of Third Military Medical University, Chongqing 400037, China
| | - Chuntao Liu
- Department of Respiratory Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
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Buhl R, Hamelmann E. Future perspectives of anticholinergics for the treatment of asthma in adults and children. Ther Clin Risk Manag 2019; 15:473-485. [PMID: 30936709 PMCID: PMC6422409 DOI: 10.2147/tcrm.s180890] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite major advances in therapeutic interventions and the availability of detailed treatment guidelines, a high proportion of patients with symptomatic asthma remain uncontrolled. Asthma management is largely guided by the Global Initiative for Asthma (GINA) strategy and is based on a backbone of inhaled corticosteroid (ICS) therapy with the use of additional therapies to achieve disease control. Inhaled long-acting bronchodilators alone and in combination are the preferred add-on treatment options. Although long-acting muscarinic antagonists (LAMAs) are a relatively recent addition to disease management recommendations for asthma, tiotropium has been extensively studied in a large clinical trial program. In Europe and the United States, tiotropium is approved for patients aged ≥6 years and uncontrolled on medium- to high-dose ICS/long-acting β2-agonists at GINA Steps 4 and 5 with a history of exacerbations. Evidence supports the efficacy of tiotropium Respimat® in adults in terms of lung function and asthma control, with a safety profile comparable with that of placebo across a range of asthma severities. Similarly, clinical trials in patients aged 1-17 years have shown improvements in lung function and trends toward improved asthma control. Furthermore, its efficacy makes tiotropium relatively easy to incorporate into routine clinical practice, irrespective of allergic status and without the need for patient phenotyping. Tiotropium is a cost-effective treatment that may offer an important alternative to other, more expensive add-on therapies. This review discusses the potential future position of LAMAs in clinical practice by considering the continuously evolving evidence. Prominence is given to tiotropium, the only LAMA supported by a structured clinical trial program in asthma to date, while also considering other recommended treatment options for patients with uncontrolled asthma. The importance of effective patient/caregiver-clinician communication and shared decision-making in enhancing treatment adherence is also highlighted.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Johannes Gutenberg University Hospital Mainz, Mainz, Germany,
| | - Eckard Hamelmann
- Children's Center Bethel, Evangelic Hospital Bethel, Department of Pediatrics, Bielefeld, Germany
- University Children's Hospital, Allergy Center Ruhr, Ruhr University Bochum, Bochum, Germany
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Ta CN, Dumontier M, Hripcsak G, Tatonetti NP, Weng C. Columbia Open Health Data, clinical concept prevalence and co-occurrence from electronic health records. Sci Data 2018; 5:180273. [PMID: 30480666 PMCID: PMC6257042 DOI: 10.1038/sdata.2018.273] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022] Open
Abstract
Columbia Open Health Data (COHD) is a publicly accessible database of electronic health record (EHR) prevalence and co-occurrence frequencies between conditions, drugs, procedures, and demographics. COHD was derived from Columbia University Irving Medical Center's Observational Health Data Sciences and Informatics (OHDSI) database. The lifetime dataset, derived from all records, contains 36,578 single concepts (11,952 conditions, 12,334 drugs, and 10,816 procedures) and 32,788,901 concept pairs from 5,364,781 patients. The 5-year dataset, derived from records from 2013-2017, contains 29,964 single concepts (10,159 conditions, 10,264 drugs, and 8,270 procedures) and 15,927,195 concept pairs from 1,790,431 patients. Exclusion of rare concepts (count ≤ 10) and Poisson randomization enable data sharing by eliminating risks to patient privacy. EHR prevalences are informative of healthcare consumption rates. Analysis of co-occurrence frequencies via relative frequency analysis and observed-expected frequency ratio are informative of associations between clinical concepts, useful for biomedical research tasks such as drug repurposing and pharmacovigilance. COHD is publicly accessible through a web application-programming interface (API) and downloadable from the Figshare repository. The code is available on GitHub.
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Affiliation(s)
- Casey N. Ta
- Department of Biomedical Informatics, Columbia University, NY, USA
| | - Michel Dumontier
- Institute of Data Science, Maastricht University, Maastricht, The Netherlands
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, NY, USA
| | - Nicholas P. Tatonetti
- Department of Biomedical Informatics, Columbia University, NY, USA
- Department of Systems Biology, Columbia University, NY, USA
- Department of Medicine, Columbia University, NY, USA
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, NY, USA
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10
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Tesse R, Borrelli G, Mongelli G, Mastrorilli V, Cardinale F. Treating Pediatric Asthma According Guidelines. Front Pediatr 2018; 6:234. [PMID: 30191146 PMCID: PMC6115494 DOI: 10.3389/fped.2018.00234] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/01/2018] [Indexed: 12/27/2022] Open
Abstract
Asthma is a common chronic inflammatory disorder of the lower respiratory airways in childhood. The management of asthma exacerbations and the disease control are major concerns for clinical practice. The Global Strategy for Asthma Management and Prevention, published by GINA, updated in 2017, the British Thoracic Society/Scottish Intercollegiate Guideline Network, revised in 2016, the National Institute for Health and Care Excellence asthma guideline consultation, available in 2017, are widely accepted documents, frequently implemented, with conflicting advices, and different conclusion on asthma definition and treatment. An International Consensus on Pediatric Asthma was carried out in 2012 by a Committee with expertise in the field, to critically review differences on current guidelines. In addition, the specific issue of treating severe and difficult asthma has been recently highlighted throughout the International European Respiratory Society/American Thoracic Society guidelines on severe asthma. The aim of this paper is to describe conventional treatments and some new therapeutic approaches to pediatric asthma according to guidelines, highlighting key aspects, and differences on proposed clinical recommendations for asthma management. Age specific therapy are proposed in steps, according to clinical severity and the level of disease control. If control is not achieved within 3 months, stepping-up should be considered; otherwise, if control is achieved after 3 months, stepping down may be considered. The most used drug classes of asthma medications are beta-2 adrenergic agonists, corticosteroids, and leukotriene modifiers. Intramuscolar triamcinolone has been used for severe asthma treatment. Chromones and xanthines have been extensively used in the past, but they have shown limits related to their efficacy and safety profile. Omalizumab, a monoclonal antibody against IgE, is an immunomodulatory biological agent, used as new drug in patients with confirmed IgE-mediated allergic asthma, only for patient's specific range of total IgE level. There are low evidences in the efficacy of metotrexate, as well as macrolide antibiotics in children with asthma. Antifungal agents are also not recommended in asthmatic patients. Non-pharmacological measures that may improve patient's quality of life should also be attempted. We conclude that treatment decisions on childhood asthma management should be critically made, pondering the differences suggested by agreed international consensus documents.
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Affiliation(s)
- Riccardina Tesse
- Allergy, Immunology and Pediatric Pulmonology Unit, Ospedale Pediatrico Papa Giovanni XXIII, Bari, Italy
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11
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Abstract
Asthma is one of the most common chronic diseases in children, with a high proportion of patients demonstrating poor control despite the availability of disease management guidelines. Global Initiative for Asthma guidelines include tiotropium as an add-on therapy option at Steps 4 and 5 in patients aged ≥ 12 years with a history of exacerbations, and tiotropium delivered via the Respimat® Soft Mist™ Inhaler has recently been approved for use as once-daily maintenance therapy for children with asthma over the age of 6 years in the USA. A large clinical trial program has been conducted in children, adolescents, and adults across the spectrum of asthma severity. Findings from these clinical studies and pooled analyses in children and adolescents with symptomatic moderate or severe asthma have demonstrated that tiotropium Respimat® as add-on to inhaled corticosteroids, with or without other maintenance therapies, is a well-tolerated and efficacious bronchodilator, showing improved lung function and trends towards improved asthma control, mirroring findings in adult studies. This review discusses the evidence to date for tiotropium Respimat® for the management of asthma in adolescents and children with symptomatic moderate and severe asthma, and considers the challenges of asthma management in these patients. Factors affecting this population group, such as poor adherence, underreporting of symptoms, and social and psychological issues, are highlighted, along with the need for active review and management of treatment to help achieve optimal control.
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Affiliation(s)
- Eckard Hamelmann
- Children's Center Bethel, Evangelisches Klinikum Bethel GmbH, Grenzweg 10, 33617, Bielefeld, Germany.
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, USA
- Breathing Institute, Children's Hospital Colorado, Aurora, USA
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12
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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: 257] [Impact Index Per Article: 42.8] [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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13
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Tiotropium for the Treatment of Asthma: Patient Selection and Perspectives. Can Respir J 2018; 2018:3464960. [PMID: 29670674 PMCID: PMC5833870 DOI: 10.1155/2018/3464960] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/13/2017] [Indexed: 11/17/2022] Open
Abstract
Asthma is a chronic disease of airway inflammation with a large global burden. Despite established, guideline-based stepwise therapy, a significant proportion of patients remain symptomatic and poorly controlled. As such, there is a need for additional safe, effective, convenient, and cost-effective therapies that can be broadly applied across a range of asthma phenotypes. Tiotropium is a long-acting muscarinic antagonist (LAMA) that leads to bronchodilation by blocking endogenous acetylcholine receptors in the airways. Tiotropium has long been approved for the treatment of chronic obstructive pulmonary disease, and it has recently been recognized for its safety and efficacy in improving lung function and controlling asthma. Evidence from several Phase III trials in the adult and paediatric population has shown that tiotropium is well tolerated and significantly improves a range of endpoints as an add-on treatment to ICS therapy, regardless of baseline characteristics and clinical phenotypes. Consequently, regulatory authorities worldwide have recently licensed tiotropium as the only LAMA approved for the treatment of asthma. This review provides an overview of safety and efficacy data and discusses the use of tiotropium in patients across the range of asthma severities, ages, and phenotypes.
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14
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Abstract
Asthma is the most common chronic disease in children. As suggested by international guidelines, the main goals of asthma treatment are symptoms control and lung function preservation, through a stepwise and control-based approach. The first line therapy based on inhaled corticosteroids may fail to reach control in more than one third of patients, especially adolescents, and in these lung function and quality of life may progressively worsen. Treatment with omalizumab, the first anti-immunoglobulin E recombinant humanized monoclonal antibody, has been definitely approved in pediatric uncontrolled asthma. In this review, we discuss the mechanisms and potential roles of emerging therapies for pediatric severe asthma. Novel biologic drugs (i.e., dupilumab, mepolizumab, reslizumab, and benralizumab) seem to be promising in reducing annual exacerbation rates and steroid-use in glucocorticoid-dependent cases, but available data are few and limited to adolescents and adults. Evidences on the use of the muscarinic antagonist tiotropium as controller medication in pediatric settings are progressively growing, sustaining an application as asthma maintenance treatment in children aged >6 years and in preschool children with persistent asthmatic symptoms, but well powered trials are needed to confirm its safety and efficacy. New inhaled corticosteroids (i.e., ciclesonide and mometasone) are effective as once-daily controller therapy, but long-term studies in the different pediatric ages are needed to compare effectiveness and safety to usual treatments. At present, the role of macrolides in pediatric severe asthma is controversial and their administration is not recommended routinely, but may be considered in children with neutrophilic asthma for reducing daily oral steroids administration and improving lung function. Despite the availability of several novel therapeutic strategies for uncontrolled asthma, future trials targeted at specific pediatric age subgroups are needed to support evidences of safety and efficacy also in children.
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Affiliation(s)
- Marco Maglione
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
| | - Marco Poeta
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
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15
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Kirkland SW, Vandenberghe C, Voaklander B, Nikel T, Campbell S, Rowe BH. Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma. Cochrane Database Syst Rev 2017; 1:CD001284. [PMID: 28076656 PMCID: PMC6465060 DOI: 10.1002/14651858.cd001284.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Inhaled short-acting anticholinergics (SAAC) and short-acting beta₂-agonists (SABA) are effective therapies for adult patients with acute asthma who present to the emergency department (ED). It is unclear, however, whether the combination of SAAC and SABA treatment is more effective in reducing hospitalisations compared to treatment with SABA alone. OBJECTIVES To conduct an up-to-date systematic search and meta-analysis on the effectiveness of combined inhaled therapy (SAAC + SABA agents) vs. SABA alone to reduce hospitalisations in adult patients presenting to the ED with an exacerbation of asthma. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, SCOPUS, LILACS, ProQuest Dissertations & Theses Global and evidence-based medicine (EBM) databases using controlled vocabulary, natural language terms, and a variety of specific and general terms for inhaled SAAC and SABA drugs. The search spanned from 1946 to July 2015. The Cochrane Airways Group provided search results from the Cochrane Airways Group Register of Trials which was most recently conducted in July 2016. An extensive search of the grey literature was completed to identify any other potentially relevant studies. SELECTION CRITERIA Included studies were randomised or controlled clinical trials comparing the effectiveness of combined inhaled therapy (SAAC and SABA) to SABA treatment alone to prevent hospitalisations in adults with acute asthma in the emergency department. Two independent review authors assessed studies for inclusion using pre-determined criteria. DATA COLLECTION AND ANALYSIS For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RR) or odds ratios (OR) with 95% confidence intervals (CI) using a random-effects model and reporting heterogeneity (I²). For continuous outcomes, we reported individual trial results using mean differences (MD) and pooled results as weighted mean differences (WMD) or standardised mean differences (SMD) with 95% CIs using a random-effects model. MAIN RESULTS We included 23 studies that involved a total of 2724 enrolled participants. Most studies were rated at unclear or high risk of bias.Overall, participants receiving combination inhaled therapy were less likely to be hospitalised (RR 0.72, 95% CI 0.59 to 0.87; participants = 2120; studies = 16; I² = 12%; moderate quality of evidence). An estimated 65 fewer patients per 1000 would require hospitalisation after receiving combination therapy (95% 30 to 95), compared to 231 per 1000 patients receiving SABA alone. Although combination inhaled therapy was more effective than SABA treatment alone in reducing hospitalisation in participants with severe asthma exacerbations, this was not found for participants with mild or moderate exacerbations (test for difference between subgroups P = 0.02).Participants receiving combination therapy were more likely to experience improved forced expiratory volume in one second (FEV₁) (MD 0.25 L, 95% CI 0.02 to 0.48; participants = 687; studies = 6; I² = 70%; low quality of evidence), peak expiratory flow (PEF) (MD 36.58 L/min, 95% CI 23.07 to 50.09; participants = 1056; studies = 12; I² = 25%; very low quality of evidence), increased percent change in PEF from baseline (MD 24.88, 95% CI 14.83 to 34.93; participants = 551; studies = 7; I² = 23%; moderate quality of evidence), and were less likely to return to the ED for additional care (RR 0.80, 95% CI 0.66 to 0.98; participants = 1180; studies = 5; I² = 0%; moderate quality of evidence) than participants receiving SABA alone.Participants receiving combination inhaled therapy were more likely to experience adverse events than those treated with SABA agents alone (OR 2.03, 95% CI 1.28 to 3.20; participants = 1392; studies = 11; I² = 14%; moderate quality of evidence). Among patients receiving combination therapy, 103 per 1000 were likely to report adverse events (95% 31 to 195 more) compared to 131 per 1000 patients receiving SABA alone. AUTHORS' CONCLUSIONS Overall, combination inhaled therapy with SAAC and SABA reduced hospitalisation and improved pulmonary function in adults presenting to the ED with acute asthma. In particular, combination inhaled therapy was more effective in preventing hospitalisation in adults with severe asthma exacerbations who are at increased risk of hospitalisation, compared to those with mild-moderate exacerbations, who were at a lower risk to be hospitalised. A single dose of combination therapy and multiple doses both showed reductions in the risk of hospitalisation among adults with acute asthma. However, adults receiving combination therapy were more likely to experience adverse events, such as tremor, agitation, and palpitations, compared to patients receiving SABA alone.
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Affiliation(s)
- Scott W Kirkland
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | | | - Britt Voaklander
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Taylor Nikel
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Sandra Campbell
- University of AlbertaJohn W. Scott Health Sciences LibraryEdmontonABCanada
| | - Brian H Rowe
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
- University of AlbertaSchool of Public HeathEdmontonCanada
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16
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Martin Alonso A, Saglani S. Mechanisms Mediating Pediatric Severe Asthma and Potential Novel Therapies. Front Pediatr 2017; 5:154. [PMID: 28725641 PMCID: PMC5497140 DOI: 10.3389/fped.2017.00154] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/20/2017] [Indexed: 12/21/2022] Open
Abstract
Although a rare disease, severe therapy-resistant asthma in children is a cause of significant morbidity and results in utilization of approximately 50% of health-care resources for asthma. Improving control for children with severe asthma is, therefore, an urgent unmet clinical need. As a group, children with severe asthma have severe and multiple allergies, steroid resistant airway eosinophilia, and significant structural changes of the airway wall (airway remodeling). Omalizumab is currently the only add-on therapy that is licensed for use in children with severe asthma. However, limitations of its use include ineligibility for approximately one-third of patients because of serum IgE levels outside the recommended range and lack of clinical efficacy in a further one-third. Pediatric severe asthma is thus markedly heterogeneous, but our current understanding of the different mechanisms underpinning various phenotypes is very limited. We know that there are distinctions between the factors that drive pediatric and adult disease since pediatric disease develops in the context of a maturing immune system and during lung growth and development. This review summarizes the current data that give insight into the pathophysiology of pediatric severe asthma and will highlight potential targets for novel therapies. It is apparent that in order to identify novel treatments for pediatric severe asthma, the challenge of undertaking mechanistic studies using age appropriate experimental models and airway samples from children needs to be accepted to allow a targeted approach of personalized medicine to be achieved.
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Affiliation(s)
- Aldara Martin Alonso
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Sejal Saglani
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Respiratory Pediatrics, The Royal Brompton Hospital, London, United Kingdom
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17
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Halpin DMG. Tiotropium in asthma: what is the evidence and how does it fit in? World Allergy Organ J 2016; 9:29. [PMID: 27679681 PMCID: PMC5022240 DOI: 10.1186/s40413-016-0119-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/03/2016] [Indexed: 12/11/2022] Open
Abstract
Despite current therapeutic approaches asthma remains uncontrolled in a significant proportion of patients. Short-acting anticholinergic bronchodilators have a very long history of use in asthma, and recent data confirms the importance of acetylcholine as both a bronchoconstrictor and as a regulator of inflammation and remodeling in the lungs. Data from a comprehensive clinical trial programme, as well as use in primary care, show the efficacy and safety of tiotropium in adults with mild to moderate asthma when it is added to ICS and in severe asthma when it is added to high doses of ICS plus LABA, as well as in adolescents. Tiotropium is cost effective and its benefits are not restricted to particular phenotypes, making it a useful addition to the therapeutic options recommended by the Global Initiative for Asthma (GINA) for people with poorly controlled asthma at steps 4 & 5.
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18
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Vogelberg C. Tiotropium in the add-on treatment of asthma in adults: clinical trial evidence and experience. Ther Adv Respir Dis 2016; 10:525-533. [PMID: 27612491 PMCID: PMC5933593 DOI: 10.1177/1753465816662571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease, and its treatment is frequently
challenging despite detailed national and international guidelines. While basic
anti-inflammatory therapy usually consists of inhaled corticosteroids in doses
adapted to the asthma severity, add-on treatment with bronchodilators is
essential in more severe asthma. Only recently, the long-acting anticholinergic
tiotropium was introduced into the GINA guidelines. This review reports on the
studies that have been performed with tiotropium in adult asthmatic patients.
Following early proof-of-concept studies, several studies with tiotropium as an
add-on therapy to inhaled corticosteroids (ICS), with or without a long-acting
beta agonist (LABA), demonstrated convincing clinical benefit for patients.
Important lung function parameters and quality of life scores significantly
improved shortly after onset of the add-on therapy with tiotropium, and some
studies even demonstrated non-inferiority against salmeterol. All studies
reported an excellent safety profile of tiotropium. The still growing body of
tiotropium studies, both in adults and children, will help to identify the
position of tiotropium in future asthma guidelines and might also indicate which
patients benefit most from an add-on therapy with tiotropium.
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Affiliation(s)
- Christian Vogelberg
- University Hospital Carl Gustav Carus, Department of Pediatric Pulmonology and Allergology, Fetscherstr. 74, 01307 Dresden, Germany
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19
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Abstract
Viral exacerbations continue to represent the major burden in terms of morbidity, mortality and health care costs associated with asthma. Those at greatest risk for acute asthma are those with more severe airways disease and poor asthma control. It is this group with established asthma in whom acute exacerbations triggered by virus infections remain a serious cause of increased morbidity. A range of novel therapies are emerging to treat asthma and in particular target this group with poor disease control, and in most cases their efficacy is now being judged by their ability to reduce the frequency of acute exacerbations. Critical for the development of new treatment approaches is an improved understanding of virus-host interaction in the context of the asthmatic airway. This requires research into the virology of the disease in physiological models in conjunction with detailed phenotypic characterisation of asthma patients to identify targets amenable to therapeutic intervention.
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Affiliation(s)
- Hock Tay
- a Hunter Medical Research Institute , Newcastle , Australia.,b Priority Research Centre for Healthy Lungs , The University of Newcastle , Australia
| | - Peter A B Wark
- a Hunter Medical Research Institute , Newcastle , Australia.,b Priority Research Centre for Healthy Lungs , The University of Newcastle , Australia.,c Centre of Excellence in Severe Asthma , The University of Newcastle , Australia.,d Department of Respiratory and Sleep Medicine , John Hunter Hospital , Newcastle , Australia
| | - Nathan W Bartlett
- a Hunter Medical Research Institute , Newcastle , Australia.,b Priority Research Centre for Healthy Lungs , The University of Newcastle , Australia.,e National Heart and Lung Institute , Imperial College London , London , UK
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20
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Donohue JF, Wise R, Busse WW, Garfinkel S, Zubek VB, Ghafouri M, Manuel RC, Schlenker-Herceg R, Bleecker ER. Efficacy and safety of ipratropium bromide/albuterol compared with albuterol in patients with moderate-to-severe asthma: a randomized controlled trial. BMC Pulm Med 2016; 16:65. [PMID: 27130202 PMCID: PMC4851785 DOI: 10.1186/s12890-016-0223-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 04/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many patients with asthma require frequent rescue medication for acute symptoms despite appropriate controller therapies. Thus, determining the most effective relief regimen is important in the management of more severe asthma. This study's objective was to evaluate whether ipratropium bromide/albuterol metered-dose inhaler (CVT-MDI) provides more effective acute relief of bronchospasm in moderate-to-severe asthma than albuterol hydrofluoroalkaline (ALB-HFA) alone after 4 weeks. METHODS In this double-blind, crossover study, patients who had been diagnosed with asthma for ≥1 year were randomized to two sequences of study medication "as needed" for symptom relief (1-7 day washout before second 4-week treatment period): CVT-MDI/ALB-HFA or ALB-HFA/CVT-MDI. On days 1 and 29 of each sequence, 6-hour serial spirometry was performed after administration of the study drug. Co-primary endpoints were FEV1 area under the curve (AUC0-6) and peak (post-dose) forced expiratory volume in 1 s (FEV1) response (change from test day baseline) after 4 weeks. The effects of "as needed" treatment with ALB-HFA/CVT-MDI were analyzed using mixed effect model repeated measures (MMRM). RESULTS A total of 226 patients, ≥18 years old, with inadequately controlled, moderate-to-severe asthma were randomized. The study met both co-primary endpoints demonstrating a statistically significant treatment benefit of CVT-MDI versus ALB-HFA. FEV1 AUC0-6h response was 167 ml for ALB-HFA, 252 ml for CVT-MDI (p <0.0001); peak FEV1 response was 357 ml for ALB-HFA, 434 ml for CVT-MDI (p <0.0001). Adverse events were comparable across groups. CONCLUSIONS CVT-MDI significantly improved acute bronchodilation over ALB-HFA alone after 4 weeks of "as-needed" use for symptom relief, with a similar safety profile. This suggests additive bronchodilator effects of β2-agonist and anticholinergic treatment in moderate-to-severe, symptomatic asthma. TRIAL REGISTRATION ClinicalTrials.gov No.: NCT00818454 ; Registered November 16, 2009.
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Affiliation(s)
- James F Donohue
- Division of Pulmonary Diseases & Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Robert Wise
- Pulmonary and Critical Care Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William W Busse
- Department of Medicine, University of Wisconsin, Wisconsin, WI, USA
| | | | | | - Mo Ghafouri
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA.,Previously of Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | | | | | - Eugene R Bleecker
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine, Winston-Salem, NC, 27157, USA.
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21
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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22
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Albertson TE, Sutter ME, Chan AL. The acute management of asthma. Clin Rev Allergy Immunol 2015; 48:114-25. [PMID: 25213370 DOI: 10.1007/s12016-014-8448-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, PSSB 3400, 4150 V Street, Sacramento, CA, 95817, USA,
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23
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Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, Prasad KT, Yenge LB, Singh N, Behera D, Jindal SK, Gupta D, Balamugesh T, Bhalla A, Chaudhry D, Chhabra SK, Chokhani R, Chopra V, Dadhwal DS, D’Souza G, Garg M, Gaur SN, Gopal B, Ghoshal AG, Guleria R, Gupta KB, Haldar I, Jain S, Jain NK, Jain VK, Janmeja AK, Kant S, Kashyap S, Khilnani GC, Kishan J, Kumar R, Koul PA, Mahashur A, Mandal AK, Malhotra S, Mohammed S, Mohapatra PR, Patel D, Prasad R, Ray P, Samaria JK, Singh PS, Sawhney H, Shafiq N, Sharma N, Sidhu UPS, Singla R, Suri JC, Talwar D, Varma S. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015; 32:S3-S42. [PMID: 25948889 PMCID: PMC4405919 DOI: 10.4103/0970-2113.154517] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Venkata N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Lakshmikant B Yenge
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Thanagakunam Balamugesh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashish Bhalla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dhruva Chaudhry
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sunil K Chhabra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ramesh Chokhani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vishal Chopra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Devendra S Dadhwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - George D’Souza
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Mandeep Garg
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Shailendra N Gaur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Bharat Gopal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Aloke G Ghoshal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Krishna B Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Indranil Haldar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sanjay Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nirmal K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vikram K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok K Janmeja
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surya Kant
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surender Kashyap
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai Kishan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Raj Kumar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok Mahashur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Amit K Mandal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Samir Malhotra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sabir Mohammed
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dharmesh Patel
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rajendra Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Pallab Ray
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai K Samaria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Potsangbam Sarat Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Honey Sawhney
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nusrat Shafiq
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Updesh Pal S Sidhu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rupak Singla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jagdish C Suri
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Deepak Talwar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Subhash Varma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
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Schivo M, Phan C, Louie S, Harper RW. Critical asthma syndrome in the ICU. Clin Rev Allergy Immunol 2015; 48:31-44. [PMID: 25759905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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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Ansarin K, Attaran D, Jamaati H, Masjedi MR, Abtahi H, Alavi A, Aliyali M, Asnaashari AMH, Farid-Hosseini R, Ghayumi SMA, Ghobadi H, Ghotb A, Halvani A, Nemati A, Rahimi Rad MH, Rahimian M, Sami R, Sohrabpour H, Tavana S, Torabi-Nami M, Vahedi P. Approach to Patients with Severe Asthma: a Consensus Statement from the Respiratory Care Experts' Input Forum (RC-EIF), Iran. TANAFFOS 2015; 14:73-94. [PMID: 26528362 PMCID: PMC4629434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Challenges in the assessment, diagnosis and management of severe, difficult-to-control asthma are increasingly regarded as clinical needs yet unmet. The assessments required to determine asthma severity, comorbidities and confounding factors, disease phenotypes and optimal treatment are among the controversial issues in the field. The respiratory care experts' input forum (RC-EIF), comprised of an Iranian panel of experts, reviewed the definition, appraised the available guidelines and provided a consensus for evaluation and treatment of severe asthma in adults. A systematic literature review followed by discussions during and after the forum, yielded the present consensus. The expert panel used the appraisal of guidelines for research and evaluation-II (AGREE-II) protocol to define an initial locally-adapted strategy for the management of severe asthma. Severe asthma is considered a heterogeneous condition with various phenotypes. Issues such as assessment of difficult-to-control asthma, phenotyping, the use of blood and sputum eosinophil count, exhaled nitric oxide to guide therapy, the position of anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty as well as the use of established, recently-developed and evolving treatment approaches were discussed and unanimously agreed upon in the panel. A systematic approach is required to ensure proper diagnosis, evaluate compliance, and to identify comorbidities and triggering factors in severe asthma. Phenotyping helps select optimized treatment. The treatment approach laid down by the Global Initiative for Asthma (GINA) needs to be followed, while the benefit of using biological therapies should be weighed against the cost and safety concerns.
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Affiliation(s)
- Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Davood Attaran
- Lung Disease Research Center, Mashhad University of Medical Science, Mashhad, Iran
| | - Hamidreza Jamaati
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Masjedi
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Abtahi
- Advanced Thoracic Research Center, Pulmonary and Critical Care Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Alavi
- Department of Pulmonology, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Masoud Aliyali
- Department of Internal Medicine, Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Reza Farid-Hosseini
- Allergy Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyyed Mohammad Ali Ghayumi
- Department of Internal Medicine, Division of Pulmonology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hassan Ghobadi
- Department of Internal Medicine, Pulmonary Division, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Atabak Ghotb
- Behphar Scientific Committee, Behphar Group, Tehran, Iran
| | | | - Abbas Nemati
- Department of Pulmonology, Artesh University of Medical Sciences, Tehran, Iran
| | | | - Masoud Rahimian
- Department of Internal medicine, Division of Pulmonary and Critical Care Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Ramin Sami
- Department of Pulmonary Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Hamid Sohrabpour
- Department of Pulmonary Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sasan Tavana
- Clinical Research & Development Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Torabi-Nami
- Behphar Scientific Committee, Behphar Group, Tehran, Iran,Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence to: Torabi-Nami M, Address: Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran, Email address:
| | - Parviz Vahedi
- Division of Pulmonology, Department of Internal Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Soler X, Ramsdell J. Anticholinergics/antimuscarinic drugs in asthma. Curr Allergy Asthma Rep 2014; 14:484. [PMID: 25283149 DOI: 10.1007/s11882-014-0484-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Anticholinergic alkaloids have been used for thousands of years for the relief of bronchoconstriction and other respiratory symptoms, and their use in the treatment of chronic obstructive pulmonary disease is well established. Acetylcholine, acting through muscarinic receptor (M) receptor, modulates multiple physiologic functions pertinent to asthma including airway muscle tone, mucus gland secretion, and various parameters of inflammation and remodeling. In addition, activation of M receptors may inhibit beta2 adrenoreceptor. These observations offer the rationale for the use of M receptors antagonists in the treatment of asthma. Short-acting antimuscarinic agents may be effective alone or in combination with short-acting beta agonists for the relief of acute symptoms. Long-acting antimuscarinic agents have emerged as potentially useful in the long-term treatment of difficult-to-control asthma. This review will analyze the mechanisms of action and therapeutic role of antimuscarinic agents on asthma including current guidelines regarding antimuscarinic drugs, recent studies in asthma, special populations to consider, and possible predictors of response.
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Affiliation(s)
- Xavier Soler
- Department of Medicine, University of California, 200 West Arbor Dr., San Diego, CA, 92103, USA
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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: 84] [Impact Index Per Article: 8.4] [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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Dasgupta S, Williams EW, Walters C, Eldemire-Shearer D, Williams-Johnson J. A clinical audit of the management of acute asthmatic attacks in adults and children presenting to an emergency department. W INDIAN MED J 2014; 63:226-33. [PMID: 25314279 PMCID: PMC4663904 DOI: 10.7727/wimj.2013.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 02/27/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the guidelines in the University Hospital of the West Indies (UHWI) acute asthma management protocol with actual practice in the Accident and Emergency Department. METHODS A prospective docket audit was done of all consecutive medical records of patients, presenting with a diagnosed acute asthmatic attack between June 1 and September 30, 2010, to the emergency department of the UHWI. A convenient sample was used. The audit tool used was created from the UHWI protocol for the emergency management of asthma in adults and children, as well as the British Adult Asthma Audit Tool. The audit tool assessed three main sections: initial assessment, initial management, and discharge considerations. Data were coded and entered in Microsoft Excel 2007 and statistical analyses conducted using Stata version 10. Management patterns were compared to the actual protocol and then discussed. RESULTS A total of 15 864 patients were seen during the study period. Of these, a total of 293 patients were seen for a presentation of acute asthma. More females (57.3%) than males were seen, with the mean age of 33.53 years. Only 31% of patients were given a severity assessment of mild, moderate, or severe. Peak expiratory flow rate (PEFR) was attempted and recorded in 62%, but only 18.1% of patients had both pre and post PEFR done. Only 4.4% of patients were administered nebulizations within the suggested time frame. Positively, 94.2% of patients were given a prescription for inhaled corticosteroids and bronchodilators to continue post-discharge. CONCLUSIONS Acute asthma management still remains an area of medical practice that continues to have long-standing difficulties. Failure to assess and document the severity of asthma attacks along with the under-utilization of PEFR was noted.
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Affiliation(s)
- S Dasgupta
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies, Kingston 7, Jamaica.
| | - E W Williams
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies, Kingston 7, Jamaica
| | - C Walters
- Office of Research, Dean's Office, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica
| | - D Eldemire-Shearer
- Department of Community Health and Psychiatry, The University of the West Indies, Kingston 7, Jamaica
| | - J Williams-Johnson
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies, Kingston 7, Jamaica
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Szefler SJ, Chmiel JF, Fitzpatrick AM, Giacoia G, Green TP, Jackson DJ, Nielsen HC, Phipatanakul W, Raissy HH. Asthma across the ages: knowledge gaps in childhood asthma. J Allergy Clin Immunol 2014; 133:3-13; quiz 14. [PMID: 24290281 PMCID: PMC3925634 DOI: 10.1016/j.jaci.2013.10.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/17/2013] [Accepted: 10/21/2013] [Indexed: 01/01/2023]
Abstract
The Eunice Kennedy Shriver National Institute of Child Health and Human Development convened an Asthma Group in response to the Best Pharmaceuticals for Children Act. The overall goal of the Best Pharmaceuticals for Children Act Program is to improve pediatric therapeutics through preclinical and clinical drug trials that lead to drug-labeling changes. Although significant advances have been made in the understanding and management of asthma in adults with appropriately labeled medications, less information is available on the management of asthma in children. Indeed, many medications are inadequately labeled for use in children. In general, the younger the child, the less information there is available to guide clinicians. Because asthma often begins in early childhood, it is incumbent on us to continue to address the primary questions raised in this review and carefully evaluate the medications used to manage asthma in children. Meanwhile, continued efforts should be made in defining effective strategies that reduce the risk of exacerbations. If the areas of defined need are addressed in the coming years, namely prevention of exacerbations and progression of disease, as well as primary intervention, we will see continuing reduction in asthma mortality and morbidity along with improved quality of life for children with asthma.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics and Pharmacology, National Jewish Health, and the University of Colorado School of Medicine, Denver, Colo.
| | - James F Chmiel
- University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anne M Fitzpatrick
- Emory University Department of Pediatrics and Children's Healthcare of Atlanta Center for Developmental Lung Biology, Atlanta, Ga
| | - George Giacoia
- National Institute of Child Health and Development, Bethesda, Md
| | - Thomas P Green
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Heber C Nielsen
- Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
| | | | - Hengameh H Raissy
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
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Nievas IFF, Anand KJS. Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit. J Pediatr Pharmacol Ther 2013; 18:88-104. [PMID: 23798903 DOI: 10.5863/1551-6776-18.2.88] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients. METHODS Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980-2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital. RESULTS Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status. CONCLUSIONS Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.
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Affiliation(s)
- I Federico Fernandez Nievas
- Departments of Pediatrics, Anesthesiology, Anatomy & Neurobiology, Division of Critical Care Medicine, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee
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Ortiz-Alvarez O, Mikrogianakis A. Managing the paediatric patient with an acute asthma exacerbation. Paediatr Child Health 2013; 17:251-62. [PMID: 23633900 DOI: 10.1093/pch/17.5.251] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Children with acute asthma exacerbations frequently present to an emergency department with signs of respiratory distress. The most severe episodes are potentially life-threatening. Effective treatment depends on the accurate and rapid assessment of disease severity at presentation. This statement addresses the assessment, management and disposition of paediatric patients with a known diagnosis of asthma who present with an acute asthma exacerbation, especially preschoolers at high risk for persistent asthma. Guidance includes the assessment of asthma severity, treatment considerations, proper discharge planning, follow-up, and prescription for inhaled corticosteroids to prevent exacerbation and decrease chronic morbidity.
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32
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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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Hodder R. Critical care in the ED: potentially fatal asthma and acute lung injury syndrome. Open Access Emerg Med 2012; 4:53-68. [PMID: 27147862 PMCID: PMC4753975 DOI: 10.2147/oaem.s30998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Emergency department clinicians are frequently called upon to assess, diagnose, and stabilize patients who present with acute respiratory failure. This review describes a rapid initial approach to acute respiratory failure in adults, illustrated by two common examples: (1) an airway disease - acute potentially fatal asthma, and (2) a pulmonary parenchymal disease - acute lung injury/acute respiratory distress syndrome. As such patients are usually admitted to hospital, discussion will be focused on those initial management aspects most relevant to the emergency department clinician.
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Affiliation(s)
- Rick Hodder
- Divisions of Pulmonary and Critical Care, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
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34
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Advanced nursing directives: integrating validated clinical scoring systems into nursing care in the pediatric emergency department. Nurs Res Pract 2012; 2012:596393. [PMID: 22778944 PMCID: PMC3384969 DOI: 10.1155/2012/596393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 02/06/2012] [Accepted: 02/20/2012] [Indexed: 11/24/2022] Open
Abstract
In an effort to improve the quality and flow of care provided to children presenting to the emergency department the implementation of nurse-initiated protocols is on the rise. We review the current literature on nurse-initiated protocols, validated emergency department clinical scoring systems, and the merging of the two to create Advanced Nursing Directives (ANDs). The process of developing a clinical pathway for children presenting to our pediatric emergency department (PED) with suspected appendicitis will be used to demonstrate the successful integration of validated clinical scoring systems into practice through the use of Advanced Nursing Directives. Finally, examples of 2 other Advanced Nursing Directives for common clinical PED presentations will be provided.
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Okpapi A, Friend AJ, Turner SW. Asthma and other recurrent wheezing disorders in children (acute). BMJ CLINICAL EVIDENCE 2012; 2012:0300. [PMID: 24807832 PMCID: PMC3390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Acute childhood asthma is a common clinical emergency presenting across a range of ages and with a range of severities. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute asthma in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 35 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: beta2 agonists (high-dose nebulised, metered-dose inhaler plus spacer device versus nebuliser, intravenous), corticosteroids (systemic, high-dose inhaled), ipratropium bromide (single- or multiple-dose inhaled), magnesium sulphate, oxygen, and theophylline or aminophylline.
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36
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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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37
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Abstract
In healthy lungs, muscarinic receptors control smooth muscle tone, mucus secretion, vasodilation, and inflammation. In chronic obstructive pulmonary disease (COPD) and asthma, cholinergic mechanisms contribute to increased bronchoconstriction and mucus secretion that limit airflow. This chapter reviews neuronal and nonneuronal sources of acetylcholine in the lung and the expression and role of M₁, M₂, and M₃ muscarinic receptor subtypes in lung physiology. It also discusses the evidence for and against the role of parasympathetic nerves in asthma, and the current use and therapeutic potential of muscarinic receptor antagonists in COPD and asthma.
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Affiliation(s)
- Kalmia S. Buels
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, UHN67, Portland, OR 97239, USA
| | - Allison D. Fryer
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, UHN67, Portland, OR 97239, USA
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38
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Grover S, Jindal A, Bansal A, Singhi SC. Acute bronchial asthma. Indian J Pediatr 2011; 78:1388-95. [PMID: 21769523 DOI: 10.1007/s12098-011-0524-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 05/30/2011] [Indexed: 11/29/2022]
Abstract
Acute asthma is the third commonest cause of pediatric emergency visits at PGIMER. Typically, it presents with acute onset respiratory distress and wheeze in a patient with past or family history of similar episodes. The severity of the acute episode of asthma is judged clinically and categorized as mild, moderate and severe. The initial therapy consists of oxygen, inhaled beta-2 agonists (salbutamol or terbutaline), inhaled budesonide (three doses over 1 h, at 20 min interval) in all and ipratropium bromide and systemic steroids (hydrocortisone or methylprednisolone) in acute severe asthma. Other causes of acute onset wheeze and breathing difficulty such as pneumonia, foreign body, cardiac failure etc. should be ruled out with help of chest radiography and appropriate laboratory investigations in first time wheezers and those not responding to 1 h of inhaled therapy. In case of inadequate response or worsening, intravenous infusion of magnesium sulphate, terbutaline or aminophylline may be used. Magnesium sulphate is the safest and most effective alternative among these. Severe cases may need ICU care and rarely, ventilatory support.
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Affiliation(s)
- Sudhanshu Grover
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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39
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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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40
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Tapp H, Hebert L, Dulin M. Comparative effectiveness of asthma interventions within a practice based research network. BMC Health Serv Res 2011; 11:188. [PMID: 21846401 PMCID: PMC3176175 DOI: 10.1186/1472-6963-11-188] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/16/2011] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers. METHODS/DESIGN This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance. DISCUSSION Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.
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Affiliation(s)
- Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Charlotte, NC 28207. USA
| | - Lisa Hebert
- Carolinas Physicians Network, Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232, USA
| | - Michael Dulin
- Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Charlotte, NC 28207. USA
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41
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Moulton BC, Fryer AD. Muscarinic receptor antagonists, from folklore to pharmacology; finding drugs that actually work in asthma and COPD. Br J Pharmacol 2011; 163:44-52. [PMID: 21198547 DOI: 10.1111/j.1476-5381.2010.01190.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In the lungs, parasympathetic nerves provide the dominant control of airway smooth muscle with release of acetylcholine onto M3 muscarinic receptors. Treatment of airway disease with anticholinergic drugs that block muscarinic receptors began over 2000 years ago. Pharmacologic data all indicated that antimuscarinic drugs should be highly effective in asthma but clinical results were mixed. Thus, with the discovery of effective β-adrenergic receptor agonists the use of muscarinic antagonists declined. Lack of effectiveness of muscarinic antagonists is due to a variety of factors including unwanted side effects (ranging from dry mouth to coma) and the discovery of additional muscarinic receptor subtypes in the lungs with sometimes competing effects. Perhaps the most important problem is ineffective dosing due to poorly understood differences between routes of administration and no effective way of testing whether antagonists block receptors stimulated physiologically by acetylcholine. Newer muscarinic receptor antagonists are being developed that address the problems of side effects and receptor selectivity that appear to be quite promising in the treatment of asthma and chronic obstructive pulmonary disease.
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Affiliation(s)
- Bart C Moulton
- Division Pulmonary and Critical Care Medicine, Oregon Health Sciences University, Portland, 97239, USA.
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42
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Rodrigo G. Asthma in adults (acute). BMJ CLINICAL EVIDENCE 2011; 2011:1513. [PMID: 21463536 PMCID: PMC3661228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION About 10% of adults have suffered an attack of asthma, and up to 5% of these have severe disease that responds poorly to treatment. Patients with severe disease have an increased risk of death, but patients with mild to moderate disease are also at risk of exacerbations. Most guidelines about the management of asthma follow stepwise protocols. This review does not endorse or follow any particular protocol, but presents the evidence about specific interventions. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute asthma? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 100 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: beta(2) agonists (plus ipratropium bromide, pressured metered-dose inhalers, short-acting continuous nebulised, short-acting intermittent nebulised, short-acting iv, and inhaled formoterol); corticosteroids (inhaled); corticosteroids (single oral, combined inhaled, and short courses); education about acute asthma; generalist care; helium-oxygen mixture (heliox); magnesium sulphate (iv and adding isotonic nebulised magnesium to inhaled beta(2) agonists); mechanical ventilation; oxygen supplementation (controlled 28% oxygen and controlled 100% oxygen); and specialist care.
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Affiliation(s)
- Gustavo Rodrigo
- Departmento de Emergencia, Hospital Central de las Fuerzas Armadas, Uraguay
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43
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Kelly HW. Anticholinergics in Chronic Asthma: A Promising Future? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2011; 24:51-53. [PMID: 35927851 DOI: 10.1089/ped.2010.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Anticholinergics have been used for the treatment of asthma as bronchodilators for centuries, yet they have not gained U.S. Food and Drug Administration approval for use in asthma. Previous studies with the short-acting inhaled anticholinergics, ipratropium bromide, oxitropium bromide, and atropine methonitrate, have failed to demonstrate improved outcomes in chronic persistent asthma. Ipratropium bromide is recommended by national and international guidelines for the adjunctive treatment of severe acute asthma exacebations in the emergency department to reduce hospitalizations. A recent trial reported that the long-acting anticholinergic, tiotropium bromide, in those adult patients not adequately controlled on inhaled corticosteroid monotherapy improved impairment outcomes of lung function and symptoms compared to doubling the dose of inhaled corticosteroid similar to the effect of the addition of a long-acting β2 agonist. More studies are needed to determine whether tiotropium bromide can reduce the risk of asthma exacerbations, but the early results from the first study are promising.
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Affiliation(s)
- H William Kelly
- Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico
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44
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Saharan S, Lodha R, Kabra SK. Management of status asthmaticus in children. Indian J Pediatr 2010; 77:1417-23. [PMID: 20824393 DOI: 10.1007/s12098-010-0189-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 08/18/2010] [Indexed: 11/27/2022]
Abstract
Asthma is a common chronic inflammatory disorder of the airways characterized by recurrent wheezing, breathlessness, and coughing. Acute exacerbations of asthma can be life-threatening; annual worldwide estimated mortality is 250,000 and most of these deaths are preventable. While most of the acute exacerbations can be managed successfully in the emergency room, few children have severe exacerbations requiring intensive care. Mainstay of treatment for status asthmaticus are inhaled β2 agonist and anticholinergic agents, oxygen along with corticosteroids. Children who do not respond well to initial treatment require parenteral β2 agonist and magnesium. Rarely, sick children need parenteral aminophylline infusion and mechanical ventilation. Guidelines for diagnosis, treatment, ventilator management and supportive care for status asthmaticus in children are discussed in the protocol.
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Affiliation(s)
- Sunil Saharan
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 10029, India
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45
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Papiris SA, Manali ED, Kolilekas L, Triantafillidou C, Tsangaris I. Acute severe asthma: new approaches to assessment and treatment. Drugs 2010; 69:2363-91. [PMID: 19911854 DOI: 10.2165/11319930-000000000-00000] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The precise definition of a severe asthmatic exacerbation is an issue that presents difficulties. The term 'status asthmaticus' relates severity to outcome and has been used to define a severe asthmatic exacerbation that does not respond to and/or perilously delays the repetitive or continuous administration of short-acting inhaled beta(2)-adrenergic receptor agonists (SABA) in the emergency setting. However, a number of limitations exist concerning the quantification of unresponsiveness. Therefore, the term 'acute severe asthma' is widely used, relating severity mostly to a combination of the presenting signs and symptoms and the severity of the cardiorespiratory abnormalities observed, although it is well known that presentation does not foretell outcome. In an acute severe asthma episode, close observation plus aggressive administration of bronchodilators (SABAs plus ipratropium bromide via a nebulizer driven by oxygen) and oral or intravenous corticosteroids are necessary to arrest the progression to severe hypercapnic respiratory failure leading to a decrease in consciousness that requires intensive care unit (ICU) admission and, eventually, ventilatory support. Adjunctive therapies (intravenous magnesium sulfate and/or others) should be considered in order to avoid intubation. Management after admission to the hospital ward because of an incomplete response is similar. The decision to intubate is essentially based on clinical judgement. Although cardiac or respiratory arrest represents an absolute indication for intubation, the usual picture is that of a conscious patient struggling to breathe. Factors associated with the increased likelihood of intubation include exhaustion and fatigue despite maximal therapy, deteriorating mental status, refractory hypoxaemia, increasing hypercapnia, haemodynamic instability and impending coma or apnoea. To intubate, sedation is indicated in order to improve comfort, safety and patient-ventilator synchrony, while at the same time decrease oxygen consumption and carbon dioxide production. Benzodiazepines can be safely used for sedation of the asthmatic patient, but time to awakening after discontinuation is prolonged and difficult to predict. The most common alternative is propofol, which is attractive in patients with sudden-onset (near-fatal) asthma who may be eligible for extubation within a few hours, because it can be titrated rapidly to a deep sedation level and has rapid reversal after discontinuation; in addition, it possesses bronchodilatory properties. The addition of an opioid (fentanyl or remifentanil) administered by continuous infusion to benzodiazepines or propofol is often desirable in order to provide amnesia, sedation, analgesia and respiratory drive suppression. Acute severe asthma is characterized by severe pulmonary hyperinflation due to marked limitation of the expiratory flow. Therefore, the main objective of the initial ventilator management is 2-fold: to ensure adequate gas exchange and to prevent further hyperinflation and ventilator-associated lung injury. This may require hypoventilation of the patient and higher arterial carbon dioxide (PaCO(2)) levels and a more acidic pH. This does not apply to asthmatic patients intubated for cardiac or respiratory arrest. In this setting the post-anoxic brain oedema might demand more careful management of PaCO(2) levels to prevent further elevation of intracranial pressure and subsequent complications. Monitoring lung mechanics is of paramount importance for the safe ventilation of patients with status asthmaticus. The first line of specific pharmacological therapy in ventilated asthmatic patients remains bronchodilation with a SABA, typically salbutamol (albuterol). Administration techniques include nebulizers or metered-dose inhalers with spacers. Systemic corticosteroids are critical components of therapy and should be administered to all ventilated patients, although the dose of systemic corticosteroids in mechanically ventilated asthmatic patients remains controversial. Anticholinergics, inhaled corticosteroids, leukotriene receptor antagonists and methylxanthines offer little benefit, and clinical data favouring their use are lacking. In conclusion, expertise, perseverance, judicious decisions and practice of evidence-based medicine are of paramount importance for successful outcomes for patients with acute severe asthma.
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Affiliation(s)
- Spyros A Papiris
- 2nd Pulmonary Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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46
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Hodder R, Lougheed MD, Rowe BH, FitzGerald JM, Kaplan AG, McIvor RA. Management of acute asthma in adults in the emergency department: nonventilatory management. CMAJ 2010; 182:E55-67. [PMID: 19858243 PMCID: PMC2817338 DOI: 10.1503/cmaj.080072] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rick Hodder
- Division of Pulmonary Medicine, University of Ottawa, Ottawa, Ontario.
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47
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Dennis RJ, Solarte I, Rodrigo G. Asthma in adults. BMJ CLINICAL EVIDENCE 2010; 2010:1501. [PMID: 21718577 PMCID: PMC2907598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION About 10% of adults have suffered an attack of asthma, and up to 5% of these have severe disease that responds poorly to treatment. Patients with severe disease have an increased risk of death, but patients with mild-to-moderate disease are also at risk of exacerbations. Most guidelines about the management of asthma follow stepwise protocols. This review does not endorse or follow any particular protocol, but presents the evidence about specific interventions. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for chronic asthma? What are the effects of treatments for acute asthma? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 99 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review, we present information relating to the effectiveness and safety of the following interventions. For acute asthma: beta(2) agonists (plus ipratropium bromide, pressured metered-dose inhalers, short-acting continuous nebulised, short-acting intermittent nebulised, and short-acting intravenous); corticosteroids (inhaled); corticosteroids (single oral, combined inhaled, and short courses); education about acute asthma; generalist care; helium-oxygen mixture (heliox); magnesium sulphate (intravenous and adding isotonic nebulised magnesium to inhaled beta(2) agonists); mechanical ventilation; oxygen supplementation (controlled 28% oxygen and controlled 100% oxygen); and specialist care. For chronic asthma: beta(2) agonists (adding long-acting inhaled beta(2) agonists when asthma is poorly controlled by inhaled corticosteroids, or short-acting inhaled beta(2) agonists as needed for symptom relief); inhaled corticosteroids (low dose and increasing dose); leukotriene antagonists (with or without inhaled corticosteroids); and theophylline (when poorly controlled by inhaled corticosteroids).
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Affiliation(s)
- Rodolfo J Dennis
- Head, Departments of Medicine and Research, Fundacion Cardioinfantil Instituto de Cardiologia, Bogota, Colombia
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48
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Potter PC. Current guidelines for the management of asthma in young children. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2009; 2:1-13. [PMID: 20224672 PMCID: PMC2831604 DOI: 10.4168/aair.2010.2.1.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 10/28/2009] [Indexed: 01/09/2023]
Abstract
The diagnosis and management of asthma in young children is difficult, since there are many different wheezy phenotypes with varying underlying aetiologies and outcomes. This review discusses the different approaches to managing young children with wheezy illnesses presented in recently published global guidelines. Four major guidelines published since 2007 are considered. Helpful approaches are presented to assist the clinician to decide whether a clinical diagnosis of asthma can, or should be made in a young child with a recurrent wheezy illness and which treatments would be appropriate, dependent on risk factors, age of presentation, response to initial treatment and safety considerations. Each of the guidelines provide useful information for clinicians assessing young children with recurrent wheezy illnesses. There are differences in classification of the disease and treatment protocols. Although a firm diagnosis of asthma may only be made retrospectively in some cases and there are several effective guidelines to initiating treatment. Consistent review of the need for ongoing treatment with a particular pharmacological modality is essential, since many children with recurrent wheezing in infancy go into spontaneous remission. It is probable that newer biomarkers of airway inflammation will assist the clinician as to when to initiate and when to continue pharmacological treatment in the future.
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Affiliation(s)
- Paul C Potter
- Allergy Diagnostic & Clinical Research Unit, University of Cape Town Lung Institute, Cape Town, South Africa
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49
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Øymar K, Halvorsen T. Emergency presentation and management of acute severe asthma in children. Scand J Trauma Resusc Emerg Med 2009; 17:40. [PMID: 19732437 PMCID: PMC2749010 DOI: 10.1186/1757-7241-17-40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 09/04/2009] [Indexed: 01/19/2023] Open
Abstract
Acute severe asthma is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition. In this article we present a summary of the pathophysiology as well as guidelines for the treatment of acute severe asthma in children. The cornerstones of the management of acute asthma in children are rapid administration of oxygen, inhalations with bronchodilators and systemic corticosteroids. Inhaled bronchodilators may include selective b2-agonists, adrenaline and anticholinergics. Additional treatment in selected cases may involve intravenous administration of theophylline, b2-agonists and magnesium sulphate. Both non-invasive and invasive ventilation may be options when medical treatment fails to prevent respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.
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Affiliation(s)
- Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Paediatrics, Haukeland University Hospital, Bergen, Norway
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50
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Abstract
Asthma is the most commonly observed chronic disease in childhood and the incidence has been increasing in industrialized countries over the last decades. Airway obstruction due to increased sensitivity of the small airways, mucus production and chronic inflammation are key features in the pathophysiology of asthma. Environmental and genetic factors predispose for the disease, which is clinically characterized by sudden occurrence of episodes of expiratory airway obstruction (wheezing). In the majority of preschool infants such obstructive episodes are triggered by viral infections (especially during the winter season) and do not necessarily predispose for asthma later in adulthood. Patient and family history (e.g. atopy), good clinical examination and differential diagnosis (e.g. exclusion of cystic fibrosis) are of prime importance as the role of lung function measurements is limited as the disease frequently occurs before the age of 5 years. Information about asthma is important for children, parents and caregivers. Acute and chronic medication should control asthma symptoms and allow the affected child to lead a normal life including physical exercise.
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Affiliation(s)
- E Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein,Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
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