Real-life experience with high-frequency chest wall oscillation vest therapy in adults with non-cystic fibrosis bronchiectasis

Background:

High frequency chest wall oscillation (HFCWO) has long been used for airway clearance for patients with cystic fibrosis. Only limited research has evaluated this therapy in adult patients with non-cystic fibrosis bronchiectasis (NCFB).

Methods:

Data from 2596 patients from a registry of adult bronchiectasis patients using HFCWO therapy was used to evaluate hospitalization patterns before and after initiation of HFCWO therapy, as well as antibiotic use and self-reported metrics of quality of life. Self-reported outcomes were also reviewed by cross-checking with sampled patient charts and found to be consistent.

Results:

The number of patients who had at least one respiratory-related hospitalization decreased from 49.1% (192/391) in the year before to 24.0% (94/391) in the year after starting HFCWO therapy (p-value < 0.001). At the same time, the number of patients who required three or more hospitalizations dropped from 14.3% (56/391) to 5.6% (22/391). Patients currently taking oral antibiotics for respiratory conditions decreased from 57.7% upon initiation of therapy to 29.9% within 1 year (p < 0.001). Patients who subjectively rated their “overall respiratory health” as good to excellent increased from 13.6% upon initiation of therapy to 60.5% in 1 year (p < 0.001) and those who rated their “ability to clear your lungs” as good to excellent increased from 13.9% to 76.6% (p < 0.001).

Conclusion:

NCFB patients showed improved self-reported outcomes associated with the initiation of HFCWO therapy as measured by number of hospitalizations, antibiotic use, and the subjective experience of airway clearance. The improvement was observed early on after initiation of therapy and sustained for at least 1 year.

The reviews of this paper are available via the supplemental material section.

Inhaled antibiotics beyond aminoglycosides, polymyxins and aztreonam: A systematic review

We sought to evaluate published evidence regarding clinical or microbiological outcomes related to the use of inhaled antibiotics other than aminoglycosides, polymyxins and aztreonam. A systematic search of PubMed and Scopus databases as well as bibliographies of eligible articles was performed. In total, 34 eligible studies were identified. Among several inhaled β-lactams, ceftazidime was used with varying success in the prevention and treatment of ventilator-associated pneumonia (VAP) and improved clinical outcomes in chronic Pseudomonas aeruginosa lower respiratory tract infections (LRTIs) in patients with cystic fibrosis (CF) or bronchiectasis. Inhaled vancomycin, as an adjunctive therapy, was effective in treating Gram-positive VAP, whilst inhaled levofloxacin, ciprofloxacin and an inhaled combination of fosfomycin and tobramycin were associated with improved microbiological or clinical outcomes in chronic LRTI in patients with CF or bronchiectasis. In conclusion, published evidence is heterogeneous with regard to antibiotics used, studied indications, patient populations and study designs. Therefore, although the currently available data are encouraging, no safe conclusion regarding the effectiveness and safety of the drugs in question can be reached.

Non cystic fibrosis bronchiectasis: A longitudinal retrospective observational cohort study of Pseudomonas persistence and resistance

BACKGROUND

The hallmark of non-cystic fibrosis bronchiectasis is recurrent bronchial infection, yet there are significant gaps in our understanding of pathogen persistence, resistance and exacerbation frequencies. Pseudomonas aeruginosa is a key pathogen thought to be a marker of disease severity and progression, yet little is known if the infection risk is seen in those with milder disease or if there is any potential for eradication. These data are important in determining risk stratification and follow up.

METHODS AND PATIENT COHORT

A retrospective review of consecutive adult patients attending a specialist UK bronchiectasis clinic over a two-year recruitment period between July 2007 and June 2009 was performed. Analysis of our primary outcome, longitudinal microbiological status, was recorded based on routine clinical follow-up through to data capture point or date of death. Patients were stratified by lung function and infecting organism.

RESULTS

155 patients (mean (SD) age 62.2 (12.4) years; 60.1% female) were identified from clinic records with microbiological data for a median (IQR) follow up duration of 46 (35-62) months. Baseline mean FEV1% predicted was 60.6% (24.8) with mean exacerbation frequency of 4.42/year; 73.6% reported 3 or more exacerbations/year. Haemophilus influenzae was isolated in 90 (58.1%) patients and P. aeruginosa in 78 (50.3%) patients with persistent infection in 51 (56.7%) H. influenzae and 47 (60.3%) P. aeruginosa, respectively. Of the P. aeruginosa colonised patients, 16 (34%) became culture negative on follow-up with a mean of 5.2 negative sputum cultures/patient. P. aeruginosa was isolated from 5 out of 39 patients (12.8%) with minimal airflow limitation as compared to 18 out of 38 patients (47.4%) with severe airflow limitation. Although hospital admissions were significantly higher in the P. aeruginosa infected group (1.3 vs. 0.7 admissions per annum, p = 0.035), overall exacerbation rates were the same (4.6 vs. 4.3, p = 0.58). Independent predictors of P. aeruginosa colonisation were low FEV1% predicted (OR 2.46; 95% CI 1.27-4.77) and polymicrobial colonisation (OR 4.07; 95% CI 1.56-10.58). 17 (11%) patients were infected with multi-resistant strains; however, none were pan-resistant.

CONCLUSIONS

P. aeruginosa is associated with greater persistent infection rates and more hospital admissions than H. influenzae. Exacerbation rates, however, were similar; therefore H. influenzae causes significant out-patient morbidity. P. aeruginosa infection occurs across all strata of lung function impairment but is infrequently multi-resistant in bronchiectasis. Careful microbiology follow up is required even in those with well-preserved lung function.

Economic burden of non-cystic fibrosis bronchiectasis in the first year after diagnosis from a US health plan perspective

BACKGROUND

Recent estimates suggest the prevalence of non-cystic fibrosis bronchiectasis (NCFB) may be increasing in the US. The objective of this study was to determine the current economic burden of NCFB compared with non-NCFB controls in the first year after diagnosis within a commercially enrolled US population.

METHODS

A retrospective matched cross-sectional case control (1:3) study design was used. Data were derived from MarketScan(®) Commercial Claims and Encounters Database, which captures all patient-level demographic data and all medical and pharmacy claims during the period 1 January 2005 to 31 December 2009. NCFB patients were identified using ICD-9 codes 494.0 and 494.1. Individuals with medical claims for cystic fibrosis or chronic obstructive pulmonary disease were excluded. Incremental burden of NCFB was estimated for overall and respiratory-related expenditures using multivariate regression models which adjusted for baseline characteristics and healthcare resource utilization. All demographic characteristics and economic outcomes were ascertained in 12 months before (baseline period) and 12 months after (follow-up) index event, which was defined as the first bronchiectasis-related medical event. Non-parametric bootstrap technique was used to calculate the 95 % confidence limits for the adjusted estimate. All costs are inflation-adjusted to a baseline year of 2009 using the consumer price index. All statistical tests were conducted using SAS 9.2 and STATA 12.0.

RESULTS

The study sample used for healthcare burden analyses had 9,146 cases and 27,438 matched controls. The majority of the sample was between the ages of 45-64 years old and 64 % were female. A greater proportion of cases than controls had an increase from baseline to follow-up in both total (49 vs 40 %) and respiratory-related costs (57 vs 25 %). The average increase in overall and respiratory-related costs compared with controls after adjusting for differences in baseline characteristics was US$2,319 (95 % CI 1,872-2,765) and US$1,607 (95 % CI 1,406-1,809), respectively. The primary driver for this increment was increase in outpatient visits of approximately 2 overall and 1.6 respiratory-related visits per patient per year, which translated to US$1,730 (95 % CI 1,332-2,127) and US$1,253 (95 % CI 1,097-1,408), respectively.

CONCLUSION

This study found that the cost of managing NCFB in the first year within a commercially enrolled population may be burdensome. Compared with previously published estimates in the literature, the burden of NCFB may be also increasing.

Efficacy of inhaled ciprofloxacin in the management of non-cystic fibrosis bronchiectasis

Non-cystic fibrosis bronchiectasis (NCFBE), a historically under-recognized chronic respiratory condition, is a significant diagnosis currently experiencing a resurgence of interest in its clinical management. Ciprofloxacin is part of the current armamentarium used in the treatment of the recurrent respiratory tract infections seen in NCFBE. Inhaled ciprofloxacin, a novel method of drug delivery for the fluoroquinolone class, is being actively investigated. The inhaled formulation is designed to enhance drug delivery to the site of infection in the lung while minimizing the risk of systemic toxicity. This review summarizes the pharmacology and pharmacokinetics of ciprofloxacin and the rationale for the development of an inhaled formulation for NCFBE. Preclinical and clinical data regarding current development of inhaled ciprofloxacin formulations is also evaluated. Lastly, the anticipated role of inhaled ciprofloxacin in the management of NCFBE is discussed, including future considerations and potential limitations of therapy.

Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis

Background

High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways.

HFCWC can lead to changes in volume of 15–57 ml and in flow up to 1.6 L/s, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20–30 minutes, and consists of short periods of compression at different frequencies, separated by coughing.

The aim of this study was to find the more efficacious treatment in patients with bronchiectasis: traditional techniques of chest physiotherapy (CPT) versus high frequency oscillation of the chest wall in patients with bronchiectasis.

Methods

37 patients were enrolled. Seven of them were excluded. Computer randomization divided the patients into three groups:

– 10 patients treated with HFCWO by using the Vest® Airway Clearance System;

– 10 patients treated with traditional techniques of air way clearance (PEP bottle, PEP mask, ELTGOL, vibratory positive expiratory pressure);

– 10 patients received medical therapy only (control group).

To be eligible for enrollment, participants had to be between 18 and 85 years old and have a diagnosis of bronchiectasis, confirmed on high resolution computed tomography. Exclusion criteria: lack of informed consent, signs of exacerbation, cystic fibrosis. Before the treatment, each patient had blood tests, sputum volume and cell count, pulmonary function tests and on the quality of life inventories (MMRC, CAT, BCSS). The results were processed through the covariance analysis, performed with the R-Project statistical program. It has been considered a positive result p <005.

Results

Both treatments (traditional CPT and HFCWO) showed a significant improvement in some biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter C-RP (p ≤0.019), parameters of lung functionality associated with bronchial obstruction (FVC, FEV1) (p ≤0.006 and p ≤0.001), and in the dyspnea. Improvement in quality of life scales was noted. (BCSS, CAT) (both p ≤0.001). No significant changes of total cell counts in sputum samples were observed in the two groups. In the HFCWO group a significant reduction of neutrophils percentage (p≤0.002) and a significant increase of macrophages percentage (p ≤0.012).

Conclusions

The HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy. The study was registered as ChiCTR-TRC-12002134 at http://www.chictr.org.

Pathogen- and host-directed anti-inflammatory activities of macrolide antibiotics

Macrolide antibiotics possess several, beneficial, secondary properties which complement their primary antimicrobial activity. In addition to high levels of tissue penetration, which may counteract seemingly macrolide-resistant bacterial pathogens, these agents also possess anti-inflammatory properties, unrelated to their primary antimicrobial activity. Macrolides target cells of both the innate and adaptive immune systems, as well as structural cells, and are beneficial in controlling harmful inflammatory responses during acute and chronic bacterial infection. These secondary anti-inflammatory activities of macrolides appear to be particularly effective in attenuating neutrophil-mediated inflammation. This, in turn, may contribute to the usefulness of these agents in the treatment of acute and chronic inflammatory disorders of both microbial and nonmicrobial origin, predominantly of the airways. This paper is focused on the various mechanisms of macrolide-mediated anti-inflammatory activity which target both microbial pathogens and the cells of the innate and adaptive immune systems, with emphasis on their clinical relevance.

Antimicrobial therapy for bronchiectasis

Antibiotics have a role in the management of acute exacerbations of bronchiectasis and may also benefit selected subsets of patients with bronchiectasis as a part of a long-term maintenance strategy. At present, there are no Food and Drug Administration-approved antibiotics for acute or chronic management of bronchiectasis. Clinical trials are underway to determine the efficacy and safety of various inhaled antibiotics for chronic therapy for bronchiectasis. Until those results are available, clinicians need to tailor their therapies to individual patients based on their best clinical judgment and information from data and guidelines currently available in the published literature.

Pharmacologic agents for mucus clearance in bronchiectasis

There are no approved pharmacologic agents to enhance mucus clearance in non-cystic fibrosis (CF) bronchiectasis. Evidence supports the use of hyperosmolar agents in CF, and studies with inhaled mannitol and hypertonic saline are ongoing in bronchiectasis. N-acetylcysteine may act more as an antioxidant than a mucolytic in other lung diseases. Dornase α is beneficial to patients with CF, but is not useful in patients with non-CF bronchiectasis. Mucokinetic agents such as β-agonists have the potential to improve mucociliary clearance in normals and many disease states, but have not been adequately studied in patients with bronchiectasis.

Bronchiectasis: new approaches to diagnosis and management

Non-cystic fibrosis (CF) bronchiectasis is a common, potentially serious, condition. Further investigations should be performed in an attempt to identify the underlying cause because it may lead to a change in therapy and have significant prognostic implications. MRI is being investigated as a radiation free alternative to high-resolution CT scan of the chest. Many of the treatment recommendations for non-CF bronchiectasis have not been studied in randomized controlled trials but have been extrapolated from the management recommendations for CF. Studies are beginning to inform decisions regarding the management of non-CF bronchiectasis, and an understanding of the best treatment options is beginning to emerge.

Topical mannitol reduces inflammatory edema in a rat model of arthritis

The hexahydric alcohol mannitol is widely used to shift fluids from the intracellular to the extracellular compartments, to increase diuresis and improve mucus clearance in the airways. In principle, because of its physicochemical properties, topical mannitol might also draw fluids out of epidermis or mucosa. Here, we report that topical mannitol applications on the hind paws of rats with adjuvant-induced arthritis reduced paw thickness and tissue edema without affecting the inflammatory infiltrates. Of note, the anti-edema effects of acute (4 h) mannitol application occurred earlier than those prompted by a similar treatment with classic anti-inflammatory drugs such as diclofenac or ketoprofen. Yet, the extent of edema reduction was higher with diclofenac or ketoprofen than with mannitol when the drugs were applied in a chronic (16 h) paradigm. Together, data demonstrate that topical application of mannitol exerts potent and fast anti-edema effects in a rat model of joint inflammation, suggesting a possible utilization in patients affected by osseo-arthritic disorders.

Oxidative DNA damage and somatic mutations: a link to the molecular pathogenesis of chronic inflammatory airway diseases

BACKGROUND

Acquired somatic mutations induced by oxidative stress may contribute to the molecular pathogenesis of chronic inflammatory airway diseases. The objective of this study was to assess the intensity of oxidative DNA damage and the presence of microsatellite DNA instability (MSI), a marker of acquired somatic mutations, in patients with COPD, patients with noncystic fibrosis bronchiectasis, and control subjects.

METHODS

Induced sputum and peripheral blood from 97 subjects were analyzed; 36 patients with COPD, 36 patients with bronchiectasis, 15 smokers without COPD, and 10 healthy control subjects. DNA was extracted and analyzed for MSI. 8-hydroxy-2'-deoxyguanosine (8-OHdG), a specific marker of oxidant-induced DNA damage, was measured in serum and sputum supernatants.

RESULTS

None of the patients with bronchiectasis or control subjects (non-COPD smokers, healthy subjects) exhibited any genetic alteration. In contrast, MSI was found in 38% of COPD specimens. Sputum 8-OHdG was statistically significantly increased in COPD when compared with subjects with bronchiectasis (P = .0002), smokers without COPD (P = .0056), and healthy subjects (P = .0003). Sputum 8-OHdG in MSI-positive patients with COPD differed significantly from that of MSI-negative patients with COPD (P = .04) and smokers without COPD (P = .008), but was not statistically different (P = .07) among MSI-negative patients with COPD and smokers without COPD. Serum 8-OHdG was significantly increased in MSI-positive compared with MSI-negative patients with COPD (P = .001), but was not statistically significant in smokers without COPD (P = .09). Serum 8-OHdG was increased in smokers without COPD compared with MSI-negative patients with COPD (P = .009).

CONCLUSIONS

There is a clear disparity in COPD regarding oxidant-induced DNA damage and somatic mutations. This may reflect a difference in the oxidative stress per se or a deficient antioxidant and/or repair capacity in the lungs of patients with COPD.