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Erste Hilfe. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00886-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Zideman DA, Singletary EM, Borra V, Cassan P, Cimpoesu CD, De Buck E, Djärv T, Handley AJ, Klaassen B, Meyran D, Oliver E, Poole K. European Resuscitation Council Guidelines 2021: First aid. Resuscitation 2021; 161:270-290. [PMID: 33773828 DOI: 10.1016/j.resuscitation.2021.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.
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Affiliation(s)
| | | | - Vere Borra
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium
| | - Pascal Cassan
- International Federation of Red Cross and Red Crescent, France
| | - Carmen D Cimpoesu
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Emergency Department and Prehospital EMS SMURD Iasi Emergency County Hospital "Sf. Spiridon" Iasi, Romania
| | - Emmy De Buck
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden
| | | | - Barry Klaassen
- Emergency Medicine, Ninewells Hospital and Medical School Dundee, UK; British Red Cross, UK
| | - Daniel Meyran
- French Red Cross, Bataillon de Marins Pompiers de Marseille, France
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Abstract
Cardiac life support is a form of first aid for cardiac emergencies. However, research and evidence in this field is lacking compared with other forms of first aid. Having identified the common emergencies that are encountered in the hospital, based on the available evidence, we have put together what could be an evidence-based approach to the first aid management of some of these common emergencies, viz. breathlessness, chest pain, allergies, stroke, heat injury, poisoning, unconsciousness, seizures, and trauma situations such as bleeding, wounds, contusions, head injury, burns and fractures. Educating the public is the key to developing a first responder bystander. These guidelines could become the basis for training of the public.
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Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, Sengkang Health, Singapore
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Yuan J, Lu ZK, Zhang Y, Wu J, Love BL, Schulz RM. Clinical outcomes of levalbuterol versus racemic albuterol in pediatric patients with asthma: Propensity score matching approach in a medicaid population. Pediatr Pulmonol 2017; 52:516-523. [PMID: 27701831 DOI: 10.1002/ppul.23565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 07/22/2016] [Accepted: 08/16/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Racemic albuterol and levalbuterol are used to treat acute episodes of asthma. The main objective of this study was to compare levalbuterol therapy to albuterol therapy on incidence rates of subsequent emergency department (ED) visits and hospitalizations. METHOD We conducted a retrospective cohort study of asthmatic children who had pharmacy refills for levalbuterol/albuterol in the South Carolina Medicaid database in 2002-2011. Children receiving levalbuterol were matched to those receiving albuterol using propensity score matching technique. For ED visits and separately for hospitalizations, multivariable negative binomial regression was used to estimate the two group-specific incidence rates and the incidence rate ratio (IRR). RESULTS A total of 8,172 asthmatic patients aged 2-18 years were identified in the South Carolina Medicaid database. During the 12-month follow-up period, the levalbuterol group had fewer asthma-related ED visits and hospitalizations: 939 (11.49%) children had asthma-related ED visits (levalbuterol: 8.76%; albuterol: 14.21%), and 89 (1.09%) children had asthma-related hospitalizations (levalbuterol: 1.07%; albuterol: 1.12%). Comparing the levalbuterol group to the albuterol group, the adjusted IRR estimate was 0.57 (95% confidence interval [CI], 0.49-0.65) for of asthma-related ED visits, and 0.93 (95%CI, 0.99-1.63) for hospitalizations. Children filling levalbuterol also had a lower IRR of all-cause ED visit (0.88; 95%CI, 0.82-0.95), but similar IRR of all-cause hospitalizations (1.08; 95%CI, 0.82-1.42). CONCLUSION This observational study of children aged 2-18 demonstrated levalbuterol prescription fills were associated with reduced ED visits, but not hospitalizations. Additional research may be necessary to assess this association. Pediatr Pulmonol. 2017;52:516-523. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jing Yuan
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, 715 Sumter Street, CLS Building Room 311G, Columbia, South Carolina, 29208
| | - Zhiqiang Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, 715 Sumter Street, CLS Building Room 311G, Columbia, South Carolina, 29208
| | - Yanjun Zhang
- University of Cincinnati College of Pharmacy, Cincinnati, Ohio
| | - Jun Wu
- Presbyterian College School of Pharmacy, Clinton, South Carolina
| | - Bryan L Love
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, 715 Sumter Street, CLS Building Room 311G, Columbia, South Carolina, 29208
| | - Richard M Schulz
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, 715 Sumter Street, CLS Building Room 311G, Columbia, South Carolina, 29208
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Virk MK, Hotz J, Khemani RG, Newth CJL, Ross PA. Change in Oxygen Consumption Following Inhalation of Albuterol in Comparison with Levalbuterol in Healthy Adult Volunteers. Lung 2017; 195:233-239. [PMID: 28210808 DOI: 10.1007/s00408-017-9982-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/04/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Albuterol is the most commonly used β agonist to treat reversible lower airway obstruction. Albuterol contains a racemic mixture of two enantiomers. Levalbuterol contains the single R form enantiomer. Levalbuterol is frequently prescribed to limit cardiovascular toxicity. OBJECTIVE We examined changes in oxygen consumption (V'O2) and heart rate (HR) following administration of albuterol and levalbuterol. METHODS This is a prospective, randomized, single-blinded, controlled study of healthy adult volunteers. Subjects separately received albuterol (5 mg) and levalbuterol (2.5 mg) aerosolized over 15 min. V'O2 and vital signs were measured before the medications and 5, 10, 20, 40, and 60 min after. RESULTS We enrolled 24 volunteers with a median age of 32 years. Compared to baseline, there was a significant maximum increase in V'O2 following administration of both albuterol (median 17% (1, 3 IQR 9, 43%) p < 0.001) and levalbuterol (median 23% (1, 3 IQR 10, 32%) p < 0.001). There was no significant difference between the maximum increase in V'O2 following administration of albuterol compared to levalbuterol (p = 0.57). Compared to baseline, there was a significant maximal increase in HR with both albuterol (median 30% (1, 3 IQR 19, 43%) p < 0.001) and levalbuterol (median 23% (1, 3 IQR 19, 31%) p < 0.001). There was a statistically significant greater increase in maximal HR following administration of albuterol as compared to levalbuterol (p = 0.009). CONCLUSION Albuterol and levalbuterol both cause a significant increase in V'O2 and HR. There was no significant difference between albuterol and levalbuterol regarding the maximum increase in V'O2. There was a statistically significant but likely clinically insignificant difference in maximum increase in HR in patients with adequate oxygen delivery when comparing albuterol to levalbuterol.
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Affiliation(s)
- Manpreet K Virk
- Department of Pediatrics, Section of Critical Care, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA.
| | - Justin Hotz
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick A Ross
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Singletary EM, Zideman DA, De Buck EDJ, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ. Part 9: First Aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation 2016; 132:S269-311. [PMID: 26472857 DOI: 10.1161/cir.0000000000000278] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zideman DA, Singletary EM, De Buck EDJ, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ. Part 9: First aid: 2015 International Consensus on First Aid Science with Treatment Recommendations. Resuscitation 2015; 95:e225-61. [PMID: 26477426 DOI: 10.1016/j.resuscitation.2015.07.047] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Vézina K, Chauhan BF, Ducharme FM. Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital. Cochrane Database Syst Rev 2014; 2014:CD010283. [PMID: 25080126 PMCID: PMC10772940 DOI: 10.1002/14651858.cd010283.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Inhaled anticholinergics given in addition to β2-agonists are effective in reducing hospital admissions in children presenting to the emergency department with a moderate to severe asthma exacerbation. It seems logical to assume a similar beneficial effect in children hospitalised for an acute asthma exacerbation. OBJECTIVES To assess the efficacy and safety of anticholinergics added to β2-agonists as inhaled or nebulised therapy in children hospitalised for an acute asthma exacerbation. To investigate the characteristics of patients or therapy, if any, that would influence the magnitude of response attributable to the addition of anticholinergics. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO and through handsearching of respiratory journals and meeting abstracts. The search is current to November 2013. SELECTION CRITERIA Randomised trials comparing the combination of inhaled or nebulised anticholinergics and short-acting β2-agonists versus short-acting β2-agonists alone in children one to 18 years of age hospitalised for an acute asthma exacerbation were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the methodological quality of trials and extracted data; disagreement was resolved by consensus or with the input of a third review author, when needed. Primary outcomes were duration of hospital stay and serious adverse events. Secondary outcomes included admission and duration of stay in the intensive care unit (ICU), ventilation assistance, time to short-acting β2-agonists spaced at four hours or longer, supplemental asthma therapy, duration of supplemental oxygen, change from baseline in asthma severity, relapse after discharge, adverse health effects and withdrawals. MAIN RESULTS Seven randomised trials were included, four of which reported usable data on 472 children with asthma one to 18 years of age who were admitted to paediatric wards. No trials included patients admitted to the ICU. The anticholinergic used, ipratropium bromide 250 μg, was given every one to eight hours over a period from four hours to the entire length of the hospital stay. Two of four trials (50%) contributing data were deemed of high methodological quality. The addition of anticholinergics to β2-agonists showed no evidence of effect on the duration of hospital admission (mean difference (MD) -0.28 hours, 95% confidence interval (CI) -5.07 to 4.52, 3 studies, 327 participants, moderate quality evidence) and no serious or non-serious adverse events were reported in any included trials. As a result of the similarity of trials, we could not explore the influence of age, admission site, intensity of anticholinergic treatment and co-interventions on primary outcomes. No statistically significant group difference was noted in other secondary outcomes, including the need for supplemental asthma therapy, time to short-acting β2-agonists spaced at four hours or longer, asthma clinical scores, lung function and overall withdrawals for any reason. AUTHORS' CONCLUSIONS In children hospitalised for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulised anticholinergics were added to short-acting β2-agonists. No adverse health effects were reported, yet the small number of trials combined with inadequate reporting prevent firm reassurance regarding the safety of anticholinergics. In the absence of trials conducted in ICUs, no conclusion can be drawn regarding children with impending respiratory failure. These findings support current national and international recommendations indicating that healthcare practitioners should refrain from using anticholinergics in children hospitalised for acute asthma.
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Affiliation(s)
- Kevin Vézina
- CHU Sainte‐JustineDepartment of PediatricsMontrealQCCanada
| | - Bhupendrasinh F Chauhan
- Research Centre, CHU Sainte‐JustineClinical Research Unit on Childhood Asthma3175, Cote Sainte‐CatherineMontrealQCCanada
| | - Francine M Ducharme
- University of MontrealDepartment of PaediatricsMontrealQCCanada
- CHU Sainte‐JustineResearch CentreMontrealCanada
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Chauhan BF, Ducharme FM. Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. Cochrane Database Syst Rev 2012; 2012:CD002314. [PMID: 22592685 PMCID: PMC4164381 DOI: 10.1002/14651858.cd002314.pub3] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anti-leukotrienes (5-lipoxygenase inhibitors and leukotriene receptors antagonists) serve as alternative monotherapy to inhaled corticosteroids (ICS) in the management of recurrent and/or chronic asthma in adults and children. OBJECTIVES To determine the safety and efficacy of anti-leukotrienes compared to inhaled corticosteroids as monotherapy in adults and children with asthma and to provide better insight into the influence of patient and treatment characteristics on the magnitude of effects. SEARCH METHODS We searched MEDLINE (1966 to Dec 2010), EMBASE (1980 to Dec 2010), CINAHL (1982 to Dec 2010), the Cochrane Airways Group trials register, and the Cochrane Central Register of Controlled Trials (Dec 2010), abstract books, and reference lists of review articles and trials. We contacted colleagues and the international headquarters of anti-leukotrienes producers. SELECTION CRITERIA We included randomised trials that compared anti-leukotrienes with inhaled corticosteroids as monotherapy for a minimum period of four weeks in patients with asthma aged two years and older. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the methodological quality of trials and extracted data. The primary outcome was the number of patients with at least one exacerbation requiring systemic corticosteroids. Secondary outcomes included patients with at least one exacerbation requiring hospital admission, lung function tests, indices of chronic asthma control, adverse effects, withdrawal rates and biological inflammatory markers. MAIN RESULTS Sixty-five trials met the inclusion criteria for this review. Fifty-six trials (19 paediatric trials) contributed data (representing total of 10,005 adults and 3,333 children); 21 trials were of high methodological quality; 44 were published in full-text. All trials pertained to patients with mild or moderate persistent asthma. Trial durations varied from four to 52 weeks. The median dose of inhaled corticosteroids was quite homogeneous at 200 µg/day of microfine hydrofluoroalkane-propelled beclomethasone or equivalent (HFA-BDP eq). Patients treated with anti-leukotrienes were more likely to suffer an exacerbation requiring systemic corticosteroids (N = 6077 participants; risk ratio (RR) 1.51, 95% confidence interval (CI) 1.17, 1.96). For every 28 (95% CI 15 to 82) patients treated with anti-leukotrienes instead of inhaled corticosteroids, there was one additional patient with an exacerbation requiring rescue systemic corticosteroids. The magnitude of effect was significantly greater in patients with moderate compared with those with mild airway obstruction (RR 2.03, 95% CI 1.41, 2.91 versus RR 1.25, 95% CI 0.97, 1.61), but was not significantly influenced by age group (children representing 23% of the weight versus adults), anti-leukotriene used, duration of intervention, methodological quality, and funding source. Significant group differences favouring inhaled corticosteroids were noted in most secondary outcomes including patients with at least one exacerbation requiring hospital admission (N = 2715 participants; RR 3.33; 95% CI 1.02 to 10.94), the change from baseline FEV(1) (N = 7128 participants; mean group difference (MD) 110 mL, 95% CI 140 to 80) as well as other lung function parameters, asthma symptoms, nocturnal awakenings, rescue medication use, symptom-free days, the quality of life, parents' and physicians' satisfaction. Anti-leukotriene therapy was associated with increased risk of withdrawals due to poor asthma control (N = 7669 participants; RR 2.56; 95% CI 2.01 to 3.27). For every thirty one (95% CI 22 to 47) patients treated with anti-leukotrienes instead of inhaled corticosteroids, there was one additional withdrawal due to poor control. Risk of side effects was not significantly different between both groups. AUTHORS' CONCLUSIONS As monotherapy, inhaled corticosteroids display superior efficacy to anti-leukotrienes in adults and children with persistent asthma; the superiority is particularly marked in patients with moderate airway obstruction. On the basis of efficacy, the results support the current guidelines' recommendation that inhaled corticosteroids remain the preferred monotherapy.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- Research Centre, CHU Sainte‐JustineClinical Research Unit on Childhood Asthma3175, Cote Sainte‐CatherineMontrealQCCanada
| | - Francine M Ducharme
- University of MontrealDepartment of PaediatricsMontrealQCCanada
- CHU Sainte‐JustineResearch CentreMontrealCanada
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10
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Wilkinson M, Bulloch B, Garcia-Filion P, Keahey L. Efficacy of racemic albuterol versus levalbuterol used as a continuous nebulization for the treatment of acute asthma exacerbations: a randomized, double-blind, clinical trial. J Asthma 2011; 48:188-93. [PMID: 21275850 DOI: 10.3109/02770903.2011.554939] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare racemic albuterol (RAC) with levalbuterol (LEV) in continuous form for the treatment of acute pediatric asthma exacerbations in the emergency department. STUDY DESIGN Children between the ages of 6 and 17 inclusive were enrolled if they had a history of asthma, presented to the emergency department with an acute asthma exacerbation, and had an initial forced expiratory volume in 1 second (FEV1) <70% predicted. Patients were then randomized to receive either 7.5 mg of RAC or 3.75 mg of LEV over 1 hour, in addition to standard asthma therapies. Spirometry and asthma scoring were performed at the end of the first hour, and a second hour-long nebulization with the same drug was administered if deemed necessary. Spirometry and asthma scoring were again performed and the final disposition was recorded. As a second, optional part of the study, baseline serum albuterol levels were collected on some patients before treatment. RESULTS A total of 99 patients completed the study (44 RAC and 55 LEV). Baseline characteristics were similar except that the RAC group had a higher baseline asthma score. Children in the RAC group had a greater improvement in their FEV1 (p = .043) as well as in their asthma scores (p = .01) after 1 hour of continuous treatment compared to the LEV group. The greater improvement in asthma scores was maintained after the second hour of continuous therapy in the RAC group (p = .008) but not for FEV1 measurements (p = .57). There were no differences between groups for changes in heart rate, respiratory rate, oxygen saturation, or rates of admission. CONCLUSIONS At the doses used, RAC appears to be superior to LEV with respect to changes in FEV1 and asthma score. There was no significant difference between the drugs with respect to admission rates or side-effect profile.
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Affiliation(s)
- Matthew Wilkinson
- Department of Emergency Medicine, Dell Children's Medical Center of Central Texas, Austin, TX, USA
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11
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Beta-Adrenergic Agonists. Pharmaceuticals (Basel) 2010; 3:1016-1044. [PMID: 27713285 PMCID: PMC4034018 DOI: 10.3390/ph3041016] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 03/15/2010] [Accepted: 03/26/2010] [Indexed: 12/31/2022] Open
Abstract
Inhaled β2-adrenoceptor (β2-AR) agonists are considered essential bronchodilator drugs in the treatment of bronchial asthma, both as symptoms-relievers and, in combination with inhaled corticosteroids, as disease-controllers. In this article, we first review the basic mechanisms by which the β2-adrenergic system contributes to the control of airway smooth muscle tone. Then, we go on describing the structural characteristics of β2-AR and the molecular basis of G-protein-coupled receptor signaling and mechanisms of its desensitization/ dysfunction. In particular, phosphorylation mediated by protein kinase A and β-adrenergic receptor kinase are examined in detail. Finally, we discuss the pivotal role of inhaled β2-AR agonists in the treatment of asthma and the concerns about their safety that have been recently raised.
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Andrews T, McGintee E, Mittal MK, Tyler L, Chew A, Zhang X, Pawlowski N, Zorc JJ. High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial. J Pediatr 2009; 155:205-10.e1. [PMID: 19464028 DOI: 10.1016/j.jpeds.2009.01.073] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 12/16/2008] [Accepted: 01/30/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the use of high-dose continuous levalbuterol (LEV), the single active (R)-enantiomer of racemic albuterol (RAC), in the treatment of status asthmaticus. STUDY DESIGN Children age 6 to 18 years with severe asthma exacerbation were enrolled in this randomized, double-blind trial if they failed initial emergency department (ED) therapy with RAC and systemic steroids. Subjects received equipotent doses of RAC (20 mg/hour) or LEV (10 mg/hour) within a standardized inpatient protocol. Blood samples for measurements of albuterol enantiomer, potassium, and glucose levels were obtained from the first 40 subjects. The median time until discontinuation of continuous therapy was compared using the rank-sum test, and other outcomes were compared using general linear mixed models. RESULTS A total of 81 subjects (40 in the RAC group and 41 in the LEV group) were enrolled; the 2 groups were similar at baseline. Both groups tolerated continuous therapy with similar changes in heart rate and serum potassium and glucose levels but higher serum (S)-albuterol concentrations in the subjects treated with RAC. The median time for continuous therapy was similar in the RAC and LEV groups (18.3 hours vs 16.0 hours), as were the other clinical measures. CONCLUSIONS Substituting high-dose continuous LEV for RAC did not reduce the time on continuous therapy and had similar adverse effects in children who had failed initial treatment with RAC.
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Affiliation(s)
- Timothy Andrews
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4399, USA
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13
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Affiliation(s)
- Christopher H Fanta
- Partners Asthma Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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14
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Uspal NG, Agrawal D. Misconceptions regarding levalbuterol in the treatment of acute asthma exacerbations in children. Am J Emerg Med 2009; 27:117-119. [PMID: 19041546 DOI: 10.1016/j.ajem.2008.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 08/24/2008] [Accepted: 08/26/2008] [Indexed: 11/15/2022] Open
Affiliation(s)
- Neil G Uspal
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Dewesh Agrawal
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC
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15
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Tripp K, McVicar WK, Nair P, Corren J, Pleskow WW, Goodwin E, Baumgartner RA, Hanrahan JP. A cumulative dose study of levalbuterol and racemic albuterol administered by hydrofluoroalkane-134a metered-dose inhaler in asthmatic subjects. J Allergy Clin Immunol 2008; 122:544-9. [PMID: 18692886 DOI: 10.1016/j.jaci.2008.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Revised: 05/16/2008] [Accepted: 06/09/2008] [Indexed: 11/15/2022]
Abstract
BACKGROUND The short-acting beta(2)-agonists levalbuterol and racemic albuterol are available for administration through a hydrofluoroalkane-134a (HFA) metered-dose inhaler (MDI). OBJECTIVE This study compared the short-term safety and efficacy of cumulative doses of levalbuterol HFA MDI and racemic albuterol HFA MDI in asthmatic subjects. METHODS This was a randomized, modified-blind, active-controlled, multicenter, 2-way crossover study. Subjects (n = 49) were randomized to 16 cumulative doses (1x, 2x, 4x, 8x, and 16x) of levalbuterol (45 microg per dose) or racemic albuterol (90 microg per dose) administered over a 2-hour period. After a 7-day washout period, subjects were crossed over to the other treatment. After each dose, safety outcomes and pulmonary function were assessed. RESULTS Heart rate and (R)-albuterol exposure increased for both racemic albuterol HFA and levalbuterol HFA. For cumulative doses of 8x or greater, racemic albuterol HFA treatment had greater increases in mean heart rate than levalbuterol HFA (least-squares mean [+/- SD] difference at the 8x dose was 2.8 beats/min [95% CI, 0.3-5.3] and at the 16x dose was 3.5 beats/min [95% CI, 0.6-6.4]). (R)-albuterol plasma levels ranged from 10% to 18% higher after racemic albuterol HFA MDI dosing versus after levalbuterol HFA MDI. FEV(1) improvements were similar for both treatments. The relative potencies of the 2 therapies, based on FEV(1), were similar (ratio, 1.1 [90% CI, 0.9-1.2]; Finney method). CONCLUSION In this study single-day cumulative dosing of asthmatic subjects with levalbuterol HFA MDI or racemic albuterol HFA MDI resulted in similar improvements in FEV(1) and tolerability. Plasma (R)-albuterol levels and mean heart rate were less with levalbuterol HFA MDI.
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16
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Matteucci MJ, Tanen DA. A levalbuterol therapeutic misadventure. J Emerg Med 2008; 35:209. [PMID: 18281181 DOI: 10.1016/j.jemermed.2007.07.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2007] [Accepted: 07/26/2007] [Indexed: 05/25/2023]
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17
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Jalba MS. Three generations of ongoing controversies concerning the use of short acting beta-agonist therapy in asthma: a review. J Asthma 2008; 45:9-18. [PMID: 18259990 DOI: 10.1080/02770900701495512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
An increase in asthma mortality in 1960s noted by British authors stirred a debate about the use of beta-adrenergic therapy that has persisted in the medical literature. The cause appears to be isoproterenol and fenoterol overuse. A second debate evolved around the possible deleterious, pro-inflammatory effects, of the albuterol distomer. Most clinical studies showed improved bronchodilatation, but limited benefits from using levalbuterol. Recently, genotyping has uncovered a single nucleotide polymorphism at codon 16 that appears to affect the long term response to both regular and as needed use of albuterol, calling for a new genotype based therapeutic approach in asthma.
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Affiliation(s)
- Mihai-Sergiu Jalba
- Health Services Research Postdoctoral Fellowship Program, Division of Research, Department of Family Medicine, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, New Jersey, USA.
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18
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Hamilos DL, D'Urzo A, Levy RJ, Marcus M, Tripp K, Parsey M, Baumgartner RA, McVicar WK. Long-term safety study of levalbuterol administered via metered-dose inhaler in patients with asthma. Ann Allergy Asthma Immunol 2008; 99:540-8. [PMID: 18219836 DOI: 10.1016/s1081-1206(10)60384-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous studies have raised concerns regarding the safety of regular use of beta2-agonists for treating asthma. Few studies have explored the safety of at least 1 year of use of racemic albuterol, and none have examined long-term dosing of levalbuterol. OBJECTIVE To examine the long-term safety of levalbuterol hydrofluoroalkane (HFA) vs racemic albuterol HFA administered via metered-dose inhaler (MDI) in patients with stable asthma. METHODS Patients with mild to moderate asthma (mean forced expiratory volume in 1 second [FEVI], 68.3% of predicted) 12 years or older participated in a multicenter, parallel-group, open-label study. Patients were randomized to levalbuterol HFA MDI (90 microg; 2 actuations of 45 microg; n = 496) or racemic albuterol HFA MDI (180 microg; 2 actuations of 90 microg; n = 250) for 52 weeks of 4 times daily dosing. The primary end point was the incidence of postrandomization adverse events. Asthma exacerbations and pulmonary parameters were also assessed. RESULTS The overall incidence of adverse events was similar for levalbuterol (72.0%) and racemic albuterol (76.8%). Rates of beta-mediated adverse events, serious adverse events, and discontinuations because of adverse events were low (<15%) and were comparable between groups. Rates of asthma adverse events for levalbuterol and racemic albuterol were 18.3% and 19.6%, respectively. Mean percentage of predicted FEV1 improved after dosing and was stable for both groups. CONCLUSION In this trial, up to 52 weeks of regular use of levalbuterol HFA MDI or racemic albuterol HFA MDI was well tolerated, and no deterioration of lung function was detected during the study period.
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Abstract
The purpose of this review is to determine whether the proinflammatory actions identified in vitro for (S)-albuterol provide a clinically significant therapeutic advantage for levalbuterol over racemic albuterol. Clinical trials evaluating the bronchodilation in chronic and acute asthma provide conflicting evidence. Older trials suggested an advantage for levalbuterol; however, the newer trials have failed to confirm those advantages. Although (S)-albuterol produces increased bronchial hyperresponsiveness in vitro and in animal models, this has not been consistently confirmed in clinical trials; however, the heterogeneity of the trials precludes definitive conclusions. Current clinical trials do not provide evidence of a substantial advantage of levalbuterol over racemic albuterol although the data are insufficient to determine whether subsets of the patient population might benefit from single isomer therapy.
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Affiliation(s)
- H William Kelly
- Department of Pediatrics, Pediatrics/Pulmonary, MSC10-5590, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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