Corticosteroids in chronic bronchitis and pulmonary emphysema

Eucalyptol, limonene and pinene enteric capsules attenuate airway inflammation and obstruction in lipopolysaccharide-induced chronic bronchitis rat model via TLR4 signaling inhibition

BACKGROUND

Chronic bronchitis (CB), a type of chronic obstructive pulmonary disease (COPD), poses a significant global health burden owing to its high morbidity and mortality rates. Eucalyptol, limonene and pinene enteric capsules (ELPs) are clinically used as expectorants to treat various respiratory diseases, including CB, but their acting mechanisms remain unclear. In this study, we investigated the anti-CB effects of ELP in a rat model of lipopolysaccharide (LPS)-induced CB. The molecular mechanisms underlying its inhibitory effects on airway inflammation were further explored in LPS-stimulated Beas-2B cells.

METHODS

ELP was characterized using gas chromatography. The production of inflammatory mediators in bronchoalveolar lavage fluid (BALF) was determined using an enzyme-linked immunosorbent assay. The expression of MUC5AC, MUC5B, and p-p65 in the lung tissue was measured using immunohistochemical staining. The gene expression of inflammatory mediators was determined using qRT-PCR. The expression levels of the target proteins were detected by western blotting. Nuclear localization of p65 was determined using an immunofluorescence assay.

RESULTS

Compared to the CB model rats, ELP-treated rats showed reduced airway resistance, inflammation, and goblet cell hyperplasia. In BALF, ELP decreased the levels of inflammatory mediators, including TNF-α, IL-6, MIP-1α, and CCL5. ELP also suppressed LPS-induced elevation of MUC5AC, MUC5B, and p-p65 in the lung tissue. The metabolic pathway changes caused by LPS challenge were improved by ELP treatment. In LPS-exposed Beas-2B cells, ELP treatment inhibited the expression of TNFA, IL6, CCL5, MCP1, and MIP2A and decreased the phospho-levels of toll-like receptor 4 (TLR4) signaling-related proteins, including p-p38, p-JNK, p-ERK, p-TBK1, p-IKKα/β, p-IκB, p-p65, and p-c-Jun. ELP also hindered the nuclear translocation of p65, c-Jun, and IRF3.

CONCLUSIONS

This study showed that ELP has a potential therapeutic effect in LPS-induced CB rat model, possibly by suppressing TLR4 signaling. These results justify the clinical use of ELP for the treatment of pulmonary inflammatory diseases.

The Asthma-COPD Overlap Syndrome

Although in textbooks asthma and chronic obstructive pulmonary disease (COPD) are viewed as distinct disorders, there is increasing awareness that many patients have features of both. This article reviews the asthma-COPD overlap syndrome.

Evidence suggesting that oral corticosteroids increase mortality in stable chronic obstructive pulmonary disease

BACKGROUND

Oral corticosteroids were used to control stable chronic obstructive pulmonary disease (COPD) decades ago. However, recent guidelines do not recommend long-term oral corticosteroids (LTOC) use for stable COPD patients, partly because it causes side-effects such as respiratory muscle deterioration and immunosuppression. Nonetheless, the impact of LTOC on life prognosis for stable COPD patients has not been clarified.

METHODS

We used the data of patients randomized to non-surgery treatment in the National Emphysema Treatment Trial. Severe and very severe stable COPD patients who were eligible for volume reduction surgery were recruited at 17 clinical centers in the United States and randomized during 1998-2002. Patients were followed-up for at least five years. Hazard ratios for death by LTOC were estimated by three models using Cox proportional hazard analysis and propensity score matching.

RESULTS

The pre-matching cohort comprised 444 patients (prescription of LTOC: 23.0%. Age: 66.6 ± 5.4 year old. Female: 35.6%. Percent predicted forced expiratory volume in one second: 27.0 ± 7.1%. Mortality during follow-up: 67.1%). Hazard ratio using a multiple-variable Cox model in the pre-matching cohort was 1.54 (P = 0.001). Propensity score matching was conducted with 26 parameters (C-statics: 0.73). The propensity-matched cohort comprised of 65 LTOC(+) cases and 195 LTOC(-) cases (prescription of LTOC: 25.0%. Age: 66.5 ± 5.3 year old. Female: 35.4%. Percent predicted forced expiratory volume in one second: 26.1 ± 6.8%. Mortality during follow-up: 71.3%). No parameters differed between cohorts. The hazard ratio using a single-variable Cox model in the propensity-score-matched cohort was 1.50 (P = 0.013). The hazard ratio using a multiple-variable Cox model in the propensity-score-matched cohort was 1.73 (P = 0.001).

CONCLUSIONS

LTOC may increase the mortality of stable severe and very severe COPD patients.

Asthma and chronic obstructive pulmonary disease: similarities and differences

Asthma and COPD are both heterogeneous lung diseases including many different phenotypes. The classical asthma and COPD phenotypes are easy to discern because they reflect extremes of a phenotypical spectrum. Thus asthma in childhood and COPD in smokers have their own phenotypic expression with underlying pathophysiological mechanisms that differ importantly. In older adults, asthma and COPD are more difficult to differentiate and there exists a bronchodilator response in most but not all patients with asthma and persistent airway obstruction in most but not all patients with COPD where even up to 50% have been reported to have some bronchodilator response as assessed with FEV1. Airway obstruction is generated in the large and small airways both in asthma and COPD, and this small airway obstruction is located more proximally in asthma, yet is found more distally in severe and older individuals with asthma, comparable to COPD. Though the underlying inflammation and remodelling processes in asthma and COPD are different in their extreme phenotypes, there are overlap phenotypes with eosinophilic inflammation even in stable COPD and neutrophilic inflammation in longstanding and severe asthma.

Atopy is a risk factor for respiratory symptoms in COPD patients: results from the EUROSCOP study

BACKGROUND

The pathogenesis of COPD is complex and remains poorly understood. The European Respiratory Society Study on Chronic Obstructive Pulmonary Disease (EUROSCOP) investigated long-term effects of budesonide; 18% of the COPD participants were atopic. So far effects of atopy on the long-term course of COPD have not been elucidated.

METHODS

Factors related to the presence of atopy (positive phadiatop) in 1277 mild-to-moderate COPD patients participating in EUROSCOP were analysed using regression analysis. Incidence and remission of respiratory symptoms during 3-year follow-up were analysed using generalised estimating equations models, and association of atopy with lung function decline using linear mixed effects models.

RESULTS

Independent predisposing factors associated with the presence of atopy were: male gender (OR: 2.21; 95% CI: 1.47-3.34), overweight/obese (OR: 1.41; 95% CI: 1.04-1.92) and lower age (OR: 0.98; 95% CI: 0.96-0.99). Atopy was associated with a higher prevalence of cough (OR: 1.71; 95% CI: 1.26-2.34) and phlegm (OR: 1.50; 95% CI: 1.10-2.03), but not with lung function levels or FEV1 decline. Atopic COPD patients not treated with budesonide had an increased incidence of cough over time (OR: 1.79, 95% CI: 1.03-3.08, p = 0.038), while those treated with budesonide had increased remission of cough (OR: 1.93, 95% CI: 1.11-3.37, p = 0.02) compared to non-atopic COPD patients.

CONCLUSIONS

Atopic COPD patients are more likely male, have overweight/obesity and are younger as compared with non-atopic COPD patients. Atopy in COPD is associated with an increased incidence and prevalence of respiratory symptoms. If atopic COPD patients are treated with budesonide, they more often show remission of symptoms compared to non-atopic COPD patients who are treated with budesonide. We recommend including atopy in the diagnostic work-up and management of COPD.

Is There a Role for Systemic Corticosteroids in the Management of Stable Chronic Obstructive Pulmonary Disease?

COPD, encompassing both chronic bronchitis and emphysema, usually results from exposure to tobacco smoke. Smoking causes infiltration of the airways with leukocytes, an imbalance between proteases and their naturally occurring inhibitors and local cytokine secretion in the lung, which leads to airway inflammation and alveolar destruction. Corticosteroids have a range of anti-inflammatory actions, particularly inhibition of cytokine secretion, which suggests that they may be effective in COPD. However, data from the highest quality studies available do not show any evidence of significant improvement in symptoms of patients with COPD treated with systemic corticosteroids.A meta-analysis found that about 10% of patients with stable COPD showed an improvement in lung function following treatment with short-term systemic corticosteroids compared with placebo. Exercise capacity in patients with COPD was evaluated in four studies, only one of which found a significant improvement with oral corticosteroids compared with placebo. Long-term systemic corticosteroid treatment in patients with stable COPD has not been found to alter the rate of decline in FEV(1). Although systemic corticosteroids are associated with a range of adverse effects, the data do not allow precise quantification of their contribution to morbidity. However, studies show an increased risk of osteoporosis in COPD. Recent studies have also found an association between oral corticosteroid administration and mortality in patients with stable COPD, but it is not clear if this is a cause and effect relationship. Current data do not support long-term administration of systemic corticosteroids to all patients with stable COPD. Results of studies suggest that short-term oral corticosteroid administration may identify a sub-population of patients with COPD who may benefit through a reduction in the decline in FEV(1) and better control of symptoms by long-term administration of inhaled corticosteroids; these findings need to be tested by further research.

Oral corticosteroids for stable chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common chronic lung disorder, usually related to cigarette smoking, representing a major and increasing cause of morbidity and mortality. It is defined "as a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases". The use of corticosteroids for their anti-inflammatory effects has been suggested.

OBJECTIVES

To assess the effects of oral corticosteroids on the health status of patients with stable COPD.

SEARCH STRATEGY

Searches of the Cochrane Airways Group Specialised Register and MEDLINE were carried out in December 2003 and 2004. Review articles and bibliographies were searched.

SELECTION CRITERIA

Randomised controlled prospective studies in adults with stable COPD ( post-bronchodilator FEV1 <80% of predicted, FEV1/FVC <70%) and a history of smoking, excluding known asthmatics, in which oral steroid use was compared with placebo and use of co-interventions was matched in both groups.

DATA COLLECTION AND ANALYSIS

Data was extracted independently by two reviewers. All trials were combined using Review Manager (version 4.2.7).

MAIN RESULTS

From 459 titles 24 studies met the inclusion criteria. Treatment lasted three weeks or less in 19 studies, high dose oral steroid was used in 21 studies and subjects had moderate or severe COPD in 15 studies. There was a significant difference in FEV1 after two weeks treatment, WMD 53.30 ml; 95% confidence interval 22.21 to 84.39 favouring oral steroid use compared to placebo when 14 studies with available data (n=396) were combined, with no significant heterogeneity. There was a significant increase in odds for individual patient FEV1 response greater than 20% from baseline with high dose oral steroid treatment compared to placebo, OR 2.71; 95% CI 1.84 to 4.01 (9 studies) . It would be necessary to treat 7 patients (95% CI 5 to 12) with oral corticosteroids to achieve one extra case of increasing FEV1 by more than 20%, with a placebo group risk of 0.13. All differences in health-related quality of life were less than the minimum clinically important difference. There were small statistically significant advantages for functional capacity and respiratory symptom of wheeze with oral steroid treatment but no significant difference in risk of withdrawal from study due to an exacerbation or rate of serious exacerbations over 2 years with low dose oral steroid treatment. There was an increased risk of adverse effects, including increased blood glucose, adrenal suppression and reduced serum osteocalcin.

AUTHORS' CONCLUSIONS

There is no evidence to support the long-term use of oral steroids at doses less than 10-15 mg prednisolone though some evidence that higher doses (>/= 30 mg prednisolone) improve lung function over a short period. Potentially harmful adverse effects e.g.. diabetes, hypertension, osteoporosis would prevent recommending long-term use at these high doses in most patients.

A step-wise application of methylprednisolone versus dexamethasone in the treatment of acute exacerbations of COPD

OBJECTIVE

The aim of the study was to explore the clinical value of a step-wise application of methylprednisolone (MP) compared to dexamethasone (DXM) in acute exacerbations of COPD.

METHODOLOGY

One hundred and forty-two patients with an acute exacerbation of COPD were divided randomly into two groups: 71 patients were treated with MP and the other 71 patients were treated with DXM. Otherwise each group was given the same basic treatments: antibiotics, bronchodilators, oxygen therapy as well as standard hospital care. The patients in the MP group were given a tapering dose of MP for 7-14 days, and the patients in the DXM group were given a corresponding tapering dose of DXM for 7-14 days. Then both groups were given a gradually reducing dose of oral prednisone for 2-3 weeks. Two weeks before the prednisone was tapered off, inhaled corticosteroid was introduced. The patients' symptom scores, physical signs, per cent predicted FEV1%, and arterial blood gases were monitored before treatment and after the seventh day of treatment.

RESULTS

There was an obvious improvement in symptoms after 1-3 days in all 71 patients in the MP group, with their wheezing being distinctly reduced or disappearing entirely. The maximum benefit that occurred in the MP group (90.14%) was considerably higher than that of the DXM group (25.35%), P < 0.05. The predicted FEV1% in the MP group increased from 46.7 +/- 10.6 to 67.5 +/- 12.4, compared with an increase in the DXM group from 50.1 +/- 7.6 to 58.9 +/- 10.8. The difference between the two groups was significant (P < 0.05).

CONCLUSIONS

An adequate and tapering dose of MP used in acute exacerbations of COPD can relieve the inflammatory reaction in airways and reduce airway spasm more promptly than DXM.

Anesthesia considerations for lung volume reduction surgery

Patient selection is of crucial importance for outcome after lung volume reduction surgery. The anesthesiologist should be involved actively in patient selection, because he or she is in charge of the treatment during the critical perioperative period. Patient history and status and results from chest radiographs, high-resolution CT scans, and catheterization of the right heart should be taken carefully into account in the patient selection process. Promising new results involving functional parameters may predict outcome objectively after lung volume reduction surgery in the future. Careful selection and preoperative preparation of patients also are important to avoid complications and keep the success rate high. The anesthesiologist's understanding of the principles involved is important for the successful conduct of lung volume reduction surgery. It is unclear if lung volume reduction surgery is superior to conventional therapy in the long run because the decline in lung function is progressive after the procedure. A multicenter trial comparing patients undergoing lung volume reduction surgery with patients with emphysema who are treated conventionally hopefully will clarify this important question in the future.

The effect of inhaled glucocorticosteroids in emphysema due to alpha1-antitrypsin deficiency

Despite the success of inhaled steroids in controlling asthma, the benefit in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Five subjects with moderate to severe emphysema due to alpha 1-antitrypsin deficiency (phenotype PiZ) were followed with daily home spirometry in a 2 x 8 weeks, randomized double-blind, placebo-controlled, crossover study of inhaled budesonide 0.8 mg b.i.d. In three of the five patients, there was a statistically significant increase in the mean forced expiratory volume in 1 s (FEV1), and in two of these patients, there was also a statistically significant increase in the mean forced vital capacity (FVC) during budesonide treatment. A significant diurnal variation in FEV1 and FVC was found in three and two patients, respectively, but did not change significantly during treatment. These findings emphasize the need for renewed evaluation of inhaled steroids in the treatment of patients with emphysema, and indicate that individual patients may have significant clinical improvement.

Effects of long-term treatment with corticosteroids in COPD

STUDY OBJECTIVE

To determine the effectiveness of treatment with corticosteroids in patients with COPD.

METHODS

In this study, we investigated the effect of a 2-year treatment with corticosteroids on clinical symptoms and the decline of lung function in 58 nonallergic patients with COPD. Subjects were treated in a double-blind, randomized, placebo-controlled, parallel way with inhaled budesonide (bud), 1,600 micrograms/d; inhaled budesonide, 1,600 micrograms/d, plus oral prednisolone, 5 micrograms/d (bud + pred); or placebo (plac). Clinical assessment (history, physical examination, and spirometry) was carried out every 2 months. The rate of decline in FEV1 was assessed by calculating individual regression co-efficients from linear regression of FEV1 on time for each subject.

RESULTS

Eleven patients dropped out. The number of withdrawals due to pulmonary problems was significantly higher in the plac group (n = 5 out of 18) than in the actively treated groups (n = 2 out of 40). Treatment with corticosteroids significantly reduced pulmonary symptoms. Median decline of FEV1 was 60 mL/yr in the plac group, 40 mL/yr in the bud + pred group, and 30 mL/yr in the bud group. Variation was large and differences were not statistically significant. No treatment effect was found on frequency or duration of exacerbations, possibly because of the high number of withdrawals due to pulmonary deterioration in the plac group. Treatment with a combination of inhaled plus oral corticosteroids was not more effective than inhaled corticosteroids alone. Morning plasma cortisol levels remained within the normal range in all three groups.

CONCLUSIONS

Our study shows beneficial effects of long-term daily treatment with inhaled corticosteroids in patients with COPD with regard to symptoms and drop out due to pulmonary problems. Lung function decline tends to decrease during treatment with inhaled corticosteroids. The observed effects are limited but warrant further studies on the effectiveness of corticosteroids in larger numbers of patients with COPD.

Inhaled budesonide therapy for patients with stable COPD

A significant minority of patients with COPD have favorable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with high-dose inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to inhaled beta 2-agonist will serve to individualize steroid responders. We compared a 6-week course of 800 micrograms/d inhaled budesonide with placebo, separated by 4 weeks when no medication was taken, in a double-blind crossover trial, in 8 patients responding to inhaled beta 2-agonist, and in 22 nonresponders with stable COPD. In six of eight "responders to beta 2-agonist," there was a significant improvement in the FEV1 (defined as > or = 20%) following inhaled budesonide, as compared with placebo. In the 22 "nonresponders to beta 2-agonist," there was no significant improvement in the mean FEV1 (1.41 +/- 0.1 L before, and 1.61 +/- 0.1 L after treatment) with inhaled budesonide or placebo. Over the 6-week course of treatment by either budesonide or placebo, the nonresponders reported similar beta 2-agonist consumption (4.8 +/- 0.2 and 5.0 +/- 0.1 puffs per patient per day, respectively). However, there was a significant difference between the two periods of treatment in the responders as for the mean daily number of beta 2-agonist inhalations (2.4 +/- 0.1 in the budesonide period as compared with 5.3 +/- 0.1 in the placebo period; p < 0.005). We conclude that treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about 25% of patients with stable COPD, and this rate is increased to about 75% in patients who respond to beta 2-agonist inhalation.

Inspiratory muscle training during treatment with corticosteroids in humans

In a previous study performed by us, functional alterations in the inspiratory muscles were evaluated in patients receiving corticosteroids for diseases other than respiratory. We have shown that patients who received high-dose steroids for several weeks developed inspiratory muscle weakness that was reversible following withdrawal of the drug treatment. The present study was designed to evaluate the ability of specific inspiratory muscle training (SIMT) to prevent the effects of a therapeutic dosage of corticosteroids on inspiratory muscle function in patients receiving the drug for diseases other than pulmonary, with no underlying respiratory or muscular disease. Twelve patients, 5 men and 7 women, with ages ranging from 19 to 41 years, who received corticosteroids for diseases other than respiratory were recruited into two groups: 6 patients were assigned to the control group and got sham training and 6 patients received SIMT while receiving corticosteroids in a single-blind group-comparative trial. In both groups, there was no difference between the post-treatment and pretreatment values as regard to the FEV1/FVC relationship. However, in the control group but not in the training group, there was a small but significant decrease, from 99.2 +/- 3.0 to 94.3 +/- 2.8 (mean +/- SEM, p < 0.01) in FEV1 (percent of predicted normal values) and from 103.5 +/- 4.0 to 88.7 +/- 3.1 (p < 0.001) in the FVC, following treatment. All subjects had normal inspiratory muscle strength, as expressed by the maximal inspiratory mouth pressure (PImax) at residual volume, and inspiratory muscle endurance as expressed by the relationship between peak pressure and the PImax before treatment. Following administration of corticosteroids, there was a gradual decrease in both inspiratory muscle strength (from 117.5 +/- 9.4 to 80.5 +/- 3.3 cm H2O, p < 0.005) and endurance (from 82.7 +/- 2.6 to 40.2 +/- 1.7%, p < 0.001) in the control group. On the contrary, despite corticosteroid therapy, there were no significant changes in the inspiratory muscle function in the patients whose inspiratory muscles were specifically trained. We conclude that corticosteroids have a significant deteriorating effect on respiratory muscle function in humans. This weakness is preventable by using SIMT during corticosteroid treatment.

An alteration in the host-parasite relationship in subjects with chronic bronchitis prone to recurrent episodes of acute bronchitis

Acute episodes of bronchitis have been shown to be unequally distributed within a population of subjects with chronic bronchitis. Two groups were identified based on incidence of acute bronchitis--subjects who were 'infection-prone' (2-5 infections per year) and those who were 'non-infection-prone' (0-1 infections per year). Minor differences in clinical parameters existed, except for smoking experience. The non-infection-prone group included more current smokers, and the total smoking experience (in 'pack years') was significantly greater in this group. Between-year analysis demonstrated a stability of classification, established after a minimum of two years' prospective observation. Parameters of the host-parasite relationship were assessed in both groups. A significantly greater polybacterial colonization of the oropharynx was observed for chronic bronchitics, both infection-prone (P < 0.0001) and non-infection-prone (P < 0.001), compared with control subjects. Infection-prone chronic bronchitics had significantly greater total bacteria cultured from the oropharynx compared to the non-infection-prone group (P < 0.05); adherence of indigenous microflora to buccal epithelial cells, in particular Gram-positive cocci (P < 0.01) and in vitro adherence of non-serotypable Haemophilus influenzae to buccal cells (P < 0.05) compared with the control and non-infection-prone groups. These studies suggest that an important variation in subjects with chronic bronchitis is the binding capacity of epithelial cells for bacteria, which when increased enhances susceptibility to colonization and clinical infection.

The effect of corticosteroids on inspiratory muscle performance in humans

Functional alterations in the inspiratory muscles were evaluated in patients receiving corticosteroids for diseases other than respiratory. Inspiratory muscle strength, as expressed by the maximal inspiratory mouth pressure (PImax), and inspiratory muscle endurance (PmPeak/PImax), using a pressure threshold breathing device, were evaluated in eight patients with normal pulmonary and inspiratory muscle functions (two patients with rapidly progressive glomerulonephritis, two with glomerulonephritis with minimal changes, two with idiopathic thrombocytopenic purpura, and two with subacute thyroiditis). There was a gradual decrease in both inspiratory muscle strength and endurance following corticosteroid administration. After 8 weeks of treatment PmPeak/PImax decreased from 84.4 +/- 2.4 to 67.9 +/- 3.1 percent (p < 0.001), while inspiratory muscle strength dropped from 126.9 +/- 9.6 to 86.5 +/- 7.4 cm H2O (p < 0.005). Gradual steroid dosage tapering resulted in marked improvement in both strength and endurance; the inspiratory muscle strength rose significantly to 112.2 +/- 8.1 cm H2O (p < 0.0005) when steroid treatment was stopped, and even more significantly 6 months later (to 123.1 +/- 8.1 cm H2O [p < 0.0001]), and the PmPeak/PImax rose to 60.6 +/- 3.4 percent (p < 0.001) and to 74.7 +/- 3.2 percent (p < 0.0001), respectively. We conclude that corticosteroids have a significant deteriorating effect on respiratory muscle function in humans. This weakness is reversible while tapering steroid dosage. Steroid therapy should be reconsidered in patients with underlying lung disease.

Nonresolving pneumonia in steroid-treated patients with obstructive lung disease

PURPOSE

To review autopsy-proven cases of opportunistic pneumonia and determine how many of these patients had received corticosteroid therapy for obstructive lung disease in order to define whether this therapy was the major risk factor predisposing to infection.

PATIENTS AND METHODS

All autopsies performed at Winthrop-University Hospital over a 5-year period were reviewed, and 30 cases of opportunistic pneumonia were identified. In eight of 30 cases, corticosteroid therapy for chronic obstructive pulmonary disease (COPD) was the only identifiable risk factor for opportunistic infection. The other 22 patients had other well-defined risk factors for infection. Chart review of the eight patients with COPD was undertaken to define the clinical features of their infections.

RESULTS

All eight patients had a progressive multilobar pneumonia that failed to resolve, either clinically or radiographically, despite the use of multiple broad-spectrum antibiotics. In four cases, the infection was community-acquired, while in the other four cases, it was nosocomial in origin. Despite the presence of a nonresolving pneumonia, opportunistic infection was generally not considered as a diagnostic possibility, with only one case being correctly diagnosed antemortem. Autopsy examination documented Aspergillus species as being responsible for six episodes of pneumonia, Candida albicans accounting for one episode, and cytomegalovirus accounting for one episode.

CONCLUSION

Based on this experience, it is clear that corticosteroid therapy of COPD can lead to opportunistic pulmonary infection, in or out of the hospital. This diagnosis should be considered when patients receiving this therapy develop a pneumonia that fails to respond to broad-spectrum antibiotics.

Gastroesophageal reflux and respiratory symptoms: is there an association? Proposed mechanisms and treatment

Gastroesophageal reflux (GER) is a dysfunction of the distal esophagus causing movement of stomach contents into the esophagus. Patients may develop heartburn, regurgitation, dysphagia, odynophagia, and hemorrhage. Respiratory symptoms occur in 10-60 percent of patients with GER or hiatal hernia. Although there is evidence associating pulmonary symptoms and GER, causality has not been proven. The appropriate use of antireflux therapy or surgery to treat GER may consequently alleviate respiratory symptoms.

Intravenous and oral corticosteroids for the prevention of relapse after treatment of decompensated COPD. Effect on patients with a history of multiple relapses

To determine if a regimen of intravenous and oral corticosteroids reduces the relapse rate after treatment of decompensated COPD in the ED, 30 patients were studied. Forty-five visits in which intravenous and oral corticosteroids were given (T visits) were compared with an equal number of matched visits in which they were withheld (N visits). No differences were noted between T and N visits with respect to clinical findings, laboratory results and other forms of therapy. Treatment with corticosteroids reduced the relapse rate within 24 h of discharge. At 48 h, the cumulative relapse rate for T visits (8.9 percent) was significantly lower than for N visits (33.3 percent; p = 0.005). For patients with a history of multiple relapses, a regimen consisting of intravenous and oral corticosteroids reduces the risk of relapse after ED treatment of decompensated COPD.

Rationale and use of corticosteroids in chronic obstructive pulmonary disease

Several studies of corticosteroid efficacy in patients with COPD performed in the last decade have had stronger study designs and larger patient populations than most of the previously reported investigations. These studies have provided evidence of the objective benefit of corticosteroid therapy on pulmonary function in clinically stable COPD patients. These positive results are due to a relatively marked beneficial effect of corticosteroids in a minority of the subjects studied rather than a modest effect in the majority of subjects. A controlled randomized trial of intravenous corticosteroid administration in patients with COPD and acute respiratory failure admitted to the hospital showed improvement in pulmonary function from 12 hours following initial administration through the remainder of the 3 days of the study in the treatment group as compared to the control group. A greater percentage of patients showed a beneficial response to corticosteroids in this study of patients with acute exacerbations as compared to most of the studies of clinically stable COPD patients with beneficial effects. This suggests the possibility that some patients may show a beneficial response to corticosteroids during an acute exacerbation although they have not shown a response when clinically stable. The response to inhaled corticosteroids in patients with COPD has not been studied as extensively as the response to oral corticosteroids. However, some studies have shown a beneficial response to inhaled corticosteroids, primarily but not exclusively, in individuals who have also shown a positive response to oral agents. Generally, the response in terms of improved pulmonary function has been less striking with the inhaled agent as compared to the oral drug, although higher relative doses of the oral drugs usually were studied. Several limitations of the currently available studies are evident. Most of the studies deal with the effects in clinically stable outpatients with COPD and no studies have dealt with maintenance therapy in patients who have responded to a 1 to 2 week course of 30 mg of prednisone or greater. Data on the efficacy of inhaled corticosteroids in COPD patients are limited. No studies have investigated the role of corticosteroids in acute exacerbations in outpatients with COPD. Recommendations are given regarding use of corticosteroids in patients with COPD. A trial of corticosteroids is recommended at some point during a patient's course, while clinically stable. If a beneficial response is obtained in terms of improvement in airflow obstruction, then clinical judgment must be used regarding whether maintenance therapy is continued and, if so, at what dose and by what route.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of acute exacerbations in chronic obstructive pulmonary disease

Therapeutic interventions introduced and refined over the last 10 years, including chronic home oxygen and improved bronchodilators, have resulted in more patients with chronic obstructive pulmonary disease living longer despite more severe functional abnormalities. Episodes of acute respiratory failure in this population remain a major complication requiring rapid assessment and intervention. This article focuses on the diagnostic approach and therapeutic interventions in the patient with obstructive lung disease who presents in acute respiratory distress.

Time course of response to oral and inhaled corticosteroids in non-asthmatic chronic airflow obstruction

One hundred and twenty one patients considered on clinical grounds to have non-asthmatic chronic airflow obstruction completed a double blind, crossover trial comparing oral prednisolone 40 mg per day with inhaled beclomethasone dipropionate 500 micrograms thrice daily, each given for 14 days, with a 14 day washout period between treatments. The time course of response was analysed for the 57 occasions where there was a significant increase in mean daily peak expiratory flow (PEF) over the treatment period. Mean daily PEF was still rising at day 14 on 12 occasions. After withdrawal of treatment mean daily PEF remained above pretreatments levels for more than two weeks in half the responses analysed. The peak response occurred earlier with inhaled beclomethasone (median 9.5 (range 3-14) days) than with oral prednisolone (median 12 (range 1-14) days), though both treatments produced a response that was sustained for a similar period. The results suggest that a trial of treatment with corticosteroids in this group of patients should last more than 14 days, and that in a study with a crossover design the washout period should be longer than two weeks.

Chronic cor pulmonale

Chronic cor pulmonale is defined as right heart hypertrophy and/or chronic right heart failure. There are many etiologies, but the common cause is increased right heart work from pulmonary hypertension. Etiology can be conveniently discussed by assuming two prototypes, the asphyxial or hypoxic type and the vascular obliterative type. A common cause of the asphyxial type is chronic obstructive pulmonary disease, and the obliterative type is represented by chronic pulmonary thromboembolic disease or primary pulmonary hypertension. Pathology is discussed, emphasizing the cardiac manifestations of chronic cor pulmonale including data of specific cardiac chamber size. An overview of hemodynamics is given, and the use and limitation of electrocardiography and chest x-rays are discussed. The exciting potential use of echocardiography for the serial non-invasive measurement of anatomical and pathophysiological features is outlined, along with the value of a careful physical examination and the proper utilization of laboratory tests in the diagnosis of chronic cor pulmonale. In the patient with the asphyxial type, the treatment of pulmonary infectious exacerbations, the role of corticosteroids, digoxin, diuretics, phlebotomy, bronchodilators (theophylline, beta adrenergic agonists, and anticholinergics), and long-term oxygen therapy is noted. The controversy surrounding the use of vasodilators and calcium blockers in these patients is discussed. Treatment aspects of the vascular obliterative type, including the role of vasodilators, calcium blockers, prostacyclin, anticoagulants, and overall strategy are discussed. A brief note is mentioned of the promising role of surgical therapy in chronic thromboembolic disease causing chronic cor pulmonale.

Chronic obstructive pulmonary disease and asthma. General and medical management with special attention to exacerbations

The general management of patients with chronic obstructive pulmonary disease and asthma is discussed. Pathophysiological mechanisms of bronchial obstruction and inflammation are briefly described. The importance of preventive measures is emphasized. Medicine prescribed in chronic obstructive pulmonary disease and asthma, their relative place in treatment schedules and route of administration are reviewed. Finally, the importance of maximal bronchodilatation in exacerbations is stressed and the few indications for antibiotic treatment are discussed.

Serious infectious complications of corticosteroid therapy for COPD

We report seven elderly patients with COPD who developed serious infectious complications during prolonged treatment with high doses of corticosteroids. Infections included invasive pulmonary aspergillosis, Herpes simplex stomatitis and esophagitis, cytomegalovirus pneumonia, bacterial sepsis, fungemia and meningitis due to Cryptococcus neoformans. Each of the three patients who developed invasive aspergillus pneumonia died. The efficacy of prolonged therapy with high doses of corticosteroids in patients with COPD is not proven. These cases illustrate the potential for serious infections in patients with COPD treated with corticosteroids.

Effects of oral terbutaline in chronic airflow limitation

A randomized, double-blind, crossover study was conducted to assess the efficacy of five weeks' treatment with terbutaline, 15 mg daily, compared with placebo in 17 evaluable patients with moderate to severe chronic airflow limitation (CAL) with a minor reversible component. A significant improvement after terbutaline treatment compared with placebo was observed in subjective assessments of breathlessness after two of the activities of daily living, and in daily peak flow measurements recorded in patient diaries. At the clinical assessment after five weeks' terbutaline therapy, 12 of 17 patients had improved pulmonary symptom scores compared with placebo, and a slight increase in FEV1 was observed relative to placebo (0.09 L, p less than 0.05). Thus, five weeks' treatment with oral terbutaline in patients with CAL resulted in significant improvements in several subjective assessments, despite a lack of effect on the majority of the objective variables.

A randomized controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of COPD

We conducted a randomized, controlled double-blind study to determine whether intravenous administration of methylprednisolone early in the therapy for acute exacerbations of COPD would improve pulmonary function in the Emergency Department and reduce the need for hospitalization. Ninety-six patients completed the study. All were at least 50 years of age and had no history of asthma. Patients received aminophylline and hourly administration of aerosolized isoetharine. Methylprednisolone (100 mg) or physiologic saline solution was given within one-half hour of arrival in the Emergency Department. Spirometry was performed initially and after the third and fifth aerosol treatments. We found no greater improvement in FEV1 in the group receiving the steroid (37 percent) than in the control group (43 percent; NS). There was also no difference in the rate of hospitalization (33 percent in the steroid-treated group vs 30 percent in the control group; NS). We conclude that early administration of methylprednisolone does not affect the emergency phase of treatment for acute exacerbations of COPD.

Depression, somatization and steroid use in chronic obstructive pulmonary disease

Steroid therapy has become part of the adjunctive treatment for COPD patients in some settings. Emotional changes have been reported in some patients while on these medications, but whether these changes are associated with the pathophysiological state or a side effect of the medication is not known. In this study self-reports of depression and somatic complaints were compared between two groups of COPD patients, 20 not receiving steroids and 20 receiving steroids. Both groups demonstrated comparable levels of disease and somatic complaints. Mean FEV1 value for those not receiving steroids was 34% of predicted while the mean for those receiving steroids was 30% of predicted. Depression was found to be significantly higher (t = 11.21, df = 38, p less than 0.01) in the group receiving steroids when compared to those not receiving steroids using a Student's t test. The higher degree of depression among steroid treated COPD patients has implications for clinical practice. The emotional status of this group of patients needs to be monitored and interventions initiated when necessary.

An audit of morbidity associated with chronic asthma in general practice

A survey of 312 adult asthmatic subjects has been undertaken. Only 3.5% of the total adult list were known to have asthma and this may represent underdiagnosis. Spirometry was normal in under half the patients and below 50% predicted in one fifth. Forced expired volume in 1s had declined more rapidly than expected with increasing age, particularly amongst smokers. Morbidity from asthma was extensive, patients reporting substantial breathlessness and restrictions of their life style; nearly half had lost time from work in the preceding twelve months. Morbidity was correlated with spirometry.

Corticosteroid therapy for chronic obstructive pulmonary disease. Is it worth the risks?

The majority of patients with chronic obstructive pulmonary disease (COPD) do not appear to benefit from long-term corticosteroid therapy. Nevertheless, a small minority demonstrate a response to treatment that is so dramatic that it may be worth the risk of chronic corticosteroid use. A corticosteroid trial is indicated in the patient with COPD who remains symptomatic despite adequate and aggressive routine treatment. If substantial improvement is noted in pulmonary function, chronic corticosteroid treatment should be considered. In patients without an objective response, long-term corticosteroid therapy should not be continued.

Corticosteroids in stable chronic obstructive pulmonary disease: reappraisal of efficacy

Although systemic corticosteroids are widely used in treating stable chronic obstructive pulmonary disease (COPD), the evidence for their efficacy is still disputed. To reappraise this evidence, the authors used a new analytic strategy in which the 14 available randomized clinical trials were evaluated according to a methodologic "review of systems" and an examination of the statistical precision of the outcome results. Although none of the trials satisfied all of the methodologic criteria for both validity and clinical pertinence, the trials finding steroids efficacious were generally better designed and more statistically precise than trials failing to show efficacy. The authors propose a set of five main methodologic guidelines that require a stable baseline state, a crossover design with suitable washout, adequate doses of corticosteroids, pragmatic designs, and comprehensive choices of outcome events. Attention to these guidelines can help improve both design and evaluation for future trials of systemic steroids for stable COPD.

Value of serial peak expiratory flow measurements in assessing treatment response in chronic airflow limitation

A double blind, randomised, placebo controlled, crossover trial of prednisolone (40 mg/day for 14 days) was carried out in 33 patients with chronic airflow limitation (mean age 62 years, mean FEV1 1.01 litres, mean FEV1/FVC ratio 44%), to assess the value of serial peak expiratory flow (PEF) measurements, taken five times daily in evaluating treatment response by comparison with other objective measurements and with measurements of symptoms. The mean serial PEF after a one week run in period was 189 1 min-1, during the second week of placebo 193 1 min-1, and during the second week on prednisolone 231 1 min-1. The difference in mean PEF values between placebo and prednisolone was significant (p less than 0.01). With regard to the response to steroids of the individual patients, 13 of the 33 had a detectable trend of improvement on visual inspection of serial PEF measurements during prednisolone treatment but only one during placebo administration. Of all the objective measurements made after the run in and after each treatment phase (12 minute walking distance, FEV1, forced vital capacity (FVC), serial PEF), the serial PEF chart provided the best discrimination between placebo and prednisolone treatment. There was no statistically significant association between steroid induced improvement in serial PEF measurements and in breathlessness, partly because of placebo improvements in symptoms in those who had no improvement in serial PEF values. This study indicates the importance of making objective measurements to identify a genuine steroid response rather than relying on symptomatic improvement alone. The best simple measurement to make is serial PEF during steroid trials. This is more sensitive in detecting a steroid response than are the 12 minute walking distance, FEV1, or FVC, and is also less likely than these measurements to show spurious placebo responses.

Acute respiratory failure and chronic obstructive lung disease

Patients with COPD who develop acute respiratory failure require special attention in their management. Patients with severe COPD often have cor pulmonale, complex acid/base compensations, and altered respiratory control mechanisms. These need to be considered when approaching the patient with an acute decompensation. Because of the improving prognosis in this group of patients, aggressive management should be undertaken using combinations of bronchodilator medications, oxygen, bronchial hygiene, and antibiotics.

Corticosteroids in COPD. A clinical trial and reassessment of the literature

A placebo-controlled, double-blind cross-over trial was conducted to assess whether 16 men with chronic obstructive pulmonary disease (COPD) would benefit from orally taken corticosteroids. Two weeks of treatment with 40 mg of prednisone daily did not result in improvement of pulmonary symptoms or function in the group as a whole, although one patient had small improvement in airflow. The baseline spirometric data and beta-agonist responsiveness of the patients in the study were then compared to a reference population consisting of 264 men who fulfilled a criteria for chronic obstruction out of 730 men who comprised a systematic sample drawn from all patients referred for spirometry at three hospitals. Our study subjects and those of five similar trials of corticosteroids in COPD had more severe obstruction than this reference group. Furthermore, the proportion of steroid responders found in each study was inversely related to the baseline FEV1 of the patients examined. It appears that previous studies of corticosteroids in COPD may have overestimated the number of COPD patients who might benefit from corticosteroids, due to a bias resulting from the selection of severely obstructed subjects.

Inhibition of cigarette smoke-induced airway secretory cell hyperplasia by indomethacin, dexamethasone, prednisolone, or hydrocortisone in the rat

As the nonsteroidal anti-inflammatory drug indomethacin has already been shown to inhibit cigarette smoke (CS)-induced secretory cell hyperplasia in the airway epithelium of the rat, the present study was undertaken to determine the effects of prophylactic interaperitoneal injection of indomethacin (4 mg/kg body weight) compared with each of three steroidal anti-inflammatory drugs given at comparable doses. The results show that dexamethasone (given initially at 4 mg/kg), prednisolone (4 mg/kg) and hydrocortisone (4 mg/kg) were also inhibitory. Dexamethasone proved to be toxic and its dose had to be reduced to give an average dose of 2 mg/kg over the experimental period. Prednisolone and hydrocortisone were toxic only when in combination with CS. The order of descending effectiveness in inhibiting secretory cell hyperplasia was indomethacin, dexamethasone, prednisolone and hydrocortisone. Indomethacin was the most effective drug in the trachea, whilst in distal intra-pulmonary airways dexamethasone was the most effective. Depending on airway level, inhibition was between 69 and 115% of the value obtained after CS alone. The inhibition was complete in all but one instance. The results show that steroids also inhibit secretory cell hyperplasia but at a comparable dose they are generally less effective than indomethacin and may have unacceptable side effects.

Psychological changes and improvement in chronic airflow limitation after corticosteroid treatment

Corticosteroids may produce mood changes. This could account for improvement in patients with chronic airflow limitation following trials of oral corticosteroid treatment as mood elevation might improve performance in objective measurements. This proposition was tested in 21 patients with chronic airflow limitation, who underwent detailed psychological assessment during a randomised controlled double blind crossover trial of the effect of prednisolone 40 mg daily compared with that of a placebo. Self rating visual analogue scales for various qualities of mood were completed before the study and after each phase in addition to depression and psychological symptom questionnaires. After treatment with the placebo, patients showed increases in cheerfulness (p less than 0.01) and sociability (p less than 0.01) and a decrease in depression (p less than 0.01). After treatment with prednisolone there were increases in cheerfulness (p less than 0.01), optimism (p less than 0.01), activity (p less than 0.05), and sociability (p less than 0.02) and there was a decrease in depression (p less than 0.01). When placebo and prednisolone values were compared, however, there were no significant differences. Some patients showed improvements (greater than 20%) in peak expiratory flow, FEV1 or forced vital capacity (FVC) after prednisolone, but nearly all had improvements in at least one psychological test. There were no detectable associations between changes in objective measurements and changes in psychological test ratings. This study suggests that in patients with chronic obstructive lung disease significant psychological changes are no more likely to follow treatment with a corticosteroid than treatment with a placebo and that physiological improvement after corticosteroid treatment is not tied to psychological changes.

Effects of prednisolone in chronic airflow limitation

A double-blind, randomised, placebo-controlled, crossover trial of prednisolone (40 mg daily for 14 days) was carried out in 43 patients with chronic airflow limitation (mean age 60 years, mean FEV1 1.02 litres, FEV1/FVC ratio 43.7%). Several subjective and objective variables for response were measured. Significant improvements occurred with prednisolone in most variables measured, but improvements also occurred with placebo in some variables. The improvements with prednisolone in general wellbeing, 12 min walk distance, peak expiratory flow, FEV1, and relaxed vital capacity were significantly greater than those with placebo. Clinical assessment and assessment of atopic status did not reveal any feature of major predictive value for steroid responsiveness. A proportion of patients with chronic airflow limitation do improve on oral corticosteroids and the continued use of such trials in clinical practice is justified, though a placebo period should be included, and several variables for response should be measured.

Therapy of chronic obstructive airways disease

The most frequently employed measure in attempts to alleviate symptoms and improve the quality of life of patients with chronic obstructive airways disease (COAD) is to prescribe medications. However, COAD is largely an irreversible condition and no therapeutic intervention has been shown to be universally useful. Theophylline or corticosteroid are occasionally helpful but most patients will not benefit. Of the remaining options, only oxygen has been shown to be effective in selected patients and should be administered on a continuous basis. It is becoming increasingly evident that clinicians should be more discriminating when making therapeutic decisions for persons with COAD. Maintenance therapy with pharmacological agents should be entertained only after individually conducted therapeutic trials. Moreover, enormous costs can result from treating even a small fraction of the population estimated to have COAD.

ACTH 1-17 effects in chronic obstructive bronchitis

The authors have tested the effectiveness of ACTH 1-17, administered in a single dose of 100 micrograms intramuscularly at 07(00) for 10 consecutive days, in 10 male patients suffering from chronic obstructive bronchitis with different ventilatory impairment. The subjects performed every 4 h (02(00), 06(00), 10(00), 14(00), 18(00), 22(00] for 14 consecutive days (3 days of wash-out and 10 days of treatment) spirometric tests with recording of 8 ventilatory parameters and of oral temperature. The day before and after treatment plasma cortisol levels were also determined 6 times a day. After the period of treatment 4 subjects improved, 4 remained stationary and 2 worsened as concerns the ventilatory functions, while 7 perceived a better general condition. The normal circadian synchronization of the respiratory function of the group, with acrophase in the afternoon, was maintained and the temperature rhythm was not influenced. The circadian rhythm of plasma cortisol showed a significant mesor reduction after treatment with a slight advance in acrophase indicating a partial inhibition of the hypothalamo-hypophyseal axis. The success of treatment was independent of the severity of the ventilatory impairment and the subjects showed different patterns of response both quantitatively (probably related to the dosage) and temporally (immediate or delayed). Hyperpigmentation of the skin owing to the intrinsic melanotropic activity of the peptide occurred in 2 subjects. As a side effect, weight increase was apparent in 3 subjects.

Medical education provided by a clinical pharmacist: impact on the use and cost of corticosteroid therapy in chronic obstructive pulmonary disease

The impact of medical education provided by a clinical pharmacist on the use and cost of corticosteroid therapy in acute exacerbations of chronic obstructive pulmonary disease was evaluated. Three separate two-month audits of corticosteroid use were conducted on the pulmonary medicine service (PMS) of a teaching hospital. For the first audit period, no education was given and no clinical pharmacist was on the PMS. During the second audit period, no education was given, but a clinical pharmacist was on-service. For the third audit period, education (brief discussion and a handout) was given to new house staff members by the clinical pharmacist on the PMS. A significant reduction in the mean number of intravenous steroid doses, steroid cost per day, and patient steroid charges per day occurred in the third vs. the first period. Steroid cost per day and patient steroid charges per day were lower in the third period than the second, but the difference was not statistically significant.

Effect of oral prednisolone on response to salbutamol and ipratropium bromide aerosols in patients with chronic airflow obstruction

We examined the bronchodilator responses to inhalation of salbutamol (200 micrograms) and of ipratropium bromide (40 micrograms) in the morning and in the afternoon before and during a course of oral prednisolone (40 mg daily) in 15 patients with chronic, partly reversible airflow obstruction. Bronchodilatation was assessed by measuring serial peak expiratory flow rates (PEFR) for six hours after aerosol drug administration and calculating the area under the time-response curves. Eleven patients were found to be corticosteroid resistant in not attaining a baseline bronchodilatation of at least 25% during corticosteroid treatment. These patients also failed to show any enhancement of their bronchodilator responses to either salbutamol or ipratropium bromide during prednisolone administration. We therefore conclude that there is no rationale for giving or continuing corticosteroid treatment in known steroid-resistant patients in the hope of nevertheless potentiating their bronchodilator responses to salbutamol or ipratropium bromide.