RESUMO
BACKGROUND: Although previous data suggest that intranasal fluticasone furoate (FF) improves ocular symptoms of allergic rhinitis (AR), it presents serious limitations that question its results and conclusions. Therefore, an independent systematic review with meta-analysis is required to confirm and clarify the magnitude of the effect of FF. METHODS: This review compared the efficacy of intranasal FF to placebo on ocular and nasal symptoms in patients with AR. Primary outcomes were reflective and instantaneous total ocular symptom scores (rTOSS and iTOSS), and reflective and instantaneous total nasal symptom scores (rTNSS and iTNSS). Secondary outcomes included the assessment of response to therapy, quality of life (QoL), and adverse effects. RESULTS: Sixteen trials (5.348 patients) were selected. Seven studies included seasonal AR patients and nine studies, perennial AR patients. Intranasal FF significantly improved rTOSS and iTOSS scores compared with placebo in patients with seasonal (weighted mean difference [WMD] -0.54, 95% CI, -0.70 to -0.37, and -0.59, 95% CI, -0.76 to -0.43) and perennial AR (-0.33, 95% CI, -0.31 to -0.05, and -0.38, 95% CI, -0.69 to -0.07). Intranasal FF was also significantly more effective in improving rTNSS and iTNSS scores in seasonal (WMD=-1.14, 95% CI, -1.57 to -0.72, and -1.32, 95% CI, -1.64 to -1.01) and perennial AR patients (-0.83, 95% CI, -1.08 to -0.59, and -0.90, 95% CI, -1.33 to -0.48). Finally, there were greater improvements in response to therapy and QoL with a favourable safety profile. CONCLUSIONS AND CLINICAL RELEVANCE: Intranasal FF showed a consistent ocular and nasal efficacy along with improvement in QoL in AR patients. This review provides significant evidence that treatment with FF nasal spray at a dose of 110 mcg once daily is effective in relieving ocular and nasal symptoms in adolescents and adults with AR.
Assuntos
Androstadienos/administração & dosagem , Androstadienos/uso terapêutico , Antialérgicos/administração & dosagem , Antialérgicos/uso terapêutico , Sprays Nasais , Rinite Alérgica Sazonal/tratamento farmacológico , Administração Intranasal , Humanos , PlacebosRESUMO
BACKGROUND: The EAGLE project database was analysed to assess the characteristics of patients with severe (SA) who required hospitalisation as a result of an acute episode during the period 1994-2004, and the relationship with asthma severity. METHODS: A total od 2593 clinical records corresponding to an equal number of patients hospitalised for acute asthma (15-69 years), with sufficient information to characterize their asthma severity in agreement with GNA criteria were identified (727 patients with SA compared with 1866 patients with non-severe asthma). RESULTS: Patients with SA were older, displayed a greater predominance of female asthmatics, lower antecedents of atopy, and a higher frequency of previous hospitalisations compared with non-severe asthmatics (86.1% vs. 50.5%, p< or = 0.01). Additionally, SA patients showed more severe exacerbations characterized by acidosis, significant spirometric deterioration, greater length of hospital stay (9.4 days vs. 7.0 days), as well as a higher frequency of intubation (16.8% vs. 2.1%), intensive care unit admission (11.3% vs.4.9%), cardiopulmonary arrest (5.5% vs. 1.3%), and asthma deaths (2.1% vs. 0.4%) (all < or = 0.01) compared wit non-severe patients. CONCLUSIONS: This study suggests that SA patients have greater morbidity and a disproportionate need for health care as a result of more severe exacerbations. However, non-severe asthmatics can also still present acute severe episodes (although with a lower frequency) with risk of life.
Assuntos
Asma/epidemiologia , Asma/fisiopatologia , Hospitalização , Acidose Respiratória , Doença Aguda , Adolescente , Adulto , Fatores Etários , Idoso , Antiasmáticos/uso terapêutico , Asma/terapia , Broncodilatadores/uso terapêutico , Estudos de Casos e Controles , Progressão da Doença , Feminino , Parada Cardíaca , Humanos , Intubação , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Fatores Sexuais , Espanha , Espirometria , Análise de SobrevidaRESUMO
BACKGROUND: Current guidelines recommend the use of a combination of inhaled beta(2) agonists and anticholinergics, particularly for patients with acute severe or life threatening asthma in the emergency setting. However, this statement is based on a relatively small number of randomised controlled trials and related systematic reviews. A review was undertaken to incorporate the more recent evidence available about the effectiveness of treatment with a combination of beta(2) agonists and anticholinergics compared with beta(2) agonists alone in the treatment of acute asthma. METHODS: A search was conducted of all randomised controlled trials published before April 2005. RESULTS: Data from 32 randomised controlled trials (n = 3611 subjects) showed significant reductions in hospital admissions in both children (RR = 0.73; 95% CI 0.63 to 0.85, p = 0.0001) and adults (RR = 0.68; 95% CI 0.53 to 0.86, p = 0.002) treated with inhaled anticholinergic agents. Combined treatment also produced a significant increase in spirometric parameters 60-120 minutes after the last treatment in both children (SMD = -0.54; 95% CI -0.28 to -0.81, p = 0.0001) and adults (SMD = -0.36; 95% CI -0.23 to -0.49, p = 0.00001). CONCLUSIONS: This review strongly suggests that the addition of multiple doses of inhaled ipratropium bromide to beta(2) agonists is indicated as the standard treatment in children, adolescents, and adults with moderate to severe exacerbations of asthma in the emergency setting.
Assuntos
Agonistas Adrenérgicos beta/uso terapêutico , Asma/tratamento farmacológico , Antagonistas Colinérgicos/uso terapêutico , Doença Aguda , Administração por Inalação , Adolescente , Adulto , Criança , Quimioterapia Combinada , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Testes de Função RespiratóriaRESUMO
BACKGROUND: Lactic acidosis is a recognised event in adult patients with status asthmaticus, particularly in the setting of intensive care. However, it has been infrequently studied in patients attending the emergency departments (ED). METHODS: We conducted a prospective and descriptive study to assess levels of lactate and effects on bronchodilator response in adult patients with acute severe asthma treated with high doses of albuterol in the ED. In total, 18 subjects (mean (SD) age 42.9 (2.7) years, FEV1 = 32.2 (10.9)% of predicted) who presented to an emergency department were enrolled in the study. All patients were treated with albuterol; four puffs (100 microg/puff) at 10 minute intervals, delivered by a pressurised metered dose inhaler into a spacer device over a 2 hour period. RESULTS: At the end of treatment, mean (SD) plasma lactate level (2.94 (2.1) mmol/l) was significantly higher (p = 0.001) than baseline. Of the 18 patients, nine (50%) showed lactate levels > or = 2.5 mmol/l (four patients presented values > 4 mmol/l); these patients had a shorter duration of attack prior to ED presentation (p = 0.01), a higher pretreatment heart rate (p = 0.005), a lower pretreatment SpO2 (p = 0.03), a lower pretreatment PO2 (p = 0.009), a higher pretreatment PCO2, and a lower pretreatment serum potassium (p = 0.005). However, there were no significant differences in the airway response between groups. CONCLUSIONS: This study confirmed previous observations that high lactate concentrations can develop during the first hours of inhaled beta agonist treatment. The presence of a previous hyperadrenergic state may predispose to the development of this condition. A significant improvement in lung function was associated with elevated lactate levels.
Assuntos
Albuterol/administração & dosagem , Asma/tratamento farmacológico , Lactatos/sangue , Doença Aguda , Administração por Inalação , Adulto , Asma/sangue , Asma/fisiopatologia , Dióxido de Carbono/fisiologia , Feminino , Volume Expiratório Forçado/fisiologia , Frequência Cardíaca/fisiologia , Humanos , Masculino , Oxigênio/fisiologia , Estudos Prospectivos , Resultado do TratamentoAssuntos
Agonistas Adrenérgicos beta/uso terapêutico , Asma/tratamento farmacológico , Doença Aguda , Administração por Inalação , Agonistas Adrenérgicos beta/administração & dosagem , Agonistas Adrenérgicos beta/efeitos adversos , Humanos , Injeções Intravenosas/métodos , Inaladores Dosimetrados , Nebulizadores e VaporizadoresRESUMO
This article reviews the aerosol therapy and inhalotherapy in the nonintubated adult patient with acute severe asthma in the emergency department. Factors influencing lower respiratory deposition of aerosols are summarized. The use of inhaled beta2-adrenergic agonists, anticholinergic drugs, corticosteroids, and heliox are discussed.
Assuntos
Aerossóis/administração & dosagem , Obstrução das Vias Respiratórias/tratamento farmacológico , Antiasmáticos/administração & dosagem , Tratamento de Emergência/métodos , Doença Aguda , Administração por Inalação , Corticosteroides/administração & dosagem , Agonistas Adrenérgicos beta/administração & dosagem , Adulto , Obstrução das Vias Respiratórias/etiologia , Asma/complicações , Asma/tratamento farmacológico , Antagonistas Colinérgicos/administração & dosagem , Cuidados Críticos/métodos , Serviço Hospitalar de Emergência , Feminino , Hélio/administração & dosagem , Humanos , Masculino , Oxigênio/administração & dosagem , Respiração Artificial , Sensibilidade e Especificidade , Índice de Gravidade de DoençaRESUMO
STUDY OBJECTIVES: (1) To determine the frequency of rapid-onset asthma attacks (ROAAs) and slow-onset asthma attacks (SOAAs) in adult patients with acute, severe disease (18 to 50 years old), who presented to an emergency department (ED); and (2) to establish whether ROAA patients differ from SOAA patients in terms of clinical and spirometric characteristics; and (3) in terms of the response of treatment. SUBJECTS AND METHODS: Four hundred three patients (with peak expiratory flow [PEF] or FEV(1) of < 50% of predicted value) with acute exacerbations of asthma were enrolled in the trial using a prospective cohort study. Asthma attacks were classified as an ROAA (< 6 h of symptoms) or an SOAA (> or = 6 h). All patients were treated with albuterol, four puffs at 10-min intervals (100 microg per actuation), delivered by metered-dose inhaler with a spacer device during 3 h. RESULTS: On the basis of previously determined criteria, 11.3% of patients were classified as having a ROAA. Male patients comprised 53.6% of the ROAA group (p = 0.03). In ROAA patients, the exacerbation was less likely to be attributed to respiratory tract infection (p = 0.001) and more likely to have no identifiable cause (p = 0.0001). Also, ROAA patients had lower pulmonary function (FEV(1)) at presentation (mean difference, - 0. 13; 95% confidence interval [CI], - 0.22 to - 0.04 L; p = 0.04) than SOAA patients. At the end of treatment, ROAA patients had an overall 48.0 L/min (95% CI, 14.1 to 81.8 L/min) greater improvement in PEF and a 0.31 L (95% CI, 0.08 to 0.54 L) greater improvement in FEV(1) than SOAA patients. Also, ROAA patients presented with less accessory muscle use (p < 0.05) and higher oxygen saturation (p = 0. 005). Finally, SOAA patients showed an increased incidence of hospital admission (relative risk, 3.89; 95% CI, 1.01 to 15.0). CONCLUSIONS: Data from this study support the notion that ROAAs constitute a distinct but uncommon acute asthma ED presentation, with a predominance of male patients. Upper respiratory tract infection was not believed to be a significant trigger factor in these patients, and ROAA patients had rapid deterioration of their conditions followed by a more rapid response to treatment and a lower hospital admission rate than SOAA patients. Thus, we have identified a subgroup of patients who appear to have common characteristics with patients with sudden-onset near-fatal/fatal asthma.
Assuntos
Albuterol/administração & dosagem , Asma/tratamento farmacológico , Broncodilatadores/administração & dosagem , Doença Aguda , Administração por Inalação , Adolescente , Adulto , Asma/classificação , Asma/fisiopatologia , Estudos de Coortes , Emergências , Serviço Hospitalar de Emergência , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Pico do Fluxo Expiratório , Estudos ProspectivosRESUMO
We designed a larger, double-blind, randomized, prospective trial to test our hypothesis that patients with acute asthma given combination high dose therapy with ipratropium bromide (IB) and beta(2)-agonists will have greater improvement in pulmonary function and fewer hospital admissions than those given beta(2)-agonists alone. One hundred eighty patients (mean age +/- SD, 34.3 +/- 10.5 yr) who presented to an emergency department (ED) for treatment of an exacerbation of asthma (baseline FEV(1) < 50% of predicted) were assigned in a randomized, double-blind fashion to receive albuterol and placebo (n = 92) or albuterol and IB (n = 88). Both drugs were administered through a metered-dose inhaler and spacer at 10-min intervals for 3 h (24 puffs or 2,880 microg of albuterol and 504 microg of IB each hour). Primary outcome measures were improvement in pulmonary function (FEV(1) or peak expiratory flow [PEF]), and hospital admission rates. In both groups, pulmonary function improved significantly over baseline values (p < 0.01). Subjects who received IB had an overall 20.5% (95% CI: 2.6 to 38.4%) (p = 0.02) greater improvement in PEF and a 48.1% (95% CI: 19.8 to 76.4%) (p = 0.001) greater improvement in FEV(1) from the control group. At the end of protocol (3 h), 39% (n = 36) of patients in the control group and 20% (n = 18) in the IB group were admitted (p = 0.01). The use of high doses of IB reduced the risk of hospital admission 49% (relative risk = 0.51, 95% CI: 0.31 to 0.83). Five (95% CI: 3 to 17) patients would need to be treated with high doses of IB to prevent a single admission. Kaplan-Meier-estimated curves of the proportion of patients who reached the discharge threshold during the 3 h of treatment, showed a significant difference in favor of the IB group (log-rank test = 0.005). A subgroup analysis showed that patients most likely to benefit from the addition of high doses of IB were those with more severe obstruction (FEV(1) /= 24 h). On the contrary, previous use of inhaled beta(2)-agonists did not modify the admission rate and the pulmonary function response to IB. In conclusion, our data support a substantial therapeutic benefit from the addition of IB to albuterol administered in high doses through MDI plus spacer, particularly in patients with FEV(1) less than 30%, and with long duration of symptoms before the ED presentation (>/= 24 h).