Broncodilatadores en pacientes con bronquiolitis / Bronchodilators for bronchiolitis

La bronquiolitis es una infección respiratoria aguda baja de causa viral, de aparición invernal, que es común en bebés de 0a 12 meses de edad. Conduce a que las vías respiratorias pequeñas se inflamen y se llenen de desechos, obstruyéndose.El bebé tiene una tos fuerte, secreción nasal, generalmente fiebre y puede presentar sibilancias dificultad respiratoria ydesaturación de oxígeno. Tras la presentación de un caso en la guardia se generó una controversia científica sobre lautilidad de los broncodilatadores en pacientes con bronquiolitis. Luego de realizar una búsqueda bibliográfica y seleccionarla evidencia más reciente y de mejor calidad, se concluye que la evidencia no apoya el uso de broncodilatadores enpacientes con bronquiolitis.(AU)

Bronchiolitis is a low acute respiratory lower respiratory tract infection of viral origin, winter appearance, which is commonin babies from 0 to 12 months of age. It causes the small airways in the lungs to become inflamed and fill with debris. Theinfant has a harsh cough, runny nose, usually fever and may have wheezing, respiratory distress and oxygen desaturation.After the presentation of a case in the emergency department, a scientific controversy was generated about the usefulnessof bronchodilators in patients with bronchiolitis. After conducting a literature search and selecting the most recent and bestquality evidence, it is concluded that evidence does not support the use of bronchodilators in patients with bronchioliTIS.(AU)

Clinical differences between children with asthma and rhinitis in rural and urban areas / Diferencias clínicas entre niños con asma y rinitis de áreas rurales y urbanas

Abstract Background: Epidemiological studies have shown that children who grow up on traditional farms are protected from allergic diseases. However, less is known about if the environment influences the pharmacotherapy in these patients. Objective: To compare the treatment of asthmatic and rhinitis children from urban and rural areas in Medellín, Colombia. Methods: During one year, we follow up a group of children (6 to 14 years) with diagnostic of asthma or rhinitis living for more than five years in urban or rural area. A questionnaire with socio-demographic characteristics, pharmacotherapy treatments, was obtained each three months. Atopy evaluation, spirometry and clinical test for asthma and rhinitis severity were done at the beginning and one year later. Results: Eighty six point four percent patients completed the follow up (rural n: 134, urban n: 248). Patients in rural location required less salbutamol (p: 0.01), visit to emergency department (p <0.01) and have a less number of patients with FEV1 <80% (p: 0.05). For clinical control rural children require less pharmacotherapy than urban children (p: 0.01) and more patients with rhinitis (18% vs 8% p: 0.03) and asthma (23% vs 12% p: 0.01) in the rural group could suspended pharmacotherapy. Atopy (p: <0.07) and poli-sensitization (p: <0.08) was a little higher in urban than rural area. We observe that poverty/unhygienic indicators were risk factors for higher levels of specific IgE among patients from urban area. Conclusion: Patients with respiratory allergies located in urban area require more pharmacotherapy and have less clinical response than rural children.

Resumen Introducción: Los estudios epidemiológicos han demostrado que los niños que crecen en las granjas suelen tener menos frecuencia de enfermedades alérgicas. Sin embargo, se sabe menos si el tipo de ambiente (rural vs urbano) también puede influir en la respuesta clínica de a la farmacoterapia. Objetivo: Comparar un grupo de niños localizados en área rural y área urbana de Antioquia, Colombia, en cuanto al tratamiento farmacológico recibido para el asma y/o la rinitis. Métodos: Fueron incluidos niños con asma y/o rinitis que llevaran viviendo al menos 5 años en la misma zona rural o urbana con edades entre 6 a 14 años. A todos los pacientes se les realizó un seguimiento clínico cada 3 a 4 meses. La evaluación de la atopia, la espirometría y test para evaluar la gravedad del asma y la rinitis se realizaron al principio y al final del estudio. Resultados: De los pacientes candidatos, 382 (86.4%) completaron el seguimiento (rural n= 134 urbano n= 248). Los pacientes en área rural requirieron menos salbutamol (p: 0.01), visitas al departamento de emergencias (p <0.01) y tenían un menor número de pacientes con FEV1 <80% (p <0.05). Para el control clínico, los niños en zonas rurales requieren menos farmacoterapia que los niños en zona urbana (p: 0.01). Igualmente, para la rinitis (18% vs 8% p: 0.03) y el asma (23% vs 12% p= 0.01) un mayor número de los pacientes en zona rural pudieron suspender la farmacoterapia. La atopia (p <0.07) y la poli-sensibilización (p <0.08) fue mayor en las zonas urbanas que en las rurales. Se observó que los indicadores de pobreza y los servicios de aseo, eran factores de riesgo para mayores niveles de IgE entre los pacientes de área urbana. Conclusión: Los pacientes con asma o rinitis localizado en el área urbana tienen síntomas más severos y refractarios al tratamiento farmacológico, por lo que requieren más farmacoterapia que los niños rurales. Algunos factores ambientales intra y extra domiciliarios propios de la zona rural y urbana podrían influir en estos resultados.

Hipersensibilidad a corticoides y manejo en asma severa. A propósito de un caso / Hipersensitivity to corticosteroids and management of severe bronchial asthma. Case study

Resumen Las reacciones de hipersensibilidad a corticoides son raras en la población general, se dividen en dos categorías: Inmediatas, típicamente mediadas por Inmunoglobulina E (IgE), donde se incluye la anafilaxia luego de la administración de un fármaco en un corto período. Su prevalencia descrita es de 0,3-0,5%. Otra reacción es la 'no inmediata', que se manifiesta en un tiempo mayor de una hora después de la administración del fármaco. Se revisó la literatura con el objetivo de mejorar y aclarar el tratamiento en pacientes asmáticos que poseen esta condición. Se encontró que las vías posibles para generar estas reacciones son intranasal, aerosol por inhalador, oral y parenteral. Frente a esta condición se requiere una evaluación estrecha y detallada de la historia clínica, síntomas y reacciones secundarias al fármaco sospechoso. Finalmente, al momento de elegir tipo de corticoide a usar es primordial la seguridad del paciente logrando, además, el control de la enfermedad.

Hypersensitivity reactions to corticosteroids are rare in the general population, they fall into two categories: 'immediate', typically mediated by immunoglobulin E (IgE), which includes anaphylaxis after administration of a drug in a short period of time. Its reported prevalence is 0.3-0.5%. Another reaction is 'not immediate', which manifests itself in a time longer than one hour after the administration of the drug. We reviewed the literature with the aim of improving and clarifying the treatment in asthmatic patients with this condition. It was found that the possible routes to generate these reactions are intranasal, aerosol by inhaler, oral and parenteral. Facing this condition requires a close and detailed evaluation of the clinical history, symptoms and side reactions to the suspected drug. Finally, when choosing which corticosteroid to use, the patient's safety is paramount, and control of the disease is also essential.

Study of inhaler technique in asthma patients: differences between pediatric and adult patients / Estudio sobre la técnica inhalatoria en pacientes asmáticos: diferencias entre pacientes pediátricos y adultos

Objective: Inhaler technique comprises a set of procedures for drug delivery to the respiratory system. The oral inhalation of medications is the first-line treatment for lung diseases. Using the proper inhaler technique ensures sufficient drug deposition in the distal airways, optimizing therapeutic effects and reducing side effects. The purposes of this study were to assess inhaler technique in pediatric and adult patients with asthma; to determine the most common errors in each group of patients; and to compare the results between the two groups.Methods: This was a descriptive cross-sectional study. Using a ten-step protocol, we assessed inhaler technique in 135 pediatric asthma patients and 128 adult asthma patients.Results: The most common error among the pediatric patients was failing to execute a 10-s breath-hold after inhalation, whereas the most common error among the adult patients was failing to exhale fully before using the inhaler.Conclusions: Pediatric asthma patients appear to perform most of the inhaler technique steps correctly. However, the same does not seem to be true for adult patients.

Objetivo: La técnica inhalatoria es un conjunto de procedimientos mediante el cual se administra un fármaco al sistema respiratorio. Se caracteriza por ser utilizada como primera línea para tratar las enfermedades pulmonares. Su correcta ejecución garantiza un mayor depósito del fármaco en la vía aérea distal, optimizando sus efectos terapéuticos y disminuyendo los efectos secundarios. Los objetivos de este estudio son describir la ejecución de la técnica inhalatoria en un grupo de pacientes asmáticos pediátricos versus un grupo de pacientes asmáticos adultos, definir los errores más comunes en cada grupo de pacientes y comparar los resultados entre ambos grupos.Métodos: Estudio descriptivo, transversal. Se evaluó la técnica inhalatoria según un protocolo de diez pasos en 135 pacientes asmáticos pediátricos y 128 pacientes asmáticos adultos.Resultados: Se encontró que el error más común en los pacientes pediátricos fue no realizar una apnea de 10 s después de la inhalación, mientras que en los pacientes adultos el principal error fue no exhalar completamente antes de aplicar el inhalador.Conclusiones: Se determinó que los pacientes asmáticos pediátricos cumplen con la mayoría de los pasos para una correcta técnica inhalatoria, lo que no se observa en los pacientes adultos.

Comparative Efficacy of Generic Salmeterol Xinafoate/Fluticasone Propionate MDI Fixed Dose Combination and Seretide ® MDI in Asthmatic Patients: An Open Label, Randomized, Phase III Study.

The addition of an inhaled long-acting β2-agonist (LABA) to an inhaled corticosteroid (ICS) gives optimal control of asthma in most patients. The long-acting β2-agonist (LABA) Salmeterol xinafoate (Salmeterol) and inhaled corticosteroid (ICS) fluticasone propionate (fluticasone) are being made available as a combination product Seretide® pMDI (Salmeterol/ Fluticasone) in a single aerosol inhaler. This randomized, open label, non-inferior, multicentric, 12-week, phase III study compared the efficacy and safety of generic Salmeterol/Fluticasone with commercially available product Seretide®. Materials and methods:Patients aged > 12 years inclusive of either sex (N = 372) with persistent asthma as defined by NHLBI for > 6 months prior to screening were included in the study. After a screening phase (1 week), eligible patients were enrolled in the trial with 2 weeks run in period. Eligible patients were randomized to receive either of the two treatment groups [HFA-Propelled pMDI Salmeterol/Fluticasone (25/250mcg) or HFA-Propelled Seretide® (25/250mcg) pMDI] in a ratio of 1:1 for the 12- week treatment period. The primary objective was to demonstrate non-inferiority of Salmeterol/Fluticasone versus Seretide®, measured by mean pre-dose forced expiratory volume in the first second (FEV1), at week 12. Results: This study provides evidence for the primary efficacy endpoint that Salmeterol/Fluticasone was statistically as well as clinically non-inferior to Seretide® in the treatment of patients with persistent asthma. This was supported by secondary endpoints which demonstrate that Salmeterol/Fluticasone appeared to be comparable to Seretide® in terms of efficacy for the secondary efficacy endpoints (morning PEFR, evening PEFR, diurnal variability of PEFR, daytime and night-time asthma symptoms score, average need for short acting-β2-agonists, proportion of patients that required rescue medication, patients with nocturnal asthma, patients without asthma symptoms of score 0 and average number of days without asthma symptoms of score 0). Salmeterol/Fluticasone was safe and well tolerated; and safety profile is comparable to comparator Seretide®. Conclusion: The results of study demonstrate that generic and innovator HFA formulations of Salmeterol/Fluticasone are clinically interchangeable. Overall, the study indicates that HFA-Propelled Salmeterol/ Fluticasone (25/250mcg) pMDI was safe, well tolerated and non-inferior in efficacy compared to HFA-Propelled Seretide® (25/250mcg) pMDI.

Original salbutamol versus similar salbutamol in children with asthma exacerbation: A randomized, controlled, double-blind study / Salbutamol original contra salbutamol similar en niños con crisis de asma: Estudio aleatorizado, controlado y doble ciego

Introduction.There is clinical evidence suggesting that original salbutamol is more effective than a similar salbutamol product to revert symptoms in acute asthma exacerbation.. Objective. To evaluate the bronchodilator response of both salbutamol medicinal products in children with asthma and to establish, based on the forced expiratory volume, if there is a difference between the group treated with the original salbutamol and the group treated with similar salbutamol. Design. Prospective, randomized, controlled, double-blind study. Material and Methods. One hundred and twenty six children (63 boys, age 9.18 ± 2.83 years old) were included. They were administered a dose of 20 drops (5 mg) of the original salbutamol or similar salbutamol product in nebulizing solution diluted only once in 2 ml saline solution. Preand post-bronchodilator, intra- and inter-group forced expiratory volume was compared at baseline and at 30 minutes. The weight of salbutamol drops was determined by gravimetry, the concentration by chromatography and the number of drops by bottle. Results. The bronchodilator response between the pre- and post-bronchodilator forced expiratory volume was 225 ml (95% CI: 164-286) and 224 ml (95% CI: 163-284) for original salbutamol and similar salbutamol, respectively (p < 0.001). The Delta difference was 1.3 ml (95% CI: -86+83) (p = 0.97). The mean, standard deviation and variation coefficient percentage of the weight of the drop was 364.75 mg (± 6.01, 1.65) and 543.88 mg (± 56.09, 10.31) (p < 0.001) for original salbutamol and similar salbutamol, respectively. Conclusion. There were no differences in the bronchodilator response measured by FEV1 between the original salbutamol and a similar salbutamol product.

Introducción. Existe evidencia clínica que sugiere que el salbutamol original sería más eficaz que el salbutamol similar para revertir los síntomas en el episodio agudo de asma. Objetivo. Evaluar la respuesta broncodilatadora de ambas especialidades farmacéuticas de salbutamol en niños con asma y establecer, mediante el volumen espiratorio forzado, si difiere entre los grupos tratados con salbutamol original y similar. Diseño. Estudio prospectivo, aleatorizado, controlado, a doble ciego. Material y métodos. Se incluyeron 126 niños (63 varones, edad 9,18 ± 2,83 años), que recibieron una dosis de 20 gotas (5 mg) de salbutamol original o similar en solución para nebulizar diluida en 2 ml de solución fisiológica por única vez. Se comparó el volumen espiratorio forzado prebroncodilatador y posbroncodilatador, intragrupos e intergrupos, al inicio y a los 30 minutos. Se determinó el peso de las gotas de salbutamol por gravimetría, la concentración por cromatografía y el número de gotas por envase. Resultados. La respuesta broncodilatadora entre el volumen espiratorio forzado prebroncodilatador y posbroncodilatador fue de 225 ml (IC 95%: 164-286) y 224 ml (IC 95%: 163-284) para salbutamol original y similar, respectivamente (p <0,001). El delta de la diferencia fue de 1,3 ml (IC 95%: -86+83) (p= 0,97). La media, desvío estándar y porcentaje del coeficiente de variación del peso de las gotas fue de 364,75 mg (± 6,01, 1,65) y 543,88 mg (± 56,09, 10,31) (p <0,001) para salbutamol original y similar, respectivamente. Conclusión. No hubo diferencias en la respuesta broncodilatadora medida por el VEF1 entre salbutamol original y similar.

Utilização da técnica de resistência do interruptor na avaliação da resistência das vias aéreas em pacientes com fibrose cística / Using the interrupter technique to evaluate airway resistance in cystic fibrosis patients

OBJETIVO: Medir a resistência de vias aéreas utilizando a técnica de resistência do interruptor (Rint) em pacientes com fibrose cística (FC) e correlacioná-la com parâmetros espirométricos, assim como avaliar a acurácia de Rint para determinar a resposta das vias aéreas a um broncodilatador. MÉTODOS: Estudo transversal com 38 crianças e adolescentes com FC acompanhados no Ambulatório de FC do Hospital São Lucas, em Porto Alegre (RS). Após a determinação de Rint, os pacientes foram submetidos à espirometria. Para a avaliação da resposta ao broncodilatador, as medições foram repetidas após o uso de salbutamol inalatório. RESULTADOS: Houve uma forte correlação entre o inverso de Rint e VEF1 (r = 0,8; p < 0,001) e moderadas correlações entre o inverso de Rint e FEF25-75% (r = 0,74; p < 0,001) e entre o inverso de Rint e índice de massa corpórea (r = 0,62; p < 0,001). A curva ROC foi utilizada na comparação da resposta ao broncodilatador determinada por Rint com aquela determinada por valores espirométricos. Para um ponto de corte de -28% para Rint, a área sob a curva foi de 0,75, com uma sensibilidade de 66% e uma especificidade de 82%. CONCLUSÕES: Nossos achados indicam que Rint apresenta uma boa correlação com parâmetros espirométricos, embora a técnica Rint não tenha sido suficientemente acurada para substituir a espirometria na avaliação da resposta ao broncodilatador.

OBJECTIVE: To measure airway resistance with the interrupter resistance (Rint) technique in patients with cystic fibrosis (CF) and to determine whether Rint values correlate with spirometric parameters, as well as to evaluate the accuracy of the Rint technique in determining the airway response to a bronchodilator. METHODS: This was a cross-sectional study involving 38 children and adolescents with CF followed at the Cystic Fibrosis Outpatient Clinic of the São Lucas Hospital, located in the city of Porto Alegre, Brazil. After Rint had been measured, the subjects underwent spirometry. To evaluate bronchodilator response, we repeated the measurements after the use of inhaled albuterol. RESULTS: There was a strong correlation between inverse Rint and FEV1 (r = 0.8; p < 0.001), and there was a moderate correlation between inverse Rint and FEF25-75% (r = 0.74; p < 0.001), as well as between inverse Rint and body mass index (r = 0.62; p < 0.001). We used a ROC curve to compare the bronchodilator response, as determined by Rint, with spirometric values. For a Rint cut-off point of -28%, the area under the curve was 0.75, with a sensitivity of 66% and a specificity of 82%. CONCLUSIONS: Our findings suggest that Rint correlates well with spirometric parameters, although the Rint technique was not sufficiently accurate to replace spirometry in the evaluation of bronchodilator responses.

Prova broncodilatadora na espirometria: efeito do uso de espaçador de grande volume com tratamento antiestático na resposta ao broncodilatador / Spirometry with bronchodilator test: effect that the use of large-volume spacers with antistatic treatment has on test response

OBJETIVO: Avaliar se o uso de salbutamol inalatório através de inalador dosimetrado acoplado a espaçadores de grande volume com tratamento antiestático na espirometria com prova broncodilatadora modifica os resultados do teste quando comparado à técnica usual (sem espaçador). MÉTODOS: Estudo prospectivo envolvendo 24 pacientes, com idades entre 18 e 45 anos e suspeita clínica de asma, atendidos no Ambulatório de Pneumologia do Hospital das Clínicas da Universidade Federal de Minas Gerais, em Belo Horizonte (MG). Os pacientes foram submetidos a duas espirometrias com prova broncodilatadora realizadas com e sem o uso de espaçador de grande volume. RESULTADOS: Não houve diferença significativa na variação do VEF1 antes e após o uso de broncodilatador entre as duas técnicas (ΔVEF1 média = 0,01 L; IC95 por cento: -0,05 a 0,06; p = 0,824). Não houve diferença estatisticamente significativa entre as duas técnicas em relação ao resultado qualitativo da prova broncodilatadora (p = 1,00). Houve concordância dos resultados da prova broncodilatadora entre as técnicas (coeficiente kappa = 0,909; p < 0,005). CONCLUSÕES: De acordo com os resultados deste estudo, a utilização de espaçadores de grande volume não modificou de forma significativa os resultados da prova broncodilatadora.

OBJECTIVE: To evaluate whether the use of inhaled albuterol via a metered-dose inhaler with a large-volume spacer with antistatic treatment modifies the bronchodilator test results when compared with the usual technique (no spacer). METHODS: A prospective study involving 24 patients, 18-45 years of age, clinically suspected of having asthma, and under treatment at the Outpatient Pulmonary Clinic of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. All of the patients underwent two bronchodilator tests: one with and one without the use of a large-volume spacer. RESULTS: There was no significant difference in the variation of FEV1 prior to and after bronchodilator use between the two techniques (mean ΔFEV1 = 0.01 L; 95 percent CI: -0.05 to 0.06; p = 0.824). No statistically significant difference was found between the two techniques regarding the qualitative results on the bronchodilator test (p = 1.00). There was concordance between the techniques in terms of the bronchodilator test results (kappa coefficient = 0.909; p < 0.005). CONCLUSIONS: According to the results of this study, the use of large-volume spacers does not significantly modify bronchodilator test results.

Redistributed Regional Ventilation after the Administration of a Bronchodilator Demonstrated on Xenon-Inhaled Dual-Energy CT in a Patient with Asthma

We report here on the redistributed regional ventilation abnormalities after the administration of a bronchodilator and as seen on xenon-inhaled dual-energy CT in a patient with asthma. The improved ventilation seen in the right lower lobe and the decreased ventilation seen in the right middle lobe after the administration of a bronchodilator on xenon-inhaled dual-energy CT could explain a positive bronchodilator response on a pulmonary function test. These changes may reflect the heterogeneity of the airway responsiveness to a bronchodilator in patients with asthma.

Uso da mistura gasosa de hélio e oxigênio (Heliox®) no tratamento da doença respiratória obstrutiva da via aérea inferior em serviço de emergência pediátrica / Use of helium-oxygen mixture (Heliox®) in the treatment of obstructive lower airway disease in a pediatric emergency department

OBJETIVO: Determinar se a utilização de salbutamol, em uma mistura de hélio-oxigênio (80:20), modifica a evolução e o risco de internação em pacientes pediátricos. MÉTODOS: Delineado estudo de coorte controlada que incluiu pacientes de 2 meses a 12 anos de idade, com diagnósticos de crise de asma ou bronquiolite viral. Intensidades caracterizadas de moderada a grave, aferidas através de escore clínico (pulmonary index, PI) para doença obstrutiva. Foram considerados elegíveis escores > 8. Vinte pacientes constituíram o grupo Heliox® e 40 o grupo Oxigênio. Os pacientes receberam sequencialmente, em intervalos de 20 min, até completar seis nebulizações (período de 2 h): salbutamol 0,15 mg/kg/dose (máximo 5 mg). A droga utilizou como veículo gerador do aerossol a mistura de Heliox® (80:20) ou oxigênio a 100 por cento. Os pacientes com diagnóstico de crise aguda de asma receberam, adicionalmente, prednisolona (2 mg/kg) via oral. RESULTADOS: Onze pacientes do grupo Heliox® permaneceram necessitando de tratamento na 6ª h de atendimento, enquanto que no grupo que recebia nebulização veiculada em oxigênio, esse número foi de 38 (p = 0,034). Na 12ª h, 7 pacientes do grupo Heliox® permaneciam em observação, enquanto no grupo Oxigênio foram 27 (p = 0,02). Diferenças quanto à necessidade de suplementação de oxigênio foram observadas apenas na 6ª h de tratamento (p = 0,02). CONCLUSÕES: Heliox® (80:20), para administração de salbutamol, é efetivo no tratamento da doença obstrutiva infantil que apresente resposta à terapêutica broncodilatadora. Comparado à técnica usual de nebulização, está associado à menor permanência em sala de observação após 6 h de tratamento.

OBJECTIVE: To determine whether the use of salbutamol, in a helium-oxygen mixture (80:20), can modify outcome and risk of hospitalization of pediatric patients. METHODS: A controlled cohort study including patients aged 2 months to 12 years with diagnoses of asthmatic crisis or viral bronchiolitis. Intensity was characterized from moderate to severe, as measured by clinical score (pulmonary index, PI) for obstructive disease. Scores > 8 were considered eligible. The Heliox® group was composed of 20 patients and the Oxygen group of 40 patients. Patients received sequentially, at 20-min intervals, until six nebulization cycles were completed (2-h period): salbutamol 0.15 mg/kg/dose (maximum 5 mg). The nebulized drug was driven either by Heliox® mixture (80:20) or 100 percent oxygen. Patients diagnosed with acute asthmatic crisis received, additionally, prednisolone (2 mg/kg) orally. RESULTS: Eleven patients in the Heliox® group still required treatment at 6 h, against 38 patients in the group receiving oxygen-driven nebulization (p = 0.034). At 12 h, 7 patients in the Heliox® group remained under observation, against 27 in the Oxygen group. Differences regarding the need for supplemental oxygen were observed only at 6 h of treatment (p = 0.02). CONCLUSIONS: Heliox® (80:20), for salbutamol administration, is effective in the treatment of pediatric obstructive disease that responds to bronchodilator therapy. Compared to usual aerosol delivery technique, Heliox®-driven salbutamol nebulization is associated with shorter stay in the observation room after 6 h of treatment.

Factores determinantes del éxito de la terapia con inhaladores de dosis medida en niños / Therapy with metered-dose inhalers in children

Este artículo revisa los factores que influyen en el éxito de terapias con inhaladores de dosis medida en niños las que comprenden desde características farmacocinéticas de las drogas hasta la adherencia al tratamiento.

Transient expiratory flow interruptions (TEFI) increase expiratory flow in acute asthma exacerbation / Incremento del flujo espiratorio luego de interrupciones transitorias en la exacerbación aguda de asma

We have shown that expiratory flows increase when expirations are rapidly interrupted in stable asthmatic patients. We hypothesized that a similar increase could be obtained in patients with acute exacerbation of bronchial asthma treated in the Emergency Room. A total of 30 asthmatic patients were randomly allocated into two groups, the study and the control groups. Patients in the study group were connected to a device with an inspiratory line designed to administer pressurized aerosols. The expiratory line passed through a valve completely interrupting flow at 4 Hz, with an open/closed time ratio of 10/3. The control group patients were also connected to the device, but with the valve kept open. Mean expiratory flow at tidal volume (MEFTV) was measured under basal conditions and at 4, 8 and 12 minutes after connecting the patients to the device. All patients received standard treatment throughout the procedure. At all time points MEFTV increased more in the study than in the control group (p < 0.003 by two-way ANOVA). There was no residual effect after disconnection from the device. We conclude that TEFI can rapidly improve expiratory flows in patients with acute exacerbations of asthma, while pharmacologic interventions proceed.

Demostramos que el flujo espiratorio máximo, en pacientes asmáticos en estado estable, se incrementaba cuando se generaban rápidas y transitorias interrupciones del flujo. Formulamos la hipótesis de que un incremento similar podría ser observado en pacientes con exacerbación aguda de asma tratados en la sala de emergencias. Un total de 30 pacientes asmáticos fueron distribuidos al azar en dos grupos. Los pacientes del grupo en estudio fueron conectados a un aparato con una vía inspiratoria diseñada para la administración de aerosoles. La vía espiratoria pasaba por una válvula que interrumpía el flujo completamente a 4 hz, con una relación tiempo abierta/tiempo cerrada de 10/3. Los pacientes del grupo control también fueron conectados al aparato pero con la válvula siempre abierta. Se midió el flujo medio de la espiración a volumen circulante en condiciones basales y a los 4, 8 y 12 minutos después de conectado el paciente al equipo. Todos los pacientes recibieron el tratamiento farmacológico estándar a lo largo del ensayo. Se observó un incremento significativamente mayor del flujo espiratorio medio a volumen circulante en el grupo en estudio en comparación al grupo control (p < 0.003 ANOVA de dos vías) durante todo el ensayo. No hubo efecto residual después de la desconexión del equipo. Concluimos que las interrupciones transitorias del flujo espiratorio pueden incrementar rápidamente el flujo espiratorio en pacientes con exacerbaciones agudas de asma dando tiempo a que el tratamiento farmacológico comience a actuar.

Deposição pulmonar de tobramicina inalatória antes e após fisioterapia respiratória e uso de salbutamol inalatório em pacientes com fibrose cística colonizados por Pseudomonas aeruginosa / Pulmonary deposition of inhaled tobramycin prior to and after respiratory therapy and use of inhaled albuterol in cystic fibrosis patients colonized with Pseudomonas aeruginosa

OBJETIVO: Avaliar se a fisioterapia respiratória seguida do uso de salbutamol inalatório modifica a deposição pulmonar de tobramicina inalatória em pacientes com fibrose cística (FC) e se a deposição pulmonar apresenta correlação com a gravidade da doença ou com o genótipo. MÉTODOS: Um estudo prospectivo foi realizado com pacientes com FC maiores de 6 anos e colonizados por Pseudomonas aeruginosa. Os critérios de exclusão foram exacerbação pulmonar, mudança terapêutica entre as fases do estudo e FEV1 < 25 por cento. Todos os pacientes foram submetidos à cintilografia pulmonar com câmara de cintilação com um colimador low energy all purpose para avaliar a penetração da droga após a inalação de tobramicina marcada com tecnécio (99mTc-tobramicina), e à perfusão pulmonar com 99mTc-macroagregados de albumina (fase 1). Após um mês, foi realizado o mesmo procedimento precedido de fisioterapia respiratória e administração de salbutamol inalatório (fase 2). RESULTADOS: Foram incluídos 24 pacientes (12 masculinos) com idade variando de 5 a 27 anos (média ± dp: 12,85 ± 6,64 anos). O escore de Shwachman (ES) foi excelente/bom em 8 pacientes, moderado/regular em 8 e grave em 0. A genotipagem revelou que 7 pacientes eram ΔF508 homozigotos, 13 eram ΔF508 heterozigotos, e 4 apresentavam outras mutações. A deposição pulmonar da tobramicina foi menor na fase 2 em todos os pacientes, sendo menor nos pacientes com ES moderado/regular (p = 0,017) e também nos heterozigotos (p = 0,043). CONCLUSÕES: O uso de uma técnica de fisioterapia respiratória e a administração de salbutamol inalatório imediatamente antes do uso de tobramicina inalada diminuem a deposição pulmonar desta última em pacientes com FC, e esta redução tem correlação com a gravidade da doença e genótipo.

OBJECTIVE: To evaluate whether respiratory therapy followed by the use of inhaled albuterol modifies the pulmonary deposition of inhaled tobramycin in patients with cystic fibrosis (CF) and whether pulmonary deposition correlates with disease severity or genotype. METHODS: A prospective study was carried out including patients with CF older than 6 years of age and colonized with Pseudomonas aeruginosa. Exclusion criteria were pulmonary exacerbation, changes in therapy between the study phases and FEV1 < 25 percent. All patients were submitted to pulmonary scintigraphy by means of a scintillation camera equipped with a low energy all purpose collimator in order to evaluate drug penetration following the administration of inhaled 99mTc-tobramycin, as well as to pulmonary perfusion with 99mTc-macroaggregated albumin (phase 1). One month later, the same procedure was performed following respiratory therapy and administration of inhaled albuterol (phase 2). RESULTS: We included 24 patients (12 males) aged 5-27 years (mean ± SD: 12.85 ± 6.64 years). The Shwachman score (SS) was excellent/good in 8 patients, moderate/fair in 16 and poor in 0. Genotyping revealed that 7 patients were ΔF508 homozygotes, 13 were ΔF508 heterozygotes; and 4 presented other mutations. In all patients, lung deposition of tobramycin decreased in phase 2, especially in those with moderate/fair SS (p = 0.017) and in heterozygotes (p = 0.043). CONCLUSIONS: The use of a respiratory therapy technique and the administration of inhaled albuterol immediately prior to the use of inhaled tobramycin decreased the pulmonary deposition of the latter in CF patients, and this reduction correlates with disease severity and genotype.

External cephalic version with salbutamol-Success rate and predictors of success

To determine the success rate of External Cephalic Version [ECV] with 0.25 mg Salbutamol in singleton term breech and to identify the predictors of success. Quasi experimental study. Mother and Child Health Centre, Pakistan Institute of Medical Sciences, Islamabad, from January 2000 to March 2005. Women, presenting with uncomplicated breech, between 37-40 completed weeks gestation, underwent ECV in day care ward. Fifteen minutes before the procedure, injection salbutamol 0.25 mg was administered subcutaneously. Cases with contraindication to ECV or Salbutamol injection were excluded from the study. The outcome measures included success rate of ECV [in terms of conversion from breech to cephalic presentation at the completion of procedure confirmed through ultrasound], association of maternal and fetal demographic characteristics with successful version and adverse effects related to the procedure in terms of fetal bradycardia, ante-partum still birth, antepartum hemorrhage and preterm labour. Rate of reversion to breech and drug-related side effects were also recorded as secondary outcome measures. Chi-square test was used for categorical variables and independent sample t-test for continuous variables. Of the 101 ECV procedures, 41 [40.5%] were successful. Success rate was significantly lower in nullipara [p=0.01] and with AFI 7 cm or less [p=0.04]. No significant association was found between success rate and gestational age [p=0.35] or fetal birth weight [p=0.57]. None of the patient suffered from serious maternal complications. Salbutamol related minor effects [tremors, anxiety and palpitations] were observed in 36 [35.6%] patients. Fetal tachycardia was seen in 17 [16.8%], reversible fetal bradycardia in 3 [2.9%] and intractable fetal bradycardia in one patient. External cephalic version with 0.25 mg Salbutamol was safe and a feasible option in term breech presentation in this series. Administration of tocolytic agent improved the success rate and reduced complication rate of the procedure. Major determinants of success were amniotic fluid index and parity

Traitement de la crise d'asthme

Nous bouclons le dossier consacre a l'astheme par le traitement de la crise qui survient souvent a domicile ; a l'ecole ou sur le lieu de travail. L'essentiel est de pouvoir prendre immediatemnt en charge le patient afin de reduire la mortalite et les hospitalisations

Oral salbutamol for symptomatic relief in mild bronchiolitis a double blind randomized placebo controlled trial.

OBJECTIVES: To determine the efficacy of oral salbutamol for providing symptomatic relief in mild bronchiolitis. DESIGN: Randomized double-blind placebo controlled trial. SETTING: Pediatric Outpatient Department of a tertiary care hospital. SUBJECTS: 140 infants (of 310 approached) with a clinical diagnosis of acute bronchiolitis with respiratory rate <or= 70 breath/min, heart rate <or= 200 beats/min, hemoglobin oxygen saturation (SpO2) >or= 95% in room air, no or mild accessory muscle use, and respiratory distress assessment instrument (RDAI) score <or=10. Children were followed up for 14 days. INTERVENTION: Oral salbutamol (0.1 mg/kg/dose) (n=70) or placebo (n=70) three times a day for 7 days or till complete resolution of symptoms,whichever was earlier. OUTCOME VARIABLES: Time for resolution of illness (ROI), duration of fever, cough,coryza, noisy breathing, time to achieve normal feeding and normal sleep, and frequency of hospitalization and adverse effects. RESULTS: Median (SE, 95% CI) duration of resolution of overall illness was similar in the two groups [6 (0, 5 to 7) d in the salbutamol group vs. 5 (1, 4 to 6) days in placebo group; P=0.21]. There was no significant difference in mean duration of fever, cough, coryza, noisy breathing, time to achieve normal feeding and normal sleep; and frequency of hospitalization or adverse effects, between the two groups.However, tremors were observed in 5 infants in the salbutamol group. CONCLUSION: Oral salbutamol is not superior to placebo in reducing the duration of symptoms in mild cases of acute bronchiolitis in children.

A comparative study of patients' preferences and sensory perceptions of three forms of inhalers among Thai asthma and COPD patients.

In 9 study centers, 419 patients with asthma or COPD were randomized to receive two forms of salbutamol metered-dose-inhalers (MDIs), i.e. CFC-driven MDI, non-CFC (HFA) MDI and one salbutamol dry powder inhaler (DPI), in a multi-center, comparative, cross-over and randomized study, performed to facilitate the formulation of a strategic plan to phase out CFC MDIs. After having received all three forms of test products, the patients completed an evaluation questionnaire indicating their preferences, likelihood of treatment compliance on each product and the easiest one to use. Statistical analysis showed that the CFC MDI was significantly less irritating (p < 0.014) but lower in its overall appeal (p < 0.0001). The "most preferred form to be prescribed" was DPI at 47.5% followed by non-CFC at 32.5% and CFC MDI at 20.1%. Concerning the ease of use among the three forms of test products, 59.9% of the patients indicated "no difference". Adverse events were mild and occurred in only 8.2%. In conclusion, patients' preference and sensory perception among the three forms of inhalers were comparable except that the CFC MDI was significantly less irritating but lower in its overall appeal. DPI was the most preferred and easiest form to use but also the most expensive. Taking public health into consideration, a non-CFC MDI with a similar market price to the CFC MDI would be the obvious choice in a strategic plan to phase out CFC MDIs with the least difficulty to the consumers.