Utility of exhaled nitric oxide to guide mild asthma treatment in atopic patients and its correlation with asthma control test score: a randomized controlled trial.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) is used for the diagnosis and monitoring of asthma, although its utility to guide treatment and its correlation with other tools is still under discussion. We study the possibility to withdraw inhaled corticosteroid treatment in atopic patients with mild asthma based on the FeNO level, as well as to study its correlation with other clinical control tools. METHODS: Prospective and randomized study including atopic patients aged 18 to 65 with mild asthma, stable, on low-dose inhaled corticosteroid (ICS) treatment, who had their treatment withdrawn based on a FeNO level of 40 ppb. Patients were randomized into two groups: control group (treatment with ICS was withdrawn regardless of FeNO level) and experimental group (according to the FeNO levels, patients were assigned to one of two groups: FeNO > 40 ppb on treatment with budesonide 200 mcg every 12 h and SABA on demand; FeNO ≤ 40 ppb only with SABA on demand). Follow-up was conducted for one year, during which medical assessment was performed with FeNO measurements, asthma control test (ACT), lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC), and recording of the number of exacerbations. RESULTS: Ninety-two patients were included, with a mean age of 39.92 years (SD 13.99); 46 patients were assigned to the control group, and 46 patients to the experimental group. The number of exacerbations was similar between the groups (p = 0.301), while the time to the first exacerbation was significantly shorter in the control group (30.86 vs. 99.00 days), p < 0.001, 95% CI (43.332-92.954). Lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC) showed no differences between the groups (p > 0.05). Both FeNO and ACT showed significant changes in the groups in which ICS was withdrawn (p < 0.05 for both parameters). A significant negative correlation was observed between FeNO and ACT (r = -0.139, p = 0.008). CONCLUSIONS: In atopic patients with mild asthma, withdrawal of ICS based on an FeNO of 40 ppb led to worsened symptoms but without changes in lung function tests or an increase in exacerbations. There was a negative correlation between FeNO values and symptomatic control measured by the ACT. TRIAL REGISTRATION: Clinical Trial Number: 2012-000372-42. Start Date: 2012-07-23. Trial registered prospectively ( https://www.clinicaltrialsregister.eu/ctr-search/search?query=2012-000372-42 ). This study adheres to CONSORT guidelines of randomised control trials.

Eradication Therapy against Pseudomonas aeruginosa in Non-Cystic Fibrosis Bronchiectasis.

BACKGROUND: No prospective study has assessed eradication treatment of early Pseudomonas aeruginosa colonisation in bronchiectasis not due to cystic fibrosis (CF). OBJECTIVES: To evaluate the efficacy of 3 months of nebulised tobramycin after a short course of intravenous antibiotics in the eradication of P. aeruginosa and its clinical consequences in non- CF bronchiectasis following initial P. aeruginosa infection. METHODS: A 15-month, single-masked, randomised study including 35 patients was conducted in a tertiary university hospital. Following the isolation of P. aeruginosa and a 14-day intravenous treatment with ceftazidime and tobramycin, patients received 300 mg nebulised tobramycin twice daily or placebo during 3 months, and were followed up for 12 months thereafter. RESULTS: The median time to recurrence of P. aeruginosa infection was higher in the tobramycin than in the placebo group (p = 0.048, log-rank test). At the end of the study 54.5% of the patients were free of P. aeruginosa in the tobramycin group and 29.4% in the placebo group. The numbers of exacerbations (p = 0.044), hospital admissions (p = 0.037) and days of hospitalisation (p = 0.034) were lower in the tobramycin than in the placebo group. A global, non-significant trend to improvement in the tobramycin group was observed in most of the other studied parameters on comparing the two groups. Bronchospasm in the tobramycin group was remarkable. CONCLUSIONS: Our study shows that 3 months of nebulised tobramycin following a short course of intravenous antibiotics may prevent bronchial infection with P. aeruginosa and has a favourable clinical impact on non-CF bronchiectasis.

Hemoptisis amenazante: estudio de 154 pacientes / Life-threatening hemoptysis: study of 154 patients

Fundamento y objetivo: La hemoptisis amenazante (HA) es una emergencia médica cuya historia natural no está bien definida. El objetivo de este estudio fue evaluar la etiología, los procedimientos realizados y la evolución de la HA en un hospital universitario. Pacientes y método: Estudio prospectivo en el que se incluyeron en un protocolo 154 pacientes ingresados por HA durante 3 años consecutivos. Se realizaron técnicas broncoscópicas y angiográficas según criterio del médico que les atendía. Se siguió la evolución de los pacientes durante 5 años tras el episodio de HA. Resultados: Un 79,2% eran varones. La edad media (DE) fue de 57 (15) años. La etiología más frecuente fueron las bronquiectasias, la tuberculosis activa y sus secuelas. Un 4,5% de pacientes fallecieron a consecuencia de la HA. La broncoscopia se mostró más segura en la localización del sangrado que la arteriografía cuando las exploraciones se realizaban durante la hemoptisis (84,2 frente a 20,4%) (p<0,001). Cuando la embolización o la broncoscopia se utilizaron como primera medida, durante el ingreso la primera estabilizó el sangrado con mayor eficacia que la segunda (87 frente a 53,5%) (p<0,001). Se produjeron un 10,7% de recidivas de HA, menos frecuentemente cuando la embolización había sido efectuada. Conclusiones: Las bronquiectasias y la tuberculosis fueron las causas más frecuentes. Mientras la broncoscopia durante la hemoptisis se mostró eficiente en localizar el origen del sangrado, la embolización arterial fue más eficaz en su estabilización tanto a corto como a largo plazo (AU)

Background and objectives: The natural history of life-threatening hemoptysis (LTH), a medical emergency, is ill defined. The objective of the study was to evaluate, in a university teaching hospital setting, the etiology, methods used, and evolution of LTH. Patients and methods: Prospective study in which we enrolled 154 patients admitted for LTH over 3 consecutive years. Bronchoscopy and arteriography procedures were performed, as prescribed by the attending physician. Patient evolution was followed 5 years post-event. Result: 79.2% were male. Average age was 57 (SD 15) years. Bronchiectasis and active tuberculosis and its consequences were the predominant etiologies. A total of 4.5% patients died as a result of LTH. Bronchoscopy was more effective in identifying the bleeding than arteriography when the examination was performed during an episode of hemoptysis (84.2 versus 20.4%) (P<.001). When embolization or bronchoscopy were used as first measure, embolization was more effective in stabilizing bleeding than bronchoscopy (87 versus 53.5%) (P<.001) in admitted patients. LTH relapse was 10.7%, while it was lower with embolization. Conclusions: Leading causes were bronchiectasis and tuberculosis. While bronchoscopy during a hemoptysis episode was effective in identifying the source of the bleeding, artery embolization was more effective in stabilizing the patient both at the short and long term (AU)

[Life-threatening hemoptysis: study of 154 patients]. / Hemoptisis amenazante: estudio de 154 pacientes.

BACKGROUND AND OBJECTIVES: The natural history of life-threatening hemoptysis (LTH), a medical emergency, is ill defined. The objective of the study was to evaluate, in a university teaching hospital setting, the etiology, methods used, and evolution of LTH. PATIENTS AND METHODS: Prospective study in which we enrolled 154 patients admitted for LTH over 3 consecutive years. Bronchoscopy and arteriography procedures were performed, as prescribed by the attending physician. Patient evolution was followed 5 years post-event. RESULT: 79.2% were male. Average age was 57 (SD 15) years. Bronchiectasis and active tuberculosis and its consequences were the predominant etiologies. A total of 4.5% patients died as a result of LTH. Bronchoscopy was more effective in identifying the bleeding than arteriography when the examination was performed during an episode of hemoptysis (84.2 versus 20.4%) (P<.001). When embolization or bronchoscopy were used as first measure, embolization was more effective in stabilizing bleeding than bronchoscopy (87 versus 53.5%) (P<.001) in admitted patients. LTH relapse was 10.7%, while it was lower with embolization. CONCLUSIONS: Leading causes were bronchiectasis and tuberculosis. While bronchoscopy during a hemoptysis episode was effective in identifying the source of the bleeding, artery embolization was more effective in stabilizing the patient both at the short and long term.

Budesonide efficacy and safety in patients with bronchiectasis not due to cystic fibrosis.

OBJECTIVE: The therapeutic benefit of inhaled corticoids in bronchiectasis not due to cystic fibrosis is still not well documented. The aim of the present study was to assess the efficacy and safety of inhaled corticoids in this disease. SETTING: This study was conducted at a tertiary university hospital in the city of Barcelona, Catalonia, (Spain). METHOD: A prospective, double-blind, parallel, placebo-masked study was conducted. Seventy-seven patients (40 women; mean age: 68 years) were randomly assigned to receive either 400 mcg budesonide twice daily or placebo and were regularly reviewed for six months. RESULTS: Differences in forced vital capacity and forced expiratory volume in the first second between the beginning and end of the study were not significantly lower in the budesonide group than in the placebo group, either in absolute values [-17.4 (386.9) versus -21.4 (375.5)] or in percentages [-1.9(9.5) versus -2.8 (11.6)]. Microbiological criteria applied to evaluate changes between the beginning and end of the study showed no worsening in the budesonide group compared with the control group, whereas a non-significant improvement was obtained in 8.1 % of cases in the budesonide group compared to 3 % in the placebo group. Although significance was only achieved for sputum eosinophils (p = 0.021), a consistent tendency towards improvement was also observed in secondary end-points (symptoms, number and duration of exacerbations, quality of life, sputum cytology and interleukin-8) in the budesonide group. CONCLUSION: Although further studies are required, inhaled corticoid treatment may be efficacious and safe in bronchiectasis not due to cystic fibrosis.

Indacaterol, A Novel Once Daily Inhaled beta2-Adrenoreceptor Agonist.

In this article we will review the role of long acting beta2-adrenoreceptor agonists and long-acting muscarinic agents in the management of airflow obstruction. We will then focus our attention on indacaterol, one of the new once daily inhaled beta2-adrenoreceptor agonists. Pharmacologically this drug is a nearly full beta2-agonist without loss of efficacy after prolonged administration. We will also discuss its dosing, safety and tolerability.