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1.
Respir Res ; 22(1): 25, 2021 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-33478491

RESUMO

BACKGROUND: Inhaled corticosteroids (ICS) are indicated for prevention of exacerbations in patients with COPD, but they are frequently overprescribed. ICS withdrawal has been recommended by international guidelines in order to prevent side effects in patients in whom ICS are not indicated. METHOD: Observational comparative effectiveness study aimed to evaluate the effect of ICS withdrawal versus continuation of triple therapy (TT) in COPD patients in primary care. Data were obtained from the Optimum Patient Care Research Database (OPCRD) in the UK. RESULTS: A total of 1046 patients who withdrew ICS were matched 1:4 by time on TT to 4184 patients who continued with TT. Up to 76.1% of the total population had 0 or 1 exacerbation the previous year. After controlling for confounders, patients who discontinued ICS did not have an increased risk of moderate or severe exacerbations (adjusted HR: 1.04, 95% confidence interval (CI) 0.94-1.15; p = 0.441). However, rates of exacerbations managed in primary care (incidence rate ratio (IRR) 1.33, 95% CI 1.10-1.60; p = 0.003) or in hospital (IRR 1.72, 95% CI 1.03-2.86; p = 0.036) were higher in the cessation group. Unsuccessful ICS withdrawal was significantly and independently associated with more frequent courses of oral corticosteroids the previous year and with a blood eosinophil count ≥ 300 cells/µL. CONCLUSIONS: In this primary care population of patients with COPD, composed mostly of infrequent exacerbators, discontinuation of ICS from TT was not associated with an increased risk of exacerbation; however, the subgroup of patients with more frequent courses of oral corticosteroids and high blood eosinophil counts should not be withdrawn from ICS. Trial registration European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS30851).


Assuntos
Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Broncodilatadores/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Retirada de Medicamento Baseada em Segurança/tendências , Administração por Inalação , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Resultado do Tratamento , Reino Unido/epidemiologia
2.
Cochrane Database Syst Rev ; 12: CD012965, 2020 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-33316083

RESUMO

BACKGROUND: Acute bronchiolitis is a significant burden on children, their families and healthcare facilities. It mostly affects children younger than two years of age. Treatment involves adequate hydration, humidified oxygen supplementation, and nebulisation of medications, such as salbutamol, epinephrine, and hypertonic saline. The effectiveness of magnesium sulphate for acute bronchiolitis is unclear. OBJECTIVES: To assess the effects of magnesium sulphate in acute bronchiolitis in children up to two years of age. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS, CINAHL, and two trials registries to 30 April 2020. We contacted trial authors to identify additional studies. We searched conference proceedings and reference lists of retrieved articles. Unpublished and published studies were eligible for inclusion. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs, comparing magnesium sulphate, alone or with another treatment, with placebo or another treatment, in children up to two years old with acute bronchiolitis. Primary outcomes were time to recovery, mortality, and adverse events. Secondary outcomes were duration of hospital stay, clinical severity score at 0 to 24 hours and 25 to 48 hours after treatment, pulmonary function test, hospital readmission within 30 days, duration of mechanical ventilation, and duration of intensive care unit stay. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE methods to assess the certainty of the evidence. MAIN RESULTS: We included four RCTs (564 children). One study received funding from a hospital and one from a university; two studies did not report funding sources. Comparator interventions differed among all four trials. Studies were conducted in Qatar, Turkey, Iran, and India. We assessed two studies to be at an overall low risk of bias, and two to be at unclear risk of bias, overall. The certainty of the evidence for all outcomes and comparisons was very low except for one: hospital re-admission rate within 30 days of discharge for magnesium sulphate versus placebo. None of the studies measured time to recovery, duration of mechanical ventilation, duration of intensive care unit stay, or pulmonary function. There were no events of mortality or adverse effects for magnesium sulphate compared with placebo (1 RCT, 160 children). The effects of magnesium sulphate on clinical severity are uncertain (at 0 to 24 hours: mean difference (MD) on the Wang score 0.13, 95% confidence interval (CI) -0.28 to 0.54; and at 25 to 48 hours: MD on the Wang score -0.42, 95% CI -0.84 to -0.00). Magnesium sulphate may increase hospital re-admission rate within 30 days of discharge (risk ratio (RR) 3.16, 95% CI 1.20 to 8.27; 158 children; low-certainty evidence). None of our primary outcomes were measured for magnesium sulphate compared with hypertonic saline (1 RCT, 220 children). Effects were uncertain on the duration of hospital stay in days (MD 0.00, 95% CI -0.28 to 0.28), and on clinical severity on the Respiratory Distress Assessment Instrument (RDAI) score at 25 to 48 hours (MD 0.10, 95% CI -0.39 to 0.59). There were no events of mortality or adverse effects for magnesium sulphate, with or without salbutamol, compared with salbutamol (1 RCT, 57 children). Effects on the duration of hospital stay were uncertain (magnesium sulphate: 24 hours (95% CI 25.8 to 47.4), magnesium sulphate + salbutamol: 20 hours (95% CI 15.3 to 39.0), and salbutamol: 24 hours (95% CI 23.4 to 76.9)). None of our primary outcomes were measured for magnesium sulphate + epinephrine compared with no treatment or normal saline + epinephrine (1 RCT,120 children). Effects were uncertain for the duration of hospital stay in hours (MD -0.40, 95% CI -3.94 to 3.14), and for RDAI scores (0 to 24 hours: MD -0.20, 95% CI -1.06 to 0.66; and 25 to 48 hours: MD -0.90, 95% CI -1.75 to -0.05). AUTHORS' CONCLUSIONS: There is insufficient evidence to establish the efficacy and safety of magnesium sulphate for treating children up to two years of age with acute bronchiolitis. No evidence was available for time to recovery, duration of mechanical ventilation and intensive care unit stay, or pulmonary function. There was no information about adverse events for some comparisons. Well-designed RCTs to assess the effects of magnesium sulphate for children with acute bronchiolitis are needed. Important outcomes, such as time to recovery and adverse events should be measured.


Assuntos
Bronquiolite/tratamento farmacológico , Broncodilatadores/uso terapêutico , Sulfato de Magnésio/uso terapêutico , Doença Aguda , Albuterol/uso terapêutico , Viés , Broncodilatadores/administração & dosagem , Quimioterapia Combinada/métodos , Epinefrina/uso terapêutico , Humanos , Lactente , Recém-Nascido , Tempo de Internação , Sulfato de Magnésio/administração & dosagem , Readmissão do Paciente/estatística & dados numéricos , Placebos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Solução Salina/uso terapêutico , Índice de Gravidade de Doença
5.
Mol Med ; 26(1): 91, 2020 09 29.
Artigo em Inglês | MEDLINE | ID: mdl-32993479

RESUMO

BACKGROUND: Mechanically ventilated patients with COVID-19 have a mortality of 24-53%, in part due to distal mucopurulent secretions interfering with ventilation. DNA from neutrophil extracellular traps (NETs) contribute to the viscosity of mucopurulent secretions and NETs are found in the serum of COVID-19 patients. Dornase alfa is recombinant human DNase 1 and is used to digest DNA in mucoid sputum. Here, we report a single-center case series where dornase alfa was co-administered with albuterol through an in-line nebulizer system. METHODS: Demographic and clinical data were collected from the electronic medical records of five mechanically ventilated patients with COVID-19-including three requiring veno-venous extracorporeal membrane oxygenation-treated with nebulized in-line endotracheal dornase alfa and albuterol, between March 31 and April 24, 2020. Data on tolerability and response were analyzed. RESULTS: The fraction of inspired oxygen requirements was reduced for all five patients after initiating dornase alfa administration. All patients were successfully extubated, discharged from hospital and remain alive. No drug-associated toxicities were identified. CONCLUSIONS: Results suggest that dornase alfa will be well-tolerated by patients with severe COVID-19. Clinical trials are required to formally test the dosing, safety, and efficacy of dornase alfa in COVID-19, and several have been recently registered.


Assuntos
Albuterol/administração & dosagem , Infecções por Coronavirus/tratamento farmacológico , Desoxirribonuclease I/administração & dosagem , Pneumonia Viral/tratamento farmacológico , Respiração Artificial , Adulto , Idoso , Albuterol/uso terapêutico , Broncodilatadores/administração & dosagem , Broncodilatadores/uso terapêutico , Infecções por Coronavirus/terapia , Desoxirribonuclease I/uso terapêutico , Feminino , Humanos , Intubação Intratraqueal , Masculino , Nebulizadores e Vaporizadores , Pandemias , Pneumonia Viral/terapia , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/uso terapêutico
6.
N Z Med J ; 133(1520): 61-72, 2020 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-32994594

RESUMO

AIM: In the PRACTICAL study, as-needed budesonide/formoterol reduced the rate of severe exacerbations compared with maintenance budesonide plus as-needed terbutaline. In a pre-specified analysis we analysed the efficacy in Maori and Pacific peoples, populations with worse asthma outcomes. METHOD: The PRACTICAL study was a 52-week, open-label, parallel group, randomised controlled trial of 890 adults with mild to moderate asthma, who were randomised to budesonide/formoterol Turbuhaler 200/6mcg one actuation as required or budesonide Turbuhaler 200mcg one actuation twice daily and terbutaline Turbuhaler 250mcg two actuations as required. The primary outcome was rate of severe exacerbations. The analysis strategy was to test an ethnicity-treatment interaction term for each outcome variable. RESULTS: Seventy-two participants (8%) identified as Maori, 36 participants (4%) as Pacific ethnicity. There was no evidence that ethnicity was an effect modifier for severe exacerbations (P interaction 0.70). CONCLUSION: The reduction in severe exacerbation risk with budesonide-formoterol reliever compared with maintenance budesonide was similar in Maori and Pacific adults compared with New Zealand European/Other.


Assuntos
Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Combinação Budesonida e Fumarato de Formoterol/uso terapêutico , Quimioterapia Combinada/métodos , Administração por Inalação , Adulto , Antiasmáticos/administração & dosagem , Asma/fisiopatologia , Broncodilatadores/administração & dosagem , Broncodilatadores/uso terapêutico , Budesonida/administração & dosagem , Budesonida/uso terapêutico , Combinação Budesonida e Fumarato de Formoterol/administração & dosagem , Estudos de Casos e Controles , Progressão da Doença , Grupos Étnicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nebulizadores e Vaporizadores/normas , Nova Zelândia/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Terbutalina/administração & dosagem , Terbutalina/uso terapêutico , Resultado do Tratamento
7.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32907923

RESUMO

CONTEXT: Current International Liaison Committee on Resuscitation recommendations on epinephrine administration during neonatal resuscitation were derived in 2010 from indirect evidence in animal or pediatric studies. OBJECTIVE: Systematic review of human infant and relevant animal studies comparing other doses, routes, and intervals of epinephrine administration in neonatal resuscitation with (currently recommended) administration of 0.01 to 0.03 mg/kg doses given intravenously (IV) every 3 to 5 minutes. DATA SOURCES: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, and trial registry databases. STUDY SELECTION: Predefined criteria were used for selection. DATA EXTRACTION: Risk of bias was assessed by using published tools appropriate for the study type. Certainty of evidence was assessed by using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Only 2 of 4 eligible cohort studies among 593 unique retrieved records yielded data allowing comparisons. There were no differences between IV and endotracheal epinephrine for the primary outcome of death at hospital discharge (risk ratio = 1.03 [95% confidence interval 0.62 to 1.71]) or for failure to achieve return of spontaneous circulation, time to return of spontaneous circulation (1 study; 50 infants), or proportion receiving additional epinephrine (2 studies; 97 infants). There were no differences in outcomes between 2 endotracheal doses (1 study). No human infant studies were found in which authors addressed IV dose or dosing interval. LIMITATIONS: The search yielded sparse human evidence of very low certainty (downgraded for serious risk of bias and imprecision). CONCLUSIONS: Administration of epinephrine by endotracheal versus IV routes resulted in similar survival and other outcomes. However, in animal studies, researchers continue to suggest benefit of IV administration using currently recommended doses.


Assuntos
Broncodilatadores/administração & dosagem , Epinefrina/administração & dosagem , Ressuscitação/métodos , Animais , Relação Dose-Resposta a Droga , Humanos , Recém-Nascido , Infusões Intravenosas
8.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32943536

RESUMO

OBJECTIVES: To evaluate the survival and neurodevelopmental impairment (NDI) in extremely low birth weight (ELBW) infants at 18 to 26 months with early hypoxemic respiratory failure (HRF). We also assessed whether African American infants with early HRF had improved outcomes after exposure to inhaled nitric oxide (iNO). METHODS: ELBW infants ≤1000 g and gestational age ≤26 weeks with maximal oxygen ≥60% on either day 1 or day 3 were labeled as "early HRF" and born between 2007 and 2015 in the Neonatal Research Network were included. Using a propensity score regression model, we analyzed outcomes and effects of exposure to iNO overall and separately by race. RESULTS: Among 7639 ELBW infants born ≤26 weeks, 22.7% had early HRF. Early HRF was associated with a mortality of 51.3%. The incidence of moderate-severe NDI among survivors was 41.2% at 18 to 26 months. Mortality among infants treated with iNO was 59.4%. Female sex (adjusted odds ratio [aOR]: 2.4, 95% confidence interval [CI]: 1.8-3.3), birth weight ≥720 g (aOR: 2.3, 95% CI: 1.7-3.1) and complete course of antenatal steroids (aOR: 1.6, 95% CI: 1.1-2.2) were associated with intact survival. African American infants had a similar incidence of early HRF (21.7% vs 23.3%) but lower exposure to iNO (16.4% vs 21.6%). Among infants with HRF exposed to iNO, intact survival (no death or NDI) was not significantly different between African American and other races (aOR: 1.5, 95% CI: 0.6-3.6). CONCLUSIONS: Early HRF in infants ≤26 weeks' gestation is associated with high mortality and NDI at 18 to 26 months. Use of iNO did not decrease mortality or NDI. Outcomes following iNO exposure were not different in African American infants.


Assuntos
Broncodilatadores/uso terapêutico , Hipóxia/complicações , Lactente Extremamente Prematuro , Transtornos do Neurodesenvolvimento/epidemiologia , Óxido Nítrico Sintase Tipo II/uso terapêutico , Insuficiência Respiratória/mortalidade , Administração por Inalação , Afro-Americanos , Índice de Apgar , Peso ao Nascer , Broncodilatadores/administração & dosagem , Feminino , Ruptura Prematura de Membranas Fetais , Mortalidade Hospitalar , Humanos , Hipertensão Pulmonar/tratamento farmacológico , Incidência , Lactente , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Recém-Nascido , Masculino , Transtornos do Neurodesenvolvimento/diagnóstico , Transtornos do Neurodesenvolvimento/tratamento farmacológico , Transtornos do Neurodesenvolvimento/etnologia , Óxido Nítrico Sintase Tipo II/administração & dosagem , Alta do Paciente , Gravidez , Pontuação de Propensão , Insuficiência Respiratória/tratamento farmacológico , Insuficiência Respiratória/etnologia , Insuficiência Respiratória/etiologia , Fatores de Risco , Fatores Sexuais , Esteroides/uso terapêutico
9.
Cochrane Database Syst Rev ; 8: CD012977, 2020 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-32767571

RESUMO

BACKGROUND: Asthma is an illness that commonly affects adults and children, and it serves as a common reason for children to attend emergency departments. An asthma exacerbation is characterised by acute or subacute worsening of shortness of breath, cough, wheezing, and chest tightness and may be triggered by viral respiratory infection, poor compliance with usual medication, a change in the weather, or exposure to allergens or irritants. Most children with asthma have mild or moderate exacerbations and respond well to first-line therapy (inhaled short-acting beta-agonists and systemic corticosteroids). However, the best treatment for the small proportion of seriously ill children who do not respond to first-line therapy is not well understood. Currently, a large number of treatment options are available and there is wide variation in management. OBJECTIVES: Main objective - To summarise Cochrane Reviews with or without meta-analyses of randomised controlled trials on the efficacy and safety of second-line treatment for children with acute exacerbations of asthma (i.e. after first-line treatments, titrated oxygen delivery, and administration of intermittent inhaled short-acting beta2-agonists and oral corticosteroids have been tried and have failed) Secondary objectives - To identify gaps in the current evidence base that will inform recommendations for future research and subsequent Cochrane Reviews - To categorise information on reported outcome measures used in trials of escalation of treatment for acute exacerbations of asthma in children, and to make recommendations for development and reporting of standard outcomes in future trials and reviews - To identify relevant randomised controlled trials that have been published since the date of publication of each included review METHODS: We included Cochrane Reviews assessing interventions for children with acute exacerbations of asthma. We searched the Cochrane Database of Systematic Reviews. The search is current to 28 December 2019. We also identified trials that were potentially eligible for, but were not currently included in, published reviews. We assessed the quality of included reviews using the ROBIS criteria (tool used to assess risk of bias in systematic reviews). We presented an evidence synthesis of data from reviews alongside an evidence map of clinical trials. Primary outcomes were length of stay, hospital admission, intensive care unit admission, and adverse effects. We summarised all findings in the text and reported data for each outcome in 'Additional tables'. MAIN RESULTS: We identified 17 potentially eligible Cochrane Reviews but extracted data from, and rated the quality of, 13 reviews that reported results for children alone. We excluded four reviews as one did not include any randomised controlled trials (RCTs), one did not provide subgroup data for children, and the last two had been updated and replaced by subsequent reviews. The 13 reviews included 67 trials; the number of trials in each review ranged from a single trial up to 27 trials. The vast majority of comparisons included between one and three trials, involving fewer than 100 participants. The total number of participants included in reviews ranged from 40 to 2630. All studies included children; 16 (24%) included children younger than two years of age. Most of the reviews reported search dates older than four years. We have summarised the published evidence as outlined in Cochrane Reviews. Key findings, in terms of our primary outcomes, are that (1) intravenous magnesium sulfate was the only intervention shown to reduce hospital length of stay (high-certainty evidence); (2) no evidence suggested that any intervention reduced the risk of intensive care admission (low- to very low-certainty evidence); (3) the risk of hospital admission was reduced by the addition of inhaled anticholinergic agents to inhaled beta2-agonists (moderate-certainty evidence), the use of intravenous magnesium sulfate (high-certainty evidence), and the use of inhaled heliox (low-certainty evidence); (4) the addition of inhaled magnesium sulfate to usual bronchodilator therapy appears to reduce serious adverse events during hospital admission (moderate-certainty evidence); (5) aminophylline increased vomiting compared to placebo (moderate-certainty evidence) and increased nausea and nausea/vomiting compared to intravenous beta2-agonists (low-certainty evidence); and (6) the addition of anticholinergic therapy to short-acting beta2-agonists appeared to reduce the risk of nausea (high-certainty evidence) and tremor (moderate-certainty evidence) but not vomiting (low-certainty evidence). We considered 4 of the 13 reviews to be at high risk of bias based on the ROBIS framework. In all cases, this was due to concerns regarding identification and selection of studies. The certainty of evidence varied widely (by review and also by outcome) and ranged from very low to high. AUTHORS' CONCLUSIONS: This overview provides the most up-to-date evidence on interventions for escalation of therapy for acute exacerbations of asthma in children from Cochrane Reviews of randomised controlled trials. A vast majority of comparisons involved between one and three trials and fewer than 100 participants, making it difficult to assess the balance between benefits and potential harms. Due to the lack of comparative studies between various treatment options, we are unable to make firm practice recommendations. Intravenous magnesium sulfate appears to reduce both hospital length of stay and the risk of hospital admission. Hospital admission is also reduced with the addition of inhaled anticholinergic agents to inhaled beta2-agonists. However, further research is required to determine which patients are most likely to benefit from these therapies. Due to the relatively rare incidence of acute severe paediatric asthma, multi-centre research will be required to generate high-quality evidence. A number of existing Cochrane Reviews should be updated, and we recommend that a new review be conducted on the use of high-flow nasal oxygen therapy. Important priorities include development of an internationally agreed core outcome set for future trials in acute severe asthma exacerbations and determination of clinically important differences in these outcomes, which can then inform adequately powered future trials.


Assuntos
Antiasmáticos/uso terapêutico , Asma/terapia , Broncodilatadores/uso terapêutico , Progressão da Doença , Revisões Sistemáticas como Assunto , Doença Aguda , Administração por Inalação , Agonistas de Receptores Adrenérgicos beta 2/uso terapêutico , Aminofilina/administração & dosagem , Aminofilina/efeitos adversos , Antiasmáticos/administração & dosagem , Antibacterianos/uso terapêutico , Asma/tratamento farmacológico , Viés , Broncodilatadores/administração & dosagem , Criança , Pré-Escolar , Antagonistas Colinérgicos/uso terapêutico , Hélio , Humanos , Lactente , Tempo de Internação , Antagonistas de Leucotrienos/uso terapêutico , Sulfato de Magnésio/administração & dosagem , Sulfato de Magnésio/efeitos adversos , Sulfato de Magnésio/uso terapêutico , Náusea/induzido quimicamente , Náusea/prevenção & controle , Oxigênio/administração & dosagem , Respiração com Pressão Positiva , Ensaios Clínicos Controlados Aleatórios como Assunto , Vômito/induzido quimicamente , Trabalho Respiratório/efeitos dos fármacos
10.
SEMERGEN, Soc. Esp. Med. Rural Gen. (Ed. Impr.) ; 46(5): 347-354, jul.-ago. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-197322

RESUMO

El asma es la enfermedad respiratoria más prevalente en el mundo; puede afectar a personas de todas las edades y es potencialmente mortal. En la actualidad, contamos con tratamientos de mantenimiento que son efectivos en la mayoría de los pacientes con asma y, sin embargo, una proporción importante no tiene bien controlada su enfermedad a pesar de los medios disponibles. En este documento, con el respaldo de las sociedades de los médicos que tratan el asma en España, se quiere llamar la atención de la sociedad y los profesionales sobre este problema en nuestro país. Se pone el foco sobre los aspectos clínicos, diagnósticos y terapéuticos del asma y se plantean algunas acciones de mejora en el ámbito de los pacientes y en el profesional sanitario que, en vista de los resultados actuales derivados de la falta de control del asma, podrían ser beneficiosas tanto en los resultados clínicos para los pacientes como en los de salud pública


Asthma is the most prevalent respiratory disease worldwide and it can affect people of all ages and is potentially fatal. Today, maintenance treatments are available that are effective in most patients, yet a significant proportion have poorly controlled disease, despite the resources on offer. This document, endorsed by members of the Spanish medical societies involved in the treatment of asthma, is intended to draw the attention of society and professionals to this problem in Spain. It focuses on the clinical, diagnostic and therapeutic aspects of asthma, and proposes some actions for improvement as regards patients and healthcare professionals which, in view of the current results arising from inadequate asthma control, might be beneficial to improve outcomes for both patients and public health


Assuntos
Humanos , Asma/diagnóstico , Asma/tratamento farmacológico , Broncodilatadores/administração & dosagem , Glucocorticoides/administração & dosagem , Hiper-Reatividade Brônquica/fisiopatologia , Exacerbação dos Sintomas , Espirometria/métodos , Testes de Função Respiratória/métodos , Testes de Provocação Brônquica/métodos , Abandono do Uso de Tabaco/métodos , Indicadores de Morbimortalidade , Agonistas Adrenérgicos beta/uso terapêutico
11.
Lancet Respir Med ; 8(10): 1000-1012, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32653074

RESUMO

BACKGROUND: Patients with asthma who are inadequately controlled on inhaled corticosteroid-long-acting ß2-adrenoceptor agonist (ICS-LABA) combinations might benefit from the addition of a long-acting muscarinic receptor antagonist. The aim of the IRIDIUM study was to assess the efficacy and safety of a once-daily, single-inhaler combination of mometasone furoate, indacaterol acetate, and glycopyrronium bromide (MF-IND-GLY) versus ICS-LABA in patients with inadequately controlled asthma. METHODS: In this 52-week, double-blind, double-dummy, parallel-group, active-controlled phase 3 study, patients were recruited from 415 sites across 41 countries. Patients aged 18 to 75 years with symptomatic asthma despite treatment with medium-dose or high-dose ICS-LABA, at least one exacerbation in the previous year, and a percentage of predicted FEV1 of less than 80% were included. Enrolled patients were randomly assigned (1:1:1:1:1) via interactive response technology to receive medium-dose or high-dose MF-IND-GLY (80 µg, 150 µg, 50 µg; 160 µg, 150 µg, 50 µg) or MF-IND (160 µg, 150 µg; 320 µg, 150 µg) once daily via Breezhaler, or high-dose fluticasone-salmeterol (FLU-SAL; 500 µg, 50 µg) twice daily via Diskus. The primary outcome was change from baseline in trough FEV1 with MF-IND-GLY versus MF-IND at week 26 in patients in the full analysis set, analysed by means of a mixed model for repeated measures. Safety was assessed in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, NCT02571777, and is completed. FINDINGS: Between Dec 8, 2015, and Jun 14, 2019, 3092 of 4851 patients screened were randomly assigned (medium-dose MF-IND-GLY, n=620; high-dose MF-IND-GLY, n=619; medium-dose MF-IND, n=617; high-dose MF-IND, n=618; high-dose FLU-SAL, n=618). 2747 (88·8%) patients completed the 52-week treatment and 321 (10·4%) started but discontinued study treatment prematurely. Medium-dose MF-IND-GLY (treatment difference [Δ] 76 mL [95% CI 41-111]; p<0·001) and high-dose MF-IND-GLY (Δ 65 mL [31-99]; p<0·001) showed superior improvement in trough FEV1 versus corresponding doses of MF-IND at week 26. Improvements in trough FEV1 were greater for both medium-dose MF-IND-GLY (99 mL [64-133]; p<0·001) and high-dose MF-IND-GLY (119 mL [85-154]; p<0·001) than for high-dose FLU-SAL at week 26. Overall, the incidence of adverse events was balanced across the treatment groups. Seven deaths were reported (one with medium-dose MF-IND-GLY, two with high-dose MF-IND-GLY, and four with high-dose MF-IND) during the study; none of these deaths was considered by the investigators to be caused by study drugs or other study-related factors. INTERPRETATION: Once-daily, single-inhaler MF-IND-GLY improved lung function versus ICS-LABA combinations (MF-IND and FLU-SAL) in patients with inadequately controlled asthma. The safety profile was similar across treatment groups. MF-IND-GLY therefore constitutes a good treatment option in these patients. FUNDING: Novartis Pharmaceuticals.


Assuntos
Asma/tratamento farmacológico , Combinação Fluticasona-Salmeterol/administração & dosagem , Glicopirrolato/administração & dosagem , Indanos/administração & dosagem , Furoato de Mometasona/administração & dosagem , Quinolonas/administração & dosagem , Administração por Inalação , Adolescente , Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Broncodilatadores/administração & dosagem , Criança , Método Duplo-Cego , Esquema de Medicação , Combinação de Medicamentos , Feminino , Volume Expiratório Forçado , Glucocorticoides/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas Muscarínicos/administração & dosagem , Nebulizadores e Vaporizadores , Resultado do Tratamento , Adulto Jovem
12.
Medicine (Baltimore) ; 99(25): e20718, 2020 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-32569208

RESUMO

BACKGROUND: Bronchodilators administered through inhalation devices are the mainstay treatment for patients with obstructive lung diseases. Patients do not view devices as interchangeable. This systematic review and meta-analysis examined device feature preferences among patients with obstructive lung diseases treated with handheld inhalers. STUDY APPRAISAL AND SYNTHESIS METHODS: PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify publications between 2010 and 2019 that met the following criteria:A manual search extended the study period from 2001 to 2019. Random-effects models were used to generate pooled mean effect sizes and 95% confidence intervals (CIs) for preferred device features. Heterogeneity was measured by the I statistic. RESULTS: Nineteen studies (n = 11,256) were included in this meta-analysis. Average age ranged from 50.4 to 74.3 years. The majority of patients were male (57%) and had chronic obstructive pulmonary disease (92%).Patients preferred the following device features: CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:: Adults with obstructive lung diseases preferred small inhaler devices that were portable, durable, perceived as easy to use, and fast in medication administration. Healthcare providers should give due consideration to the patient's device feature preferences when developing a treatment plan that prescribes an inhalation device.


Assuntos
Broncodilatadores/administração & dosagem , Nebulizadores e Vaporizadores , Preferência do Paciente , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Desenho de Equipamento , Humanos
13.
Am J Respir Crit Care Med ; 202(9): 1237-1243, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32584168

RESUMO

Rationale: In the IMPACT (Informing the Pathway of Chronic Obstructive Pulmonary Disease Treatment) trial, fluticasone furoate (FF)/umeclidinium (UMEC)/vilanterol (VI) significantly reduced exacerbations compared with FF/VI or UMEC/VI in patients with symptomatic chronic obstructive pulmonary disease and a history of exacerbations.Objectives: To understand whether inhaled corticosteroid (ICS) withdrawal affected IMPACT results, given direct transition from prior maintenance medication to study medication at randomization.Methods: Exacerbations and change from baseline in trough FEV1 and St. George's Respiratory Questionnaire results were analyzed by prior ICS use. Exacerbations were also analyzed while excluding data from the first 30 days.Measurements and Main Results: FF/UMEC/VI significantly reduced the annual moderate/severe exacerbation rate compared with UMEC/VI in prior ICS users (29% reduction; P < 0.001), but only a numerical reduction was seen among prior ICS nonusers (12% reduction; P = 0.115). To minimize impact from ICS withdrawal, in an analysis excluding the first 30 days, FF/UMEC/VI continued to significantly reduce the annual on-treatment moderate/severe exacerbation rate (19%; P < 0.001) compared with UMEC/VI. The benefit of FF/UMEC/VI compared with UMEC/VI was seen for severe exacerbation rates, regardless of prior ICS use (prior ICS users, 35% reduction; P < 0.001; non-ICS users, 35% reduction; P = 0.018), and overall when excluding the first 30 days (29%; P < 0.001). Improvements from baseline with FF/UMEC/VI compared with UMEC/VI were also maintained throughout the study for both trough FEV1 and St. George's Respiratory Questionnaire, regardless of prior ICS use.Conclusions: These data support the important treatment effects of FF/UMEC/VI combination therapy on exacerbation reduction, lung function, and quality of life that do not appear to be related to abrupt ICS withdrawal.Clinical trial registered with www.clinicaltrials.gov (NCT02164513).


Assuntos
Álcoois Benzílicos/administração & dosagem , Broncodilatadores/administração & dosagem , Clorobenzenos/administração & dosagem , Fluticasona/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Quinuclidinas/administração & dosagem , Síndrome de Abstinência a Substâncias/fisiopatologia , Administração por Inalação , Idoso , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
14.
Lancet Respir Med ; 8(11): 1081-1093, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32598906

RESUMO

BACKGROUND: Small airway dysfunction is a common but neglected respiratory abnormality. Little is known about its prevalence, risk factors, and prognostic factors in China or anywhere else in the world. We aimed to estimate the prevalence of small airway dysfunction using spirometry before and after bronchodilation, both overall and in specific population subgroups; assess its association with a range of lifestyle and environmental factors (particularly smoking); and estimate the burden of small airway dysfunction in China. METHODS: From June, 2012, to May, 2015, the nationally representative China Pulmonary Health study invited 57 779 adults to participate using a multistage stratified sampling method from ten provinces (or equivalent), and 50 479 patients with valid lung function testing results were included in the analysis. We diagnosed small airway dysfunction on the basis of at least two of the following three indicators of lung function being less than 65% of predicted: maximal mid-expiratory flow, forced expiratory flow (FEF) 50%, and FEF 75%. Small airway dysfunction was further categorised into pre-small airway dysfunction (defined as having normal FEV1 and FEV1/forced vital capacity [FVC] ratio before bronchodilator inhalation), and post-small airway dysfunction (defined as having normal FEV1 and FEV1/FVC ratio both before and after bronchodilator inhalation). Logistic regression yielded adjusted odds ratios (ORs) for small airway dysfunction associated with smoking and other lifestyle and environmental factors. We further estimated the total number of cases of small airway dysfunction in China by applying present study findings to national census data. FINDINGS: Overall the prevalence of small airway dysfunction was 43·5% (95% CI 40·7-46·3), pre-small airway dysfunction was 25·5% (23·6-27·5), and post-small airway dysfunction was 11·3% (10·3-12·5). After multifactor regression analysis, the risk of small airway dysfunction was significantly associated with age, gender, urbanisation, education level, cigarette smoking, passive smoking, biomass use, exposure to high particulate matter with a diameter less than 2·5 µm (PM2·5) concentrations, history of chronic cough during childhood, history of childhood pneumonia or bronchitis, parental history of respiratory diseases, and increase of body-mass index (BMI) by 5 kg/m2. The ORs for small airway dysfunction and pre-small airway dysfunction were similar, whereas larger effect sizes were generally seen for post-small airway dysfunction than for either small airway dysfunction or pre-small airway dysfunction. For post-small airway dysfunction, cigarette smoking, exposure to PM2·5, and increase of BMI by 5 kg/m2 were significantly associated with increased risk, among preventable risk factors. There was also a dose-response association between cigarette smoking and post-small airway dysfunction among men, but not among women. We estimate that, in 2015, 426 (95% CI 411-468) million adults had small airway dysfunction, 253 (238-278) million had pre-small airway dysfunction, and 111 (104-126) million had post-small airway dysfunction in China. INTERPRETATION: In China, spirometry-defined small airway dysfunction is highly prevalent, with cigarette smoking being a major modifiable risk factor, along with PM2·5 exposure and increase of BMI by 5 kg/m2. Our findings emphasise the urgent need to develop and implement effective primary and secondary prevention strategies to reduce the burden of this condition in the general population. FUNDING: Ministry of Science and Technology of China; National Natural Science Foundation of China; National Health Commission of China.


Assuntos
Poluentes Atmosféricos/efeitos adversos , Broncopatias/epidemiologia , Broncopatias/etiologia , Broncodilatadores/administração & dosagem , Obesidade/complicações , Fumar/efeitos adversos , Adulto , Distribuição por Idade , Broncopatias/diagnóstico , Broncopatias/tratamento farmacológico , China/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Testes de Função Respiratória , Medição de Risco , Índice de Gravidade de Doença , Distribuição por Sexo , Fumar/epidemiologia , Espirometria , Capacidade Vital/fisiologia , Adulto Jovem
15.
Rev Assoc Med Bras (1992) ; 66(2): 187-193, 2020 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-32428154

RESUMO

OBJECTIVE: To analyze clinical and demographic variables possibly associated with the prescriptions of non-recommended but routinely used therapies for infants with acute viral bronchiolitis. METHODS: A cross-sectional study included hospitalized infants with bronchiolitis caused by the respiratory syncytial virus. Those with other associated infections and/or morbidities were excluded. The data were collected from medical records. RESULTS: Among 120 cases, 90% used inhaled beta-agonists, 72.5% corticosteroids, 40% antibiotics, and 66.7% inhaled hypertonic saline solution. The use of bronchodilators did not present an independent association with another variable. More frequent use of corticosteroids was associated with low oximetry, longer hospitalization time, and age>3 months. Antibiotic therapy was associated with the presence of fever, longer hospitalization, and age>3 months. Inhaled hypertonic saline solution was associated with longer hospitalization time. CONCLUSIONS: Non-recommended prescriptions were frequent. Corticosteroid and antibiotic therapy were associated with signs of severity, as expected, but interestingly, they were more frequently used in infants above 3m, which suggested less safety in the diagnosis of viral bronchiolitis in these patients. The use of bronchodilators was even more worrying since they were indiscriminately used, without association with another variable related to the severity or characteristics of the host. The use of the inhaled hypertonic solution, although not associated with severity, seems to have implied a longer hospitalization time. The identification of these conditions of greater vulnerability to the prescription of inappropriate therapies contributes to the implantation of protocols for the bronchiolitis treatment, for continuing education and for analysis of the effectiveness of the strategies employed.


Assuntos
Bronquiolite Viral/tratamento farmacológico , Prescrição Inadequada/estatística & dados numéricos , Infecções por Vírus Respiratório Sincicial/tratamento farmacológico , Doença Aguda , Corticosteroides/administração & dosagem , Antibacterianos/administração & dosagem , Broncodilatadores/administração & dosagem , Pré-Escolar , Estudos Transversais , Feminino , Hospitalização , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Solução Salina Hipertônica/administração & dosagem , Estatísticas não Paramétricas
16.
Pneumologie ; 74(3): 149-158, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32143230

RESUMO

INTRODUCTION: Inhalative treatments with metered dose aerosols and dry powder inhalers are the backbone of the pharmacotherapy for asthma and COPD. In the last decade many new and generic inhalative bronchodilators were launched at the German market, both monotherapies and fixed dose double bronchodilator (LABA/LAMA, beta adrenergic and antimuscarinic) or LABA and inhaled corticosteroid (ICS) and triple (LABA/LAMA/ICS) combinations. According to two surveys in 2015 among respiratory physicians we expected a high proportion of patients receiving duplicate prescriptions, e. g. a fixed dose new LABA/LAMA combination in addition to an existing ICS/LABA fixed dose combination. METHODOLOGY: We searched the database of a large mail order pharmacy (DocMorris) to identify duplicate prescriptions of inhalative drugs for a patient by the same or by two or more different physicians during a 3 months period. RESULTS: Unexpectedly, we found as little as around 1 % duplicate prescriptions for the same patient. Duplicate prescriptions involving combination products were found to be much more common than duplicate prescriptions of different mono-products. Irrespective the low percentage number of all prescriptions we saw in just one large mail order pharmacy several thousands of erroneous prescriptions. CONCLUSION: At least in the setting of this mail order pharmacy duplicate (i. e. contraindicated and potentially dangerous) prescriptions are relatively rare. Prescribers and pharmacists should be aware of the issue of duplicates - especially when prescribing or filling prescriptions with combination products.


Assuntos
Corticosteroides/administração & dosagem , Broncodilatadores/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica , Medicamentos sob Prescrição/uso terapêutico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Agonistas de Receptores Adrenérgicos beta 2 , Bases de Dados Factuais , Quimioterapia Combinada , Humanos , Antagonistas Muscarínicos
17.
Pediatrics ; 145(4)2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32165556

RESUMO

BACKGROUND AND OBJECTIVES: The albuterol dropper bottle used to prepare solutions for continuous nebulization contains the preservative benzalkonium chloride (BAC). BAC, by itself, has been shown to cause bronchospasm. We hypothesized that BAC would decrease the therapeutic efficacy of albuterol in patients with acute asthma exacerbations. METHODS: We performed a retrospective cohort study comparing the clinical outcomes of patients <18 years of age receiving continuous nebulized albuterol with and without BAC. For the primary end point (duration of continuous albuterol nebulization), we compared the 2 groups with Kaplan-Meier estimate of survival curves, conducted a log-rank test of difference, and adjusted for baseline characteristics using multivariable Cox regression. A P value <.05 was considered significant. RESULTS: A total of 477 patients were included in the analysis (236 exposed to BAC and 241 controls). The duration of continuous nebulization was significantly longer in the BAC group than in the control group (median of 9 vs 6 hours; 15.7% required continuous nebulization compared to 5.8% of controls at 24 hours). The control group was 79% more likely to stop continuous nebulization at any particular point in time (hazard ratio 1.79; 95% confidence interval: 1.45 to 2.22; P < .001) and 43% more likely to stop additional respiratory support (hazard ratio 1.43; 95% confidence interval: 1.16 to 1.75; P < .001). CONCLUSIONS: BAC is a functional albuterol antagonist associated with a longer duration of continuous albuterol nebulization treatment and additional respiratory support, suggesting that preservative-free albuterol formulations are safer for use in continuous nebulization.


Assuntos
Albuterol/administração & dosagem , Asma/tratamento farmacológico , Compostos de Benzalcônio/administração & dosagem , Broncodilatadores/administração & dosagem , Conservantes Farmacêuticos/administração & dosagem , Administração por Inalação , Adolescente , Albuterol/antagonistas & inibidores , Albuterol/química , Compostos de Benzalcônio/efeitos adversos , Broncodilatadores/antagonistas & inibidores , Broncodilatadores/química , Criança , Pré-Escolar , Progressão da Doença , Interações Medicamentosas , Feminino , Humanos , Lactente , Recém-Nascido , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Conservantes Farmacêuticos/efeitos adversos , Análise de Regressão , Estudos Retrospectivos
18.
Tokai J Exp Clin Med ; 45(1): 24-30, 2020 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-32219806

RESUMO

OBJECTIVE: Using a commercially available breath sound analyzer, the airway reversibility in asthmatic children during healthy periods was investigated. METHODS: Fifty samples of 34 children with asthma (median age, 11 years; range, 6-16 years) who visited our hospital and whose lung function was normal were included. The breath sound parameters, the frequency limiting 99% of the power spectrum (F99) and spectrum curve indices, the total area under the curve of the dBm data (A3/AT and B4/AT) and the ratio of power and frequency at 50% and 75% of the highest frequency of the power spectrum (RPF75 and RPF50) were evaluated before and after ß2 agonist inhalation. RESULTS: The values of spectrum curve indices were significantly increased after ß2 agonist inhalation. The changes in these parameters were more marked than the changes in the FOT parameters. The changes in A3/AT and B4/AT were significantly related to two FOT parameters: R5-R20 and X5. CONCLUSIONS: Our study suggested that significant changes in breath sound parameters were present in asthmatic children during the period of good control. A breath sound analysis may be useful for assessing the airway condition of asthmatic children during long-term management.


Assuntos
Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Asma/tratamento farmacológico , Asma/fisiopatologia , Broncodilatadores/administração & dosagem , Sons Respiratórios , Administração por Inalação , Adolescente , Criança , Feminino , Humanos , Masculino , Espectrografia do Som , Fatores de Tempo
19.
J Breath Res ; 14(2): 026013, 2020 03 31.
Artigo em Inglês | MEDLINE | ID: mdl-32120351

RESUMO

In bronchial asthma, both airway inflammation and reversible airway narrowing require assessment and treatment. These two pathologies are treated primarily with inhaled corticosteroids (ICS) and long-acting ß2 agonists (LABA), respectively. Therefore, ICS-LABA combinations are widely used to treat asthma. Airway inflammation and reversible airway narrowing are assessed primarily with fraction of exhaled nitric oxide (FENO) and bronchodilator reversibility (BDR). The forced oscillation technique (FOT) has recently attracted attention as a method for assessing obstructive respiratory disturbance. However, little is known about the relationships among these assessments. Therefore, we investigated the relationships among BDR, FENO, and FOT during ICS-LABA combination therapy. The subjects comprised 87 patients (25 men and 62 women) with asthma undergoing ICS/LABA combination therapy from July to September 2017. We applied the FENO test, FOT, and BDR testing without the patients stopping their therapy. The rates of change in FEV1 (ΔFEV1%) was correlated with FENO (r = 0.278). Among the FOT parameters, X5 (r = -0.263), Fres (r = 0.292), and AX (r = 0.245) were significantly correlated with ΔFEV1%. FENO, Fres and %FEV1 at baseline in these stable asthmatics were significantly assosiated with ΔFEV1% independently of the effects of age, atopy and body mass index (BMI). These results suggest that FENO and the results of respiratory function testing and FOT reflect different aspects of asthma and should be combined and comprehensively evaluated.


Assuntos
Corticosteroides/uso terapêutico , Agonistas de Receptores Adrenérgicos beta 2/uso terapêutico , Asma/tratamento farmacológico , Asma/fisiopatologia , Broncodilatadores/uso terapêutico , Expiração , Óxido Nítrico/análise , Administração por Inalação , Corticosteroides/administração & dosagem , Corticosteroides/farmacologia , Adulto , Idoso , Testes Respiratórios , Broncodilatadores/administração & dosagem , Broncodilatadores/farmacologia , Feminino , Volume Expiratório Forçado , Humanos , Pulmão/efeitos dos fármacos , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Análise de Regressão
20.
s.l; IETSI; 24 mar. 2020.
Não convencional em Espanhol | LILACS, BRISA/RedTESA | ID: biblio-1095866

RESUMO

CONTEXTO: El paciente con diagnóstico de COVID19 puede desarrollar dentro de sus complicaciones, compromiso pulmonar y neumonía, esto se traduce en síntomas como dificultad para respirar (distress respiratorio); de confirmarse el diagnóstico se debe realizar el manejo del cuadro causado por el virus SARS-CoV-2. En ese contexto se aplican medicamentos como los broncodilatadores. Gracias a su acción beta-2- agonista, llegan por vía inhalada a los pulmones y al músculo liso bronquial donde incrementa el diámetro del bronquio, lo que mejora la ventilación pulmonar. La vía de administración del medicamento puede realizarse mediante: (a) nebulización, utilizando una mascarilla que cubra la región de nariz y boca conectada a una solución que contenga el broncodilatador, donde la solución se convierte en aerosol lo que es impulsado hacia los pulmones con ayuda de un pequeño motor eléctrico o a baterías; (b) aerocámara, es un dispositivo que por un extremo cubre la región de nariz y boca, que tiene en el otro extremo una desembocadura que encaja en la boquilla de un inhalador (producto que contiene el medicamento precargado y dosificado en puffs). Ante el escenario de administrar un broncodilatador por vía inhalada mediante nebulización versus aerocámara en pacientes con COVID19, es que nos planteamos los siguientes escenarios: (a) determinar si existen diferencias en la eficacia de la administración de medicamento (como el broncodilatador) mediante nebulización versus aerocámara, en pacientes con diagnostico de COVID19 que se encuentren estables y (b) determinar si la nebulización del paciente con diagnóstico de COVID19 con medicamentos tipo broncodilatadores, incrementan el riesgo de contagio al personal de salud. EFICACIA DE LA ADMINISTRACIÓN DE MEDICAMENTO (COMO EL BRONCODILATADOR) MEDIANTE NEBULIZACIÓN VERSUS AEROCÁMARA, EN PACIENTES CON DIAGNÓSTICO DE COVID19 QUE SE ENCUENTREN ESTABLES: Encontramos que a la fecha (21 marzo 2020), no existen estudios comparativos que evalúen la eficacia de la administración de medicamento (como el broncodilatador) mediante nebulización versus aerocámara, en pacientes con diagnóstico de COVID19 que se encuentren estables. Sin embargo, como antecedente tomamos información de una revisión sistemática (RS) donde se hace la misma comparación en pacientes con diagnóstico de asma (Cates, Welsh, and Rowe 2013). En dicha RS, se tuvo como objetivo evaluar la efectividad comparada de las aerocámaras vs nebulizadores para administración de broncodilatadores (beta-2-agonistas) en pacientes con asma aguda. No se encontraron diferencias significativas entre la cantidad de hospitalizaciones en los pacientes atendidos con broncodilatador mediante aerocámara comparada con nebulización en niños (RR=0.71 IC95% 0.47 a 1.08) ni en adultos (RR=0.94 IC95% 0.61 a 1.43) con asma (que no llegaba a comprometer la vida del paciente). En el grupo de pacientes pediátricos, los que recibieron broncodilatador mediante aerocámara permanecieron en la emergencia durante menos tiempo (media tiempo de permanencia=33 minutos), comparado con los niños que recibieron el broncodilatador mediante nebulizador (media de tiempo= 103 minutos), (IC95% -43 a -24 minutos). Por ello, los autores concluyeron de manera indirecta, que la recuperación de la crisis asmática en el paciente pediátrico con el uso de aerocámara fue más rápida que cuando se utilizó el nebulizador. LA NEBULIZACIÓN DEL PACIENTE CON DIAGNÓSTICO DE COVID19 CON MEDICAMENTOS TIPO BRONCODILATADORES, INCREMENTAN EL RIESGO DE CONTAGIO AL PERSONAL DE SALUD: Guías de Práctica Clínica: La ANZICS, publicó el 16 de marzo 2020, recomendaciones sobre el manejo de aerosoles por parte del personal de salud y del uso de equipo de protección personal (EPP). La guía recomienda el uso de equipo de protección personal (EPP) contra infecciones trasmitidas por aerosoles como precaución en la atención de pacientes hospitalizados en la UCI, con diagnóstico de COVID19. Recomienda aplicar la mínima cantidad de procedimientos que generen aerosoles en el paciente con COVID19 en la UCI, como la intubación, extubación, broncoscopía, uso de oxígeno de alto flujo, ventilación no invasiva (con pobre sello hermético), realizar procedimientos en niños en llanto, traqueostomía, resucitación cardiopulmonar antes de la intubación; en habitaciones a presión negativa (de preferencia) o en habitaciones con aire ambiental. Manifiestan una recomendación en contra de la nebulización de medicamentos como broncodilatadores o solución salina. Además, se manifiestan en contra de utilizar el EPP que no cumpla con las recomendaciones señaladas. REPORTE DE CASO: Este es el reporte de un paciente en China que ejemplifica que, si se utiliza adecuadamente la EPP, los contagios a personal de salud se pueden minimizar. En este reporte se presenta un paciente con neumonía severa inicialmente con sospecha de COVID19, en quien se realizó los siguientes procedimientos: administración de oxígeno. por presentar dificultad respiratoria, intubación endotraqueal, laringoscopía y ventilación mecánica (VM) en la UCI. El paciente mejoró y a los 3 días salió de VM. La confirmación de que el paciente tenía COVID19 se obtuvo cuando se extubó al paciente. El punto de interés es que 41 profesionales de la salud estuvieron en contacto con el paciente durante procedimientos que generaron aerosoles, por lo menos durante 10 minutos y a una distancia de menos de 2 metros del paciente. Todos los trabajadores fueron aislados por dos semanas, tuvieron monitorización cercana de los síntomas, con realización de PCR para determinar infección. Sin embargo, ninguno de los 41 trabajadores de salud desarrolló síntomas y todos los PCR fueron negativos. Este reporte no pretende determinar que no existen contagios de pacientes con COVID19 a profesionales de la salud, sino ser un ejemplo, de que cuando se tienen las medidas de protección adecuada (EPP), el riesgo de contagio puede llegar a ser muy bajo. CONCLUSIONES: No se han encontrado estudios que evalúen si hay diferencias respecto a usar nebulizadores o aerocámaras en aliviar la dificultad respiratoria en pacientes con COVID-19. No obstante, se tiene evidencia científica proveniente de estudios en asma que muestra que, para el desenlace clínico de cantidad de hospitalizaciones en el contexto de pacientes con asma aguda, no existen diferencias entre usar nebulizadores o aerocámaras. Lo que sugiere que, desde la perspectiva del paciente, podría ser igual de beneficioso usar uno u otro método para mejorar los síntomas de dificultad respiratoria. Sin embargo, al ser el SARS-CoV-2 un agente infeccioso con alto índice de transmisión existiría un riesgo de infección para los trabajadores de salud si se nebuliza a estos pacientes debido a la alta dispersión de aerosol exhalado, por lo que sería recomendable preferir administrar el broncodilatador por aerocámara.


Assuntos
Humanos , Nebulizadores e Vaporizadores , Broncodilatadores/administração & dosagem , Infecções por Coronavirus/terapia , Peru , Avaliação da Tecnologia Biomédica
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