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1.
Elife ; 122024 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-39009040

RESUMO

Background: Prinflammatory extracellular chromatin from neutrophil extracellular traps (NETs) and other cellular sources is found in COVID-19 patients and may promote pathology. We determined whether pulmonary administration of the endonuclease dornase alfa reduced systemic inflammation by clearing extracellular chromatin. Methods: Eligible patients were randomized (3:1) to the best available care including dexamethasone (R-BAC) or to BAC with twice-daily nebulized dornase alfa (R-BAC + DA) for seven days or until discharge. A 2:1 ratio of matched contemporary controls (CC-BAC) provided additional comparators. The primary endpoint was the improvement in C-reactive protein (CRP) over time, analyzed using a repeated-measures mixed model, adjusted for baseline factors. Results: We recruited 39 evaluable participants: 30 randomized to dornase alfa (R-BAC +DA), 9 randomized to BAC (R-BAC), and included 60 CC-BAC participants. Dornase alfa was well tolerated and reduced CRP by 33% compared to the combined BAC groups (T-BAC). Least squares (LS) mean post-dexamethasone CRP fell from 101.9 mg/L to 23.23 mg/L in R-BAC +DA participants versus a 99.5 mg/L to 34.82 mg/L reduction in the T-BAC group at 7 days; p=0.01. The anti-inflammatory effect of dornase alfa was further confirmed with subgroup and sensitivity analyses on randomised participants only, mitigating potential biases associated with the use of CC-BAC participants. Dornase alfa increased live discharge rates by 63% (HR 1.63, 95% CI 1.01-2.61, p=0.03), increased lymphocyte counts (LS mean: 1.08 vs 0.87, p=0.02) and reduced circulating cf-DNA and the coagulopathy marker D-dimer (LS mean: 570.78 vs 1656.96 µg/mL, p=0.004). Conclusions: Dornase alfa reduces pathogenic inflammation in COVID-19 pneumonia, demonstrating the benefit of cost-effective therapies that target extracellular chromatin. Funding: LifeArc, Breathing Matters, The Francis Crick Institute (CRUK, Medical Research Council, Wellcome Trust). Clinical trial number: NCT04359654.


Assuntos
Anti-Inflamatórios , Tratamento Farmacológico da COVID-19 , COVID-19 , Desoxirribonuclease I , Humanos , Masculino , Feminino , Desoxirribonuclease I/administração & dosagem , Desoxirribonuclease I/uso terapêutico , Pessoa de Meia-Idade , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Idoso , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/uso terapêutico , Armadilhas Extracelulares/efeitos dos fármacos , SARS-CoV-2 , Proteína C-Reativa/análise , Proteína C-Reativa/metabolismo , Dexametasona/administração & dosagem , Dexametasona/uso terapêutico , Adulto , Nebulizadores e Vaporizadores , Resultado do Tratamento , Administração por Inalação
2.
BMJ Open Qual ; 13(3)2024 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-39009461

RESUMO

BACKGROUND: Adherence to pharmacotherapy and use of the correct inhaler technique are important basic principles of asthma management. Video- or remote-direct observation of therapy (v-DOT) could be a feasible approach to facilitate monitoring and supervising therapy, supporting the delivery of standard care. OBJECTIVE: To explore the utility and the feasibility of v-DOT to monitor inhaler technique and adherence to treatment in adults attending the asthma outpatient service in a tertiary hospital in Northern Ireland. METHOD: The project evaluated use of the technology with 10 asthma patients. Patient and clinician feedback was obtained, in addition to measures of patient engagement and disease-specific clinical markers to assess the feasibility and utility of v-DOT technology in this group of patients. RESULTS: The engagement rate with v-DOT for participating patients averaged 78% (actual video uploads vs expected video uploads) over a median 7 week usage period. Although 50% of patients reported a technical issue at some stage during the usage period, all patients and clinicians reported that the technology was easy to use and that they were satisfied with the outcomes. A range of positive impacts were observed, including optimised inhaler technique and an observed improvement in lung function. An increase in asthma control test scores aligned with clinical aims to promote adherence and alleviate symptoms. CONCLUSION: The v-DOT technology was shown to be a feasible method of assessing inhaler technique and monitoring adherence in this small group of adult asthma patients. A range of positive impacts for participating patients and clinicians were observed. Not all patients invited to join the project agreed to participate or engage with using the technology, highlighting that in this setting, digital modes of delivering care provide only one of the approaches in the necessary "tool kit" for clinicians and patients.


Assuntos
Asma , Humanos , Asma/tratamento farmacológico , Asma/terapia , Adulto , Feminino , Masculino , Projetos Piloto , Pessoa de Meia-Idade , Irlanda do Norte , Tecnologia Digital/métodos , Tecnologia Digital/estatística & dados numéricos , Gravação em Vídeo/métodos , Gravação em Vídeo/estatística & dados numéricos , Terapia Diretamente Observada , Nebulizadores e Vaporizadores/estatística & dados numéricos
3.
Can Vet J ; 65(7): 667-674, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38952752

RESUMO

A 21-year-old retired polo Argentinian thoroughbred horse from a teaching herd was presented for a routine bronchoalveolar lavage demonstration, during which an incidental finding of a granulomatous mass on the dorsal aspect of the epiglottis was made. Rhinosporidium seeberi was suspected from a histological section obtained from an initial biopsy, and the mass was removed via laser surgery for cytology and PCR. Sequencing of the PCR amplicons confirmed the diagnosis of R. seeberi. A treatment protocol of nebulized voriconazole for 10 d postoperatively was used. Long-term follow-up required 2 more laser surgeries plus oral fluconazole to resolve the remaining fungal spores. However, 2.5 y later, there was no evidence of remaining fungal spores. Key clinical message: Horses from endemic regions can potentially be exposed to R. seeberi. Based on its travel history, this horse may have contracted the infection in South America, California, or Alberta. Treatments administered, including diode laser resection, voriconazole antifungal nebulization, and oral fluconazole administration, were successful but required repeated interventions.


Suivi à long terme du Rhinosporidium seeberi laryngé diagnostiqué par PCR et traité par ablation au laser et nébulisation au voriconazole chez un cheval de polo thoroughbred pur-sang à la retraiteUn cheval thoroughbred argentin de polo retraité de 21 ans, issu d'un troupeau d'enseignement, a été présenté pour une démonstration de lavage broncho-alvéolaire de routine, au cours de laquelle une découverte fortuite d'une masse granulomateuse sur la face dorsale de l'épiglotte a été faite. Rhinosporidium seeberi a été suspecté à partir d'une coupe histologique obtenue à partir d'une biopsie initiale, et la masse a été retirée par chirurgie au laser pour cytologie et PCR. Le séquençage des amplicons PCR a confirmé le diagnostic de R. seeberi. Un protocole de traitement au voriconazole nébulisé pendant 10 jours après l'opération a été utilisé. Le suivi à long terme a nécessité 2 autres interventions chirurgicales au laser et du fluconazole oral pour éliminer les spores fongiques restantes. Cependant, 2,5 ans plus tard, il n'y avait aucune trace de spores fongiques restantes.Message clinique clé:Les chevaux des régions endémiques peuvent potentiellement être exposés à R. seeberi. D'après ses antécédents de voyage, ce cheval pourrait avoir contracté l'infection en Amérique du Sud, en Californie ou en Alberta. Les traitements administrés, notamment la résection au laser à diode, la nébulisation antifongique au voriconazole et l'administration orale de fluconazole, ont été efficaces mais ont nécessité des interventions répétées.(Traduit par Dr Serge Messier).


Assuntos
Antifúngicos , Doenças dos Cavalos , Nebulizadores e Vaporizadores , Rinosporidiose , Voriconazol , Animais , Cavalos , Doenças dos Cavalos/tratamento farmacológico , Doenças dos Cavalos/cirurgia , Doenças dos Cavalos/diagnóstico , Voriconazol/uso terapêutico , Voriconazol/administração & dosagem , Antifúngicos/uso terapêutico , Antifúngicos/administração & dosagem , Masculino , Rinosporidiose/veterinária , Rinosporidiose/tratamento farmacológico , Rinosporidiose/cirurgia , Rinosporidiose/diagnóstico , Nebulizadores e Vaporizadores/veterinária , Terapia a Laser/veterinária , Reação em Cadeia da Polimerase/veterinária , Doenças da Laringe/veterinária , Doenças da Laringe/cirurgia , Doenças da Laringe/tratamento farmacológico
4.
BMC Pulm Med ; 24(1): 317, 2024 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-38965541

RESUMO

BACKGROUND: Medication non-adherence is a significant problem in patients with Chronic Obstructive Pulmonary Disease (COPD). Efforts to address this issue are receiving increased attention. Simplifying treatment by prescribing single-inhaler triple therapy (SITT) as an alternative to multi-inhaler triple therapy (MITT) or with smart inhalers are often considered potential solutions. However, the actual impact of these innovations on adherence and clinical outcomes is unclear. METHODS: To address this knowledge gap we first conducted a literature review focusing on two research questions: 1) the difference in adherence between SITT and MITT users in COPD, and 2) the effect of smart inhalers on adherence in COPD. Separate searches were conducted in PubMed and two authors independently assessed the articles. In addition, we present a protocol for a study to acquire knowledge for the gaps identified. RESULTS: To address the first research question, 8 trials were selected for further review. All trials were observational, i.e. randomized controlled trials were lacking. Seven of these trials showed higher adherence and/or persistence in patients on SITT compared with patients on MITT. In addition, four studies showed a positive effect of SITT on various clinical outcomes. For the second research question, 11 trials were selected for review. While most of the studies showed a positive effect of smart inhalers on adherence, there was considerable variation in the results regarding their effect on other clinical outcomes. The TRICOLON (TRIple therapy COnvenience by the use of one or multipLe Inhalers and digital support in ChrONic Obstructive Pulmonary Disease) trial aims to improve understanding regarding the effectiveness of SITT and smart inhalers in enhancing adherence. This open-label, randomized, multi-center study will enroll COPD patients requiring triple therapy at ten participating hospitals. In total, 300 patients will be randomized into three groups: 1) MITT; 2) SITT; 3) SITT with digital support through a smart inhaler and an e-health platform. The follow-up period will be one year, during which three methods of measuring adherence will be used: smart inhaler data, self-reported data using the Test of Adherence to Inhalers (TAI) questionnaire, and drug analysis in scalp hair samples. Finally, differences in clinical outcomes between the study groups will be compared. DISCUSSION: Our review suggests promising results concerning the effect of SITT, as opposed to MITT, and smart inhalers on adherence. However, the quality of evidence is limited due to the absence of randomized controlled trials and/or the short duration of follow-up in many studies. Moreover, its impact on clinical outcomes shows considerable variation. The TRICOLON trial aims to provide solid data on these frequently mentioned solutions to non-adherence in COPD. Collecting data in a well-designed randomized controlled trial is challenging, but the design of this trial addresses both the usefulness of SITT and smart inhalers while ensuring minimal interference in participants' daily lives. TRIAL REGISTRATION: NCT05495698 (Clinicaltrials.gov), registered at 08-08-2022. Protocol version: version 5, date 27-02-2023.


Assuntos
Adesão à Medicação , Nebulizadores e Vaporizadores , Doença Pulmonar Obstrutiva Crônica , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Humanos , Administração por Inalação , Broncodilatadores/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Quimioterapia Combinada
6.
Adv Ther ; 41(8): 3089-3118, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38874879

RESUMO

INTRODUCTION: Asthma management is strongly dependent on physician and patient beliefs and perceptions about the disease and its long-term treatment. The APPaRENT 3 study was conducted to explore factors influencing treatment choice and to understand patients' and physicians' attitudes and perspectives on the use of controller inhalers in regular versus flexible dosing for asthma management. METHODS: This cross-sectional survey of patients with asthma and treating physicians was conducted in seven countries: Indonesia, Malaysia, Philippines, Thailand, Vietnam (patient survey only), Saudi Arabia, and the United Arab Emirates. Assessment was carried out through an online/face-to-face questionnaire, where patients' viewpoints were focused on their attitudes and beliefs about asthma and treatment adherence, whereas physicians' viewpoints were gathered on their attitudes and beliefs about asthma management, knowledge of and adherence to asthma treatment guidelines, and asthma treatment regimens. RESULTS: Overall, 1400 patients (mean age, 34 years) and 599 physicians (mean age, 43 years) were included in the survey. Physicians similarly prioritised symptom control (39%) and exacerbation reduction (40%) in moderate asthma, whereas patients prioritised symptom control (41%) over exacerbation reduction (22%). Although both groups (physicians, 86%; patients, 84%) perceived asthma as well-controlled, poor management was evident based on Asthma Control Test (ACT) scores (mean, 15.7; standard deviation, 4.14; 82% had an ACT score < 20) and high symptom burden (39% reported nighttime awakenings or early mornings ≥ 2 nights/week). Most patients (76%) with moderate asthma were prescribed regular dosing, with the most common treatment being inhaled corticosteroid (ICS)/long-acting ß2-agonist (LABA) with as-needed inhaled short-acting ß2-agonist (SABA; 20%). Among patients on maintenance and reliever therapy, 93% of patients received a separate inhaled reliever. CONCLUSIONS: Despite high symptom burden, patients overestimated their level of asthma control. Physicians prioritised controlling symptoms and reducing exacerbations as treatment goals for moderate asthma, often prescribing regular dosing with ICS/LABA with as-needed inhaled SABA.


Managing asthma depends a lot on what doctors and patients think about the illness and its long-term treatment. This study looked into what influences treatment decisions and what patients and doctors think about using inhalers regularly or on an as-needed basis to manage asthma across seven countries (Indonesia, Malaysia, Philippines, Thailand, Vietnam [patient survey only], Saudi Arabia, and the United Arab Emirates). In this study, patients with asthma and doctors managing asthma completed an online/face-to-face questionnaire. The study aimed to understand what patients think about asthma and their treatment plan. Meanwhile, the doctors were asked what they think about managing asthma and how much they apply clinical guidelines for treating patients with asthma. Doctors believed it is equally important to control symptoms and prevent worsening of symptoms in patients with moderate asthma, while patients cared more about controlling symptoms than preventing worsening of symptoms. While doctors and patients both regarded asthma as well-controlled, many patients had low Asthma Control Test scores and experienced a lot of symptoms, suggesting that they are poor perceivers of asthma control. Most patients with moderate asthma were given regular treatment, usually with inhaled corticosteroid combined with long-acting ß2-agonist along with as-needed short-acting ß2-agonist as a reliever. Most patients who were prescribed the same inhaler for regular use and as a reliever also had a separate inhaler for quick relief of symptoms. This study shows the need for patients and doctors to have better conversations about asthma, its treatments, and what to expect from them.


Assuntos
Antiasmáticos , Asma , Humanos , Asma/tratamento farmacológico , Asma/terapia , Masculino , Adulto , Feminino , Estudos Transversais , Antiasmáticos/uso terapêutico , Antiasmáticos/administração & dosagem , Pessoa de Meia-Idade , Malásia , Emirados Árabes Unidos , Vietnã , Arábia Saudita , Indonésia , Atitude do Pessoal de Saúde , Tailândia , Filipinas , Conhecimentos, Atitudes e Prática em Saúde , Inquéritos e Questionários , Administração por Inalação , Nebulizadores e Vaporizadores , Adesão à Medicação/estatística & dados numéricos , Adulto Jovem , Efeitos Psicossociais da Doença , Médicos/psicologia
7.
Int J Pharm ; 660: 124370, 2024 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-38906498

RESUMO

Limited attempts have been made previously to develop high-loading CBD inhalable powders, which are essential for high dose delivery. Therefore, this study aimed to develop and characterise inhalable powders with ≥ 95 % w/w CBD by wet ball milling. The effects of magnesium stearate (2 % and 5 %) and inhaler resistance (low-resistance and high-resistance RS01 inhalers) on aerosol performance were also compared. Wet ball milling produced CBD powders with > 50 % production yield. The milled particles showed irregular shapes. The powders were crystalline with minimal amorphous content, low residual solvent level (<1%), and low moisture sorption (<4%). Magnesium stearate improved both the emitted and fine particle fractions. The aerodynamic particle size distribution of the formulations differed between the low-resistance and high-resistance RS01 inhalers. The latter decreased throat deposition but increased inhaler retention. The dissolution profiles showed that all three formulations released CBD steadily and plateaued at 30 min. The best scenario was CBD with 5 % magnesium stearate dispersed from the high resistance RS01 inhaler, showing the highest FPF with the lowest throat deposition. This combination may be tested in vivo in the future to investigate its pharmacokinetic profile.


Assuntos
Canabidiol , Tamanho da Partícula , Pós , Ácidos Esteáricos , Administração por Inalação , Ácidos Esteáricos/química , Canabidiol/administração & dosagem , Canabidiol/química , Canabidiol/farmacocinética , Aerossóis , Inaladores de Pó Seco , Excipientes/química , Química Farmacêutica/métodos , Liberação Controlada de Fármacos , Nebulizadores e Vaporizadores , Composição de Medicamentos/métodos , Solubilidade
8.
Int J Chron Obstruct Pulmon Dis ; 19: 1225-1232, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38835808

RESUMO

Purpose: The use of inhaled bronchodilators is the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Although the soft mist inhaler (SMI) was developed to overcome the disadvantages of pressurized metered dose and drug powder inhalers, misuse during handling has been frequently observed in many studies. However, few studies have focused on SMI misuse among patients with COPD. Thus, we aimed to assess and identify the risk factors associated with SMI misuse among patients with COPD. Patient and Methods: In this prospective, observational, cross-sectional study, we enrolled patients with COPD who were undergoing SMI treatment between January 2018 and March 2020. An advanced nurse practitioner assessed the participants' handling of the device by using a check list. Results: Among 159 participants, 136 (85.5%) reported inhaler misuse. Duration of COPD and COPD assessment test (CAT) scores were positively associated with inhaler misuse; adherence and education level were negatively associated with inhaler misuse. In the multivariable analysis, a low educational level (less than high school), high CAT score (≥ 10), and short duration of COPD (≤ 2 years) were identified as risk factors for SMI misuse. Conclusion: SMI misuse remains common among patients with COPD. Therefore, clinicians should pay close attention to their patients using SMIs, especially in the early period after the diagnosis of COPD.


Assuntos
Broncodilatadores , Nebulizadores e Vaporizadores , Doença Pulmonar Obstrutiva Crônica , Humanos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Masculino , Feminino , Estudos Transversais , Fatores de Risco , Idoso , Estudos Prospectivos , Pessoa de Meia-Idade , Broncodilatadores/administração & dosagem , Broncodilatadores/efeitos adversos , Administração por Inalação , Adesão à Medicação , Desenho de Equipamento , Medição de Risco , Escolaridade , Pulmão/fisiopatologia , Pulmão/efeitos dos fármacos
9.
Can Fam Physician ; 70(6): 381-387, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38886092

RESUMO

OBJECTIVE: To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers. SOURCES OF INFORMATION: This review is based on the authors' experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed. MAIN MESSAGE: There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients' control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible. CONCLUSION: Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.


Assuntos
Asma , Nebulizadores e Vaporizadores , Doença Pulmonar Obstrutiva Crônica , Humanos , Asma/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Canadá , Médicos de Família , Padrões de Prática Médica/estatística & dados numéricos , Mudança Climática , Medicina de Família e Comunidade
10.
Int J Chron Obstruct Pulmon Dis ; 19: 1357-1373, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38912054

RESUMO

Purpose: Current guidelines recommend triple therapy maintenance inhalers for patients with recurrent exacerbations of chronic obstructive pulmonary disease (COPD); however, these maintenance therapies are underutilized. This study aimed to understand how physicians make COPD treatment decisions, and how combination maintenance therapies are utilized in a real-world setting. Patients and Methods: This exploratory, hypothesis-generating, non-interventional study used a cross-sectional online survey that was administered to a sample of practicing physicians in the United States. The survey included five fictitious vignettes detailing common symptoms experienced by patients with COPD. Survey questions included factors physicians consider in their decisions, and perceived barriers to prescribing treatments. Repeated measures multivariable analyses were conducted to evaluate how likely physicians were to switch to triple therapy versus no change to patient's current maintenance therapy or change to another maintenance therapy. Results: In total, 200 physicians completed the survey. Cost of treatment and patient access to treatment were reported as the most common barriers physicians consider in their prescribing decisions. Physicians were more likely to switch a patient's maintenance inhaler to triple therapy versus no change to maintenance inhaler if they considered the patient's history of new symptoms, insurance status, and clinical guidelines in their decision. Physicians with more experience treating patients with COPD, and those who treat more patients with COPD per week, were more likely to switch to triple therapy versus no change to maintenance inhaler. Conclusion: This study demonstrates the complexity of factors that can influence physicians' decisions when prescribing treatments for patients with COPD, including considerations of treatment cost, patient access and adherence, patient comorbidities, efficacy of current treatment, clinical guidelines, and provider's level of experience treating COPD. Further research may help elucidate the relative importance of the factors influencing physicians' decisions and inform what types of decision-support tools would be most beneficial.


Chronic obstructive pulmonary disease (COPD) symptoms can be effectively managed with maintenance therapies, which are treatments that are taken routinely to help improve symptoms. A combination of three different therapies (triple therapy maintenance) has been shown to be more effective than a combination of two different therapies (dual therapy maintenance) in patients with moderate-to-severe COPD. However, maintenance therapies, including triple therapy, are underutilized. This study aimed to explore how physicians make their treatment decisions for patients with COPD, and how combination maintenance therapies are utilized. To do so, we administered a survey to a sample of practicing physicians in the United States. The survey included five clinically based, fictitious profiles, or vignettes, of patients with COPD, with common symptoms and patient characteristics being described. Physicians were then asked to answer questions about what treatment they would prescribe for each patient, and any factors they considered when deciding on a treatment for a patient. We found that cost of treatment and patient access to treatment were the most common barriers that physicians considered when choosing a treatment. Physicians were also more likely to switch a patient's maintenance inhaler to a triple therapy maintenance inhaler if they considered the patient's history of new symptoms, patient's insurance status, and clinical guidelines when making their decisions. Our study shows that there are many complex factors that influence physicians' decisions when deciding on a treatment for patients with COPD.


Assuntos
Broncodilatadores , Tomada de Decisão Clínica , Pesquisas sobre Atenção à Saúde , Padrões de Prática Médica , Doença Pulmonar Obstrutiva Crônica , Humanos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Estudos Transversais , Masculino , Feminino , Pessoa de Meia-Idade , Estados Unidos , Broncodilatadores/administração & dosagem , Administração por Inalação , Nebulizadores e Vaporizadores , Quimioterapia Combinada , Atitude do Pessoal de Saúde , Resultado do Tratamento , Conhecimentos, Atitudes e Prática em Saúde , Custos de Medicamentos , Pulmão/fisiopatologia , Pulmão/efeitos dos fármacos , Idoso , Guias de Prática Clínica como Assunto , Adulto , Acessibilidade aos Serviços de Saúde
11.
Respir Care ; 69(7): 790-798, 2024 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-38744474

RESUMO

BACKGROUND: During invasive ventilation, external flow jet nebulization results in increases in displayed exhaled tidal volumes (VT). We hypothesized that the magnitude of the increase is inaccurate. An ASL 5000 simulator measured ventilatory parameters over a wide range of adult settings: actual VT, peak inspiratory pressure (PIP), and time to minimum pressure. METHODS: Ventilators with internal and external flow sensors were tested by using a variety of volume and pressure control modes (the target VT was 420 mL). Patient conditions (normal, COPD, ARDS) defined on the ASL 5000 were assessed at baseline and with 3.5 or 8 L/min of added external flow. Patient-triggering was assessed by reducing muscle effort to the level that resulted in backup ventilation and by changing ventilator sensitivity to the point of auto-triggering. RESULTS: Results are reported as percentage change from baseline after addition of 3.5 or 8 L/min external flow. For ventilators with internal flow sensors, changes in displayed exhaled VT ranged from 10% to 118%, however, when using volume control, actual increases in actual VT and PIP were only 4%-21% (P = .063, .031) and 6%-24% (P = .25, .031), respectively. Changes in actual VT correlated closely with changes in PIP (P < .001; R2 = 0.68). For pressure control, actual VT decreased by 3%-5% (P = .031) and 4%-9% (P = .031) with 3.5 and 8 L/min respectively, PIP was unchanged. With external flow sensors at the distal Y-piece junction, volume and pressure changes were statistically insignificant. The time to minimum pressure increased at most by 8% (P = .02) across all modes and ventilators. The effects on muscle pressure were minimal (∼1 cm H2O), and ventilator sensitivity effects were nearly undetectable. CONCLUSIONS: External flow jet nebulization resulted in much smaller changes in volume than indicated by the ventilator display. Statistically significant effects were confined primarily to machines with internal flow sensors. Differences approached the manufacturer-reported variation in ventilator baseline performance. During nebulizer therapy, effects on VT can be estimated at the bedside by monitoring PIP.


Assuntos
Nebulizadores e Vaporizadores , Volume de Ventilação Pulmonar , Ventiladores Mecânicos , Humanos , Desenho de Equipamento , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/fisiopatologia , Pressões Respiratórias Máximas , Ventilação em Jatos de Alta Frequência/instrumentação , Ventilação em Jatos de Alta Frequência/métodos , Adulto
13.
J Aerosol Med Pulm Drug Deliv ; 37(3): 157-165, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38768422

RESUMO

Standard nebulizers are intended for general purpose use and typically are continuously operated jet or ultrasonic nebulizers. Evolutionary developments such as breath-enhanced and breath-triggered devices have improved delivery efficiency and ease of use, yet are still suitable for delivery of nebulized medications approved in this category. However, recent developments of vibrating membrane or mesh nebulizers have given rise to a significant increase in delivery efficiency requiring reformulation of former drug products or development of new formulations to match the enhanced delivery characteristics of these new devices. In addition, the electronic nature of the new devices enables tailoring to specific applications and patient groups, such as guiding or facilitating optimal breathing and improving adherence to the therapeutic regimen. Addressing these patient needs leads to new nebulization technologies being embedded in devices with fundamentally distinct functionality, modes of operation and patient interfaces. Therefore, new generation nebulizers can no longer be regarded as one category with fairly similar performance characteristics but must be clinically tested and approved as drug/device combinations together with the specific drug formulation, similar to the approval of pressurized metered-dose inhalers and dry powder inhalers. From a regulatory viewpoint, it is required that drug and device are associated with each other as combinations by clear, mutually conforming labels or, even more desirably, by distinct container-closure systems (closed system nebulizer).


Assuntos
Sistemas de Liberação de Medicamentos , Desenho de Equipamento , Nebulizadores e Vaporizadores , Humanos , Administração por Inalação , Aerossóis , Preparações Farmacêuticas/administração & dosagem
14.
Postgrad Med ; 136(4): 438-445, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38804969

RESUMO

OBJECTIVES: Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup. METHODS: In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED. RESULTS: NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001). CONCLUSION: With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.


Assuntos
Crupe , Dexametasona , Serviço Hospitalar de Emergência , Epinefrina , Melhoria de Qualidade , Humanos , Crupe/tratamento farmacológico , Crupe/diagnóstico , Crupe/terapia , Dexametasona/administração & dosagem , Dexametasona/uso terapêutico , Epinefrina/administração & dosagem , Epinefrina/uso terapêutico , Feminino , Masculino , Lactente , Pré-Escolar , Antibacterianos/uso terapêutico , Antibacterianos/administração & dosagem , Criança , Tempo de Internação/estatística & dados numéricos , Broncodilatadores/uso terapêutico , Broncodilatadores/administração & dosagem , Nebulizadores e Vaporizadores
15.
Respir Investig ; 62(4): 685-694, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38796907

RESUMO

BACKGROUND: Real-world data assessing characteristics of patients with asthma initiating inhaled corticosteroid/long-acting muscarinic antagonist/long-acting ß2-agonist (ICS/LAMA/LABA) triple therapy in Japan are limited. METHODS: Descriptive, observational study of patients with asthma aged ≥15 years newly initiating single- or multiple-inhaler triple therapy (SITT: fluticasone furoate/umeclidinium/vilanterol [FF/UMEC/VI], SITT: indacaterol/glycopyrronium bromide/mometasone furoate [IND/GLY/MF] or MITT) or ICS/LABA using JMDC/Medical Data Vision (MDV) health insurance databases from February 2021-February 2022 (first prescription date: index date). Patients were assigned to three non-mutually exclusive cohorts: A) new FF/UMEC/VI initiators; B) new FF/UMEC/VI, IND/GLY/MF, or MITT initiators; C) new FF/UMEC/VI, IND/GLY/MF, MITT or ICS/LABA initiators as initial maintenance therapy (IMT). Patient characteristics were assessed descriptively for 12-months pre-treatment initiation (baseline period). RESULTS: Cohort A: among new FF/UMEC/VI initiators, 12.8% and 0.1% (JMDC) and 21.7% and 0.9% (MDV) of patients had ≥1 moderate and severe exacerbation; 52.0% (JMDC) and 79.2% (MDV) had ICS/LABA use. Cohort B: most patients initiated FF/UMEC/VI and IND/GLY/MF over MITT (JMDC: 91.3% vs 8.7%; MDV: 67.8% vs 32.2%), with fewer exacerbations and lower rescue medication use. Cohort C: a greater proportion of FF/UMEC/VI initiators as IMT experienced a moderate exacerbation at index versus ICS/LABA initiators as IMT (JMDC: 17.8% vs 10.7%; MDV: 8.0% vs 5.1%). CONCLUSIONS: Patient characteristics were generally similar between treatment groups; SITT initiators had fewer exacerbations and lower rescue medication use than MITT initiators, represented by the greater proportion of IMT among SITT versus MITT initiators. Physicians may have prescribed triple over dual therapy as IMT in response to an exacerbation.


Assuntos
Androstadienos , Asma , Álcoois Benzílicos , Clorobenzenos , Quinuclidinas , Humanos , Álcoois Benzílicos/administração & dosagem , Clorobenzenos/administração & dosagem , Asma/tratamento farmacológico , Masculino , Feminino , Pessoa de Meia-Idade , Quinuclidinas/administração & dosagem , Japão , Adulto , Administração por Inalação , Androstadienos/administração & dosagem , Idoso , Combinação de Medicamentos , Antagonistas Muscarínicos/administração & dosagem , Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Nebulizadores e Vaporizadores , Adolescente , Adulto Jovem , Quimioterapia Combinada , Glicopirrolato/administração & dosagem , Quinolonas/administração & dosagem
16.
BMJ Paediatr Open ; 8(1)2024 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-38782483

RESUMO

OBJECTIVES: To review the efficacy of nebulised magnesium sulfate (MgSO4) in acute asthma in children. METHODS: The authors searched Medline, Embase, Web of Science and Cochrane Library for randomised controlled trials (RCTs) published until 15 December 2023. RCTs were included if they compared the efficacy and safety of nebulised MgSO4 as a second-line agent in children presenting with acute asthma exacerbation. A random-effects meta-analysis was performed, and the Risk of Bias V.2 tool was used to assess the biases among them. RESULTS: 10 RCTs enrolling 2301 children with acute asthma were included. All trials were placebo controlled and administered nebulised MgSO4/placebo and salbutamol (±ipratropium bromide). There was no significant difference in Composite Asthma Severity Score between the two groups (6 RCTs, 1953 participants; standardised mean difference: -0.09; 95% CI: -0.2 to +0.02, I2=21%). Children in the MgSO4 group have significantly better peak expiratory flow rate (% predicted) than the control group (2 RCTs, 145 participants; mean difference: 19.3; 95% CI: 8.9 to 29.8; I2=0%). There was no difference in the need for hospitalisation, intensive care unit admission or duration of hospital stay. Adverse events were minor, infrequent (7.3%) and similar among the two groups. CONCLUSIONS: There is low-certainty evidence that nebulised MgSO4 as an add-on second-line therapy for acute asthma in children does not reduce asthma severity or a need for hospitalisation. However, it was associated with slightly better lung functions. The current evidence does not support the routine use of nebulised MgSO4 in paediatric acute asthma management. PROSPERO REGISTRATION NUMBER: CRD42022373692.


Assuntos
Asma , Sulfato de Magnésio , Nebulizadores e Vaporizadores , Humanos , Sulfato de Magnésio/administração & dosagem , Sulfato de Magnésio/uso terapêutico , Sulfato de Magnésio/efeitos adversos , Asma/tratamento farmacológico , Criança , Doença Aguda , Administração por Inalação , Broncodilatadores/administração & dosagem , Broncodilatadores/uso terapêutico , Broncodilatadores/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Antiasmáticos/administração & dosagem , Antiasmáticos/uso terapêutico , Antiasmáticos/efeitos adversos
17.
Public Health Nurs ; 41(4): 704-708, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38745505

RESUMO

OBJECTIVE: Our goal is to examine gaps in self-carry, asthma emergency protocol, and stock inhaler policy knowledge in Illinois schools. DESIGN: A 30-item REDCap cross-sectional survey developed by a team of stakeholders was disseminated. Questions assessed policy knowledge, awareness, and practices regarding asthma emergency protocols, self-carry, and stock inhalers. SAMPLE: Participants were Illinois school nurses belonging to a governmental organization listserv. MEASUREMENTS: Analysis utilized Chi-square tests, descriptive statistics, and t-tests. RESULTS: Nurses reported 36% of students on average self-carried asthma medication. Thirty percent of nurses were not aware of their emergency asthma policy and only 60% reported having an emergency asthma protocol in their school(s). Fifty-four percent of nurses were aware of stock inhaler programming. Of the 10.3% who reported a stock inhaler program, a lower frequency reported calling 911 for asthma emergencies. Perceived school asthma prevalence varied from 0%-87%. CONCLUSIONS: Our survey demonstrates large variation in knowledge and implementation of school-based asthma health policy. This is likely due to variations in health policy education dissemination. Future efforts should focus on the dissemination and implementation of school-based asthma health policies to improve their more universal adoption and better support school-based asthma management.


Assuntos
Asma , Política de Saúde , Serviços de Enfermagem Escolar , Humanos , Asma/tratamento farmacológico , Asma/enfermagem , Illinois/epidemiologia , Estudos Transversais , Inquéritos e Questionários , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Masculino , Criança , Adulto , Serviços de Saúde Escolar/organização & administração , Nebulizadores e Vaporizadores
18.
Expert Rev Respir Med ; 18(3-4): 159-174, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38795074

RESUMO

INTRODUCTION: Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising digital technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs. AREAS COVERED: While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine. EXPERT OPINION: Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.


Assuntos
Aplicativos Móveis , Telemedicina , Humanos , Pneumologia , Asma/terapia , Asma/diagnóstico , Nebulizadores e Vaporizadores
19.
Hu Li Za Zhi ; 71(3): 43-51, 2024 Jun.
Artigo em Chinês | MEDLINE | ID: mdl-38817136

RESUMO

BACKGROUND: Poor disease control in patients with chronic obstructive pulmonary disease (COPD) is associated with suboptimal inhaler use. PURPOSE: This study was designed to explore the accuracy of inhaler use and related factors in elderly patients with COPD. METHODS: A cross-sectional survey design was used to recruit patients with COPD from a medical centre in southern Taiwan who were over 65 years old and used inhalers regularly. All of the data as well as information on inhaler use accuracy were collected using a self-designed questionnaire and inhaler operation checklist. Multivariable logistic regression was used to analyse significant correlates of correct inhaler operation. RESULTS: The average age of the 150 participants was 75.0 years (SD = 7.5) years. Most used one type of inhaler only (86.0%). The rate of accurate inhaler operation was 40.7% (n = 61) for the sample, with dry powder inhalers associated with the highest accuracy (64%) and pressurized metered-dose inhalers associated with the lowest accuracy (1.6%). Multivariate logistic regression analysis showed that using a soft mist inhaler (adjusted odds ratio, AOR = 23.29; 95% confidence interval, 95% CI [2.84, 191.07]), using a dry powder inhaler (AOR =15.60, 95% CI [1.99, 122.26]), and higher satisfaction with the inhaler were positively and independently associated with accurate inhaler use (AOR = 1.94, 95% CI [1.09, 3.44]). CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Important factors related to inhaler use accuracy include inhaler type and level of patient satisfaction with their inhaler. Healthcare professionals should regularly confirm that older patients are able to use their inhalers correctly and are satisfied with their inhalers.


Assuntos
Nebulizadores e Vaporizadores , Doença Pulmonar Obstrutiva Crônica , Humanos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Idoso , Masculino , Feminino , Estudos Transversais , Idoso de 80 Anos ou mais
20.
BMJ Open Respir Res ; 11(1)2024 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-38777583

RESUMO

INTRODUCTION: Asthma attacks are a leading cause of morbidity and mortality but are preventable in most if detected and treated promptly. However, the changes that occur physiologically and behaviourally in the days and weeks preceding an attack are not always recognised, highlighting a potential role for technology. The aim of this study 'DIGIPREDICT' is to identify early digital markers of asthma attacks using sensors embedded in smart devices including watches and inhalers, and leverage health and environmental datasets and artificial intelligence, to develop a risk prediction model to provide an early, personalised warning of asthma attacks. METHODS AND ANALYSIS: A prospective sample of 300 people, 12 years or older, with a history of a moderate or severe asthma attack in the last 12 months will be recruited in New Zealand. Each participant will be given a smart watch (to assess physiological measures such as heart and respiratory rate), peak flow meter, smart inhaler (to assess adherence and inhalation) and a cough monitoring application to use regularly over 6 months with fortnightly questionnaires on asthma control and well-being. Data on sociodemographics, asthma control, lung function, dietary intake, medical history and technology acceptance will be collected at baseline and at 6 months. Asthma attacks will be measured by self-report and confirmed with clinical records. The collected data, along with environmental data on weather and air quality, will be analysed using machine learning to develop a risk prediction model for asthma attacks. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the New Zealand Health and Disability Ethics Committee (2023 FULL 13541). Enrolment began in August 2023. Results will be presented at local, national and international meetings, including dissemination via community groups, and submission for publication to peer-reviewed journals. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12623000764639; Australian New Zealand Clinical Trials Registry.


Assuntos
Inteligência Artificial , Asma , Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Nebulizadores e Vaporizadores , Nova Zelândia , Estudos Observacionais como Assunto , Estudos Prospectivos
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