Nocturnal asthma uncontrolled by inhaled corticosteroids: theophylline or long-acting beta2 agonists?

Asthma is an inflammatory disease of the airways that is frequently characterised by marked circadian rhythm. Nocturnal and early morning symptoms are quite common among patients with asthma. Increased mortality and decreased quality of life are associated with nocturnal asthma. Although numerous mechanisms contribute to the pathophysiology of nocturnal asthma, increasing evidence suggests the most important mechanisms relate to airway inflammation. According to international guidelines, patients with persistent asthma should receive long term daily anti-inflammatory therapy. A therapeutic trial with anti-inflammatory therapy alone (without a long-acting bronchodilator) should be assessed to determine if this therapy will eliminate nocturnal and early morning symptoms. If environmental control and low to moderate doses of inhaled corticosteroids do not eliminate nocturnal symptoms, the addition of a long-acting bronchodilator is warranted. Long-acting inhaled beta2 agonists (e.g. salmeterol, formoterol) are effective in managing nocturnal asthma that is inadequately controlled by anti-inflammatory agents. In addition, sustained release theophylline and controlled release oral beta2 agonists are effective. In patients with nocturnal symptoms despite low to high doses of inhaled corticosteroids, the addition of salmeterol has been demonstrated to be superior to doubling the inhaled corticosteroid dose. In trials comparing salmeterol with theophylline, 3 studies revealed salmeterol was superior to theophylline (as measured by e.g. morning peak expiratory flow, percent decrease in awakenings, and need for rescue salbutamol), whereas 2 studies found the therapies of equal efficacy. Studies comparing salmeterol to oral long-acting beta2 agonists reveal salmeterol to be superior to terbutaline and equivalent in efficacy to other oral agents. Microarousals unrelated to asthma are consistently increased when theophylline is compared to salmeterol in laboratory sleep studies. In addition to efficacy data, clinicians must weigh benefits and risks in choosing therapy for nocturnal asthma. Long-acting inhaled beta2 agonists are generally well tolerated. If theophylline therapy is to be used safely, clinicians must be quite familiar with numerous factors that alter clearance of this drug, and they must be prepared to use appropriate doses and monitor serum concentrations. Comparative studies using validated, disease specific quality of life instruments (e.g. Asthma Quality of Life Questionnaire) have shown long-acting inhaled beta2 agonists are preferred to other long-acting bronchodilators. Examination of costs for these therapeutic options reveals that evening only doses of long-acting oral bronchodilators are less expensive than multiple inhaled doses. However, costs of monitoring serum concentrations, risks, quality of life and otheroutcome measures must also be considered. Long-acting inhaled beta2 agonists are the agents of choice for managing nocturnal asthma in patients who are symptomatic despite anti-inflammatory agents and other standard management (e.g. environmental control). These agents offer a high degree of efficacy along with a good margin of safety and improved quality of life.

Gender differences in metered-dose inhaler-spacer device technique.

STUDY OBJECTIVE: To determine whether gender affects the correct use of a metered-dose inhaler (MDI)-spacer device. DESIGN: Prospective, observational study. SETTING: University classrooms. PATIENTS: Eighty-three students in their third year of a Doctor of Pharmacy program. INTERVENTION: Students were given the device and received 20 minutes of education on its use. They then were asked to perform the technique. Assessment and retraining were done, as necessary, by clinicians who were experienced with the device. Students returned 1 week later to perform the technique again. MEASUREMENTS AND MAIN RESULTS: The performance of men versus women was analyzed with chi 2 tests and the Student's t test. Power analysis indicated that 30 students were needed in each group. CONCLUSION: There were no significant differences between men and women in proper MDI-spacer technique.

School absenteeism, parental work loss, and acceptance of childhood influenza vaccination.

BACKGROUND: Influenza causes school absenteeism and may cause parents to miss work to care for sick children. However, it is not known whether these factors influence parental acceptance of childhood vaccination. METHODS: A survey was mailed to parents of 1,805 children attending 3 elementary schools. It included questions about school absenteeism and employment status for adults who stayed home to care for an ill child. Parents were asked if they would consider vaccinating their child against a common wintertime respiratory virus. RESULTS: Of the 972 surveys returned (54% return rate), 954 could be analyzed. Only 13% of respondents stated that they would not consider vaccination for their child. Sixty-nine percent of children had been absent from school because of a nonasthma respiratory illness, with an average of 2.54 days missed per child. Among respondents whose child had missed any school, 33% would definitely consider vaccination compared with 24% of respondents whose child had not missed school (P < 0.01). As children missed more school days, vaccine acceptance increased. In 53% of families, an adult had to miss work to care for the ill child. Vaccine acceptance was higher if an adult caretaker had to lose time from work because of a child's illness (35% versus 25% for non-working caretakers, P < 0.01). CONCLUSION: Vaccine acceptance was closely linked with the amount of absenteeism caused by respiratory illness in the previous year. Parents who had to miss work to care for an ill child were more accepting of the vaccine than were other parents.

Effect of disease states on theophylline serum concentrations: are we still vigilant?

The use of theophylline has decreased over the past decade because of concerns over the risks of serious adverse effects as well as availability of more effective, safer drugs. Because of this decline in use, some clinicians may not be alert to the marked effect of some disease states on theophylline serum concentrations. The purpose of this review is to heighten awareness of the effect of decompensated heart failure, cor pulmonale, hepatic dysfunction, thyroid disease, and febrile illness on theophylline serum concentrations. Because many patients receive some benefit from this drug, safe use by clinicians requires closer monitoring of serum concentrations in patients with factors that alter theophylline clearance, including several disease states.

Analysis of mandibular motion following unilateral and bilateral alloplastic TMJ reconstruction.

The purpose of this study was to analyse the masticatory patterns and range of motion (maximal incisal opening (MIO), protrusion and lateral excursion) in patients who have had unilateral and bilateral temporomandibular joint (TMJ) replacement with an alloplastic prosthesis, and compare them to each other and to normal controls. Mandibular motion was examined in 18 patients, who had undergone alloplastic TMJ reconstruction, 13 with a bilateral prosthesis and 5 with a unilateral prosthesis, and in 13 normal controls. A statistically significant difference (P<0.01) for MIO and maximum lateral excursion was observed between the bilateral group and the control group. Maximum protrusion was only statistically significantly different (P<0.05) between the bilateral group and the control group. For the unilateral group, a statistically significant difference (P<0.01) was seen only with maximum contralateral excursion when compared with controls. No statistically significant difference existed in MIO and protrusion between the unilateral and bilateral groups. Even though maximum ipsilateral lateral excursion was greater for the unilateral group than either left or right maximum lateral excursion by the bilateral group, this difference was not statistically significant. This study provided an in vivo analysis of mandibular motion following alloplastic TMJ reconstruction.

Effect of a brief educational intervention on medical students' use of asthma devices.

Several studies have shown that a significant percentage of housestaff and attending physicians are deficient in both skill and knowledge of the metered-dose inhaler (MDI). There are no studies involving medical students, or any including the peak flow meter (PFM). The setting was a large health science center with investigators in private conference rooms with individual medical students. Twenty-two medical students in the last semester before graduation were scored in the use of these devices pre-education and post-education (instruction included both discussion and demonstration). Results revealed a lack of skill initially, followed by dramatic improvement after the intervention. The total number of correct steps for each device (MDI with spacer and PFM) improved significantly (p < 0.0001). This group of medical students was deficient in the use of common asthma devices. A short educational intervention was effective in improving skill.

Beta-blockers after myocardial infarction: do benefits ever outweigh risks in asthma?

beta-Blockers are well documented to prolong life in patients after myocardial infarction (MI), yet patients who also have asthma are frequently and understandably denied this therapy. We reviewed the literature (via MEDLINE) for the past 35 years for beta-blocker-induced asthma, and reexamined potential beta-blocker use in the context of NIH guidelines for asthma classification and management. Because beta-blockers can cause fatal or life-threatening asthma, their use should be avoided in moderate to severe persistent asthmatics. Benefits of low-dose beta(1)-blockers (e.g. atenolol 50 mg daily) may outweigh risks in some patients with mild intermittent or well-controlled mild persistent asthma. Further study is needed to verify that low doses of beta(1)-blockers are effective in prolonging life after MI, and that use specifically in mild intermittent or mild persistent asthma per NIH classification is safe.

Are there gender differences in the use of peak flow meters?

To determine if there are gender differences in correct use of peak flow meters (PEM), third-year doctor of pharmacy students (n = 83; 52 females, 31 males) were instructed in a classroom on correct use of a PFM, including demonstrations. Students were then immediately divided into five groups, given a PFM, and assessed for three attempts in private individual sessions. Males had superior performance on the first attempt for total score (p < 0.05) and for "inhale fully" (p < 0.05). On the second attempt, the total score was not different, but males scored higher on "exhale as fast and as hard as you can" (p < 0.05). Controlled gender studies examining use of PFM in adult and pediatric patients with asthma are warranted.