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Cortés Alvarez N, Martín Mateos MA, Plaza Martín AM, Giner Muñoz MT, Piquer M, Sierra Martínez JI. Risk factors of developing asthma in children with recurrent wheezing in the first three years of life. Allergol Immunopathol (Madr) 2007; 35:228-31. [PMID: 18047812 DOI: 10.1157/13112987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION recurrent wheezing is a common problem during the first years of life, but it is still difficult to identify which of these children may develop asthma in the future. OBJECTIVES To study risk factors of developing asthma in a group of patients with frequent wheezing during the first three years of life. MATERIAL AND METHODS A prospective study was performed of a group of 60 patients, aged below three, referred to our Hospital for recurrent wheezing. Age, sex, parental and personal history of atopy, clinical features, laboratory tests, evolution and response to treatment were analyzed. RESULTS 60 patients were enrolled in study. Most of children were boys and have had the first episode of wheezing after the 6 months of life. 63 % had personal history of atopy and 55 % parental history of allergy. The group of atopic children had more wheezing exacerbations and worse evolution than the group of non atopic. They also had more treatment necessities. CONCLUSIONS The identification of young children at high risk of developing asthma could permit an early intervention before irreversible changes in the airway appeared.
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Affiliation(s)
- N Cortés Alvarez
- Paediatric Allergy and Clinical Inmunology Section. Sant Joan de Déu Hospital-Clínic Hospital. University of Barcelona. Spain.
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Chen ZG, Ji JZ, Li M, Chen YF, Chen FH, Chen H. [Immunoregulants improves the prognosis of infants with wheezing]. Nan Fang Yi Ke Da Xue Xue Bao 2007; 27:1612-1613. [PMID: 17959549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To assess the value of immunoregulants in improving the prognosis of infants with wheezing. METHODS Forty-three infants with wheezing with given oxygen support, injection or inhalation of glucocorticosteroids or bronchodilatator to relieve the symptoms. Of these infants, 24 received immunoregulant treatment with bronchovaxom at the daily dose of 3.5 mg for 10 days every a month for a treatment course of 3 months. The other 19 infants were managed with budesonide aerosol at 200 microg once or twice daily for 3 months (basic treatment group). All the infants were followed up for 1 year to record the number of wheezing episode and infections. Ten healthy infants were also included in this study as the control group. RESULTS In infants with bronchovaxom treatment, 25% reported more than 3 wheezing episodes within the 1-year follow-up, a rate significantly lower than that in the control group (63.2%, Chi(2)=6.344, P<0.05). The episodes of respiratory infection were similar between bronchovaxom group and the healthy control group (t=0.72, P>0.05), but significantly higher in the basic treatment group than in bronchovaxom and the healthy control group (t=3.11 and 3.92, respectively. P<0.05). CONCLUSIONS Bronchovaxom can effectively reduce the recurrence of wheezing and respiratory infections in the infants with wheezing attack to reduce the risks of asthma development.
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Affiliation(s)
- Zhuang-Gui Chen
- Department of Pediatrics, Third Hospital Affiliated to Sun Yat-sen University, Guangzhou 510630, China
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104
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Abstract
Epidemiological studies have shown that exposure to air pollution is associated with respiratory symptoms and decreases in lung function. This paper reviews recent literature showing that exposure to particulate matter, irritant gases, environmental tobacco smoke (ETS), mixed pollutants, and molds is associated with an increase in cough and wheeze. Some pollutants, like particulate matter and mixed pollutants, appear to increase cough at least as much as wheeze. Others, like irritant gases, appear to increase wheeze more than cough. For ETS, exposure during childhood is associated with cough and wheeze in adulthood, suggesting that the pollutant permanently alters some important aspect of the lungs, immune system or nervous system. We have shown in animal studies that pollutants change the neural control of airways and cough. Second hand smoke (SHS) exposure lengthened stimulated apnoea, increased the number of stimulated coughs, and augmented the degree of stimulated bronchoconstriction. The mechanisms included enhanced reactivity of the peripheral sensory neurones and second-order neurones in the nucleus tractus solitarius (NTS). NTS effects were due to a substance P mechanism at least in part. Ozone and allergen increased the intrinsic excitability of second-order neurones in the NTS. The animal studies suggest that the cough and wheeze experienced by humans exposed to pollutants may involve plasticity in the nervous system.
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Affiliation(s)
- Jesse P Joad
- Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd., Sacramento, CA 95817, USA.
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105
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Lindner K, Panaszek B, Machaj Z. [Asthma in the elderly]. Pol Arch Med Wewn 2007; 117:350-354. [PMID: 18018382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
A population aged 65 and over has been increasing in the developed countries. The prevalence of asthma in elderly patients is estimated between 6.5 and 17%. Asthma is an important cause of morbidity and mortality in the elderly. Moreover, death due to asthma occurs mostly in elderly patients. Only a few studies have reported the characteristics of asthma in the elderly patients. Two distinct clinical presentations of asthma have been described in the elderly. There are differences both in the pathophysiology and the clinical manifestation of asthma between elderly patients with a long-standing disease and those with late-onset disease. Additionally, aging of the respiratory system influences the asthma presentation. Asthma has been presented for many years may lead to persistent obstructive ventilatory defect and can mimic chronic obstructive pulmonary disease. Irreversible obstruction is commonly observed in elderly patients with asthma. The differential diagnosis of asthma is difficult in older adults and asthma is underrecognized and undertreated in the older population. Undertreatment is common in elderly asthmatics which largely is related to diagnostic issues.
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Affiliation(s)
- Karolina Lindner
- Katedra i Klinika Chorób Wewnetrznych i Alergologii, Akademia Medyczna im Piastów Slaskich, Wrocław.
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Corneli HM, Zorc JJ, Mahajan P, Majahan P, Shaw KN, Holubkov R, Reeves SD, Ruddy RM, Malik B, Nelson KA, Bregstein JS, Brown KM, Denenberg MN, Lillis KA, Cimpello LB, Tsung JW, Borgialli DA, Baskin MN, Teshome G, Goldstein MA, Monroe D, Dean JM, Kuppermann N. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007; 357:331-9. [PMID: 17652648 DOI: 10.1056/nejmoa071255] [Citation(s) in RCA: 221] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. METHODS We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. RESULTS Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes. CONCLUSIONS In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002 [ClinicalTrials.gov].).
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109
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Simoes EAF, Groothuis JR, Carbonell-Estrany X, Rieger CHL, Mitchell I, Fredrick LM, Kimpen JLL. Palivizumab prophylaxis, respiratory syncytial virus, and subsequent recurrent wheezing. J Pediatr 2007; 151:34-42, 42.e1. [PMID: 17586188 DOI: 10.1016/j.jpeds.2007.02.032] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 12/28/2006] [Accepted: 02/08/2007] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Children who experience respiratory syncytial virus (RSV) lower respiratory tract infections (LRTIs) early in life have high rates of subsequent recurrent wheezing. Palivizumab, an anti-RSV monoclonal antibody, has 78% to 80% efficacy in preventing RSV hospitalization in premature infants without chronic lung disease. We hypothesized that palivizumab, by ameliorating or preventing early RSV LRTI in preterm infants, might decrease later recurrent wheezing. STUDY DESIGN A cohort of preterm infants who had received palivizumab and were not hospitalized for RSV (n = 191) or who never received palivizumab (n = 230; 76 who were hospitalized for RSV and 154 who were not), were prospectively followed for 24 months beginning at a mean age of 19 months. The subjects were assessed for recurrent wheezing by caretaker or physician report. RESULTS The incidences of recurrent wheezing and physician-diagnosed recurrent wheezing were significantly lower in the 191 palivizumab-treated subjects (13% and 8%, respectively) compared with all 230 untreated subjects (26%, P = .001 and 16%, P = .011, respectively) and with the 154 patients in the subgroup not hospitalized for RSV LRTI (23%, P = .022 and 16%, P = .027, respectively). The effect of palivizumab treatment remained significant after adjustment for potential confounding variables. CONCLUSIONS Our study suggests that preventing RSV LRTI with palivizumab may reduce subsequent recurrent wheezing in premature infants.
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Affiliation(s)
- Eric A F Simoes
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine and The Children's Hospital, Denver, CO 80218, USA.
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Prakash PS, Prabhakar H, Rath GP. Postoperative stridor after resection of cerebellopontine angle epidermoid. J Neurosurg Anesthesiol 2007; 19:204-5. [PMID: 17592356 DOI: 10.1097/ana.0b013e318059bf1f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Erzinger S, Schueepp KG, Brooks-Wildhaber J, Devadason SG, Wildhaber JH. Facemasks and aerosol delivery in vivo. ACTA ACUST UNITED AC 2007; 20 Suppl 1:S78-83; discussion S83-4. [PMID: 17411409 DOI: 10.1089/jam.2007.0572] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
It has been shown in vitro that even a small air leak in the facemask can drastically reduce the efficiency of drug delivery. In addition, it has been shown that drug deposition on the face does significantly add to overall drug loss and has the potential of local side effects. The aim of this study is therefore to verify these findings in vivo. Eight asymptomatic recurrently wheezy children, aged 18-36 months, inhaled a radiolabeled salbutamol formulation either from a pressurized metered-dose inhaler through a spacer with attached facemask or from a nebulizer with attached facemask. Drug deposition of radiolabeled salbutamol was assessed with a gamma camera and expressed as a percentage of the total dose. Lung deposition expressed as a percentage of the total dose (metered dose and nebulizer fill, respectively) was 0.2% and 0.3% in children who inhaled with a non-tightly fitted facemask. Lung deposition was 0.6% and 1.4% in screaming children with a tightly fitted facemask and between 4.8% and 8.2% in patients breathing normally. Overall mask deposition was between 0.8% and 5.2%. Overall face deposition was between 2.6% and 8.4%. The results from this pilot study support the results found in in vitro studies, where a facemask leak greatly reduces drug delivery to the patient.
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Affiliation(s)
- Simone Erzinger
- Division of Respiratory Medicine, University Children's Hospital Zürich , Switzerland
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Smith ME, Park AH, Muntz HR, Gray SD. Airway Augmentation and Maintenance Through Laryngeal Chemodenervation in Children With Impaired Vocal Fold Mobility. ACTA ACUST UNITED AC 2007; 133:610-2. [PMID: 17576914 DOI: 10.1001/archotol.133.6.610] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Marshall E Smith
- Division of Otolaryngology/Head and Neck Surgery, 3C-120 SOM, University of Utah School of Medicine, 50 N Medical Dr, Salt Lake City, UT 84132, USA.
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Abstract
PURPOSE OF REVIEW To review the recently published studies addressing various treatment approaches for episodic wheezing in young children. RECENT FINDINGS A landmark study demonstrated that short courses of oral corticosteroids initiated at the first sign of an upper respiratory tract infection decreased wheezing episode frequency and severity. Since then, alternative treatment strategies have been investigated. Montelukast decreased short-term daytime cough and delayed exacerbations following hospitalization for respiratory syncytial virus bronchiolitis, and led to fewer exacerbations without decreasing oral corticosteroids use among children with intermittent asthma. Preschool children with frequent wheezing at high risk for asthma receiving daily inhaled corticosteroids experienced lower rates of exacerbations requiring oral corticosteroids. Episodic use of inhaled corticosteroids, initiated at the early signs of an upper respiratory infection, led to modest reduction in symptoms, but not oral corticosteroid use. Among young children with 'preasthma', inhaled corticosteroids initiated after 3 days of wheezing did not affect the frequency or severity of wheezing episodes. SUMMARY Evidence for the preferred treatment strategies for intermittent wheezing in young children remains incomplete. Most of the studies represent heterogeneous populations and lack adequate statistical power to evaluate relevant outcomes. Based on the evidence, there is rationale for further investigation of several management strategies, including corticosteroids and/or leukotriene receptor antagonists administered daily or episodically.
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Affiliation(s)
- Caroline C Horner
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri 63110, USA
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114
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Abstract
Accumulating evidence indicates that there are at least two phenotypes of wheezing in preschool years with distinct natural history. Frequent wheezing in the first 3 years of life with risk factors for asthma (e.g., eczema, maternal asthma) predicts symptoms in older age, while infrequent viral-associated wheezing without risk factors for asthma has a benign prognosis. This systematic review summarizes evidence on the use of anti-inflammatory medications in preschool children with wheezing. Literature search was performed using Medline and the Cochrane Library. Retrieved articles were critically appraised. Episodic use of high-dose inhaled corticosteroids (>1,600 mcg/day of beclomethasone) may ameliorate severity of intermittent viral-associated wheezing. Maintenance inhaled corticosteroids can control symptoms in children with frequent wheezing associated with risk factors for asthma. Inhaled corticosteroids do not alter the natural history of wheezing even when started early in life and could have a negative impact on linear growth rate. Short courses of oral corticosteroids have been proposed as an effective measure to control exacerbations of symptoms although there is little evidence supporting their use. Some studies support the administration of non-steroidal anti-inflammatory medications (leukotriene pathway modifiers, cromones, methylxanthines) for mild frequent wheezing. Maintenance inhaled corticosteroids is the most effective measure for controlling frequent wheezing in preschool children, especially when accompanied by risk factors for asthma. This treatment does not affect the natural history of wheezing, although deceleration of linear growth rate is the most commonly recognized systemic adverse effect.
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Affiliation(s)
- Athanasios G Kaditis
- Department of Pediatrics, University of Thessaly School of Medicine, Larissa, Greece.
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Bacharier LB, Phillips BR, Bloomberg GR, Zeiger RS, Paul IM, Krawiec M, Guilbert T, Chinchilli VM, Strunk RC. Severe intermittent wheezing in preschool children: a distinct phenotype. J Allergy Clin Immunol 2007; 119:604-10. [PMID: 17336610 DOI: 10.1016/j.jaci.2006.12.607] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 12/02/2006] [Accepted: 12/04/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Young children with wheezing predominantly with respiratory tract illnesses experience severe exacerbations separated by extended periods of wellness and may be described as having "severe intermittent wheezing," a diagnostic category not currently recognized in national guidelines. OBJECTIVE We sought to characterize a cohort of children with recurrent severe wheezing. METHODS A total of 238 children 12 to 59 months enrolled in the Acute Intervention Management Strategies trial were characterized through comprehensive allergy, asthma, environmental, and quality of life assessments. RESULTS Asthma symptoms over the period of the preceding year occurred at frequencies consistent with intermittent asthma, as 94.5% of children experienced activity limitation < or = 2 times per month. However, frequent severe exacerbations were common, because 71% experienced > or = 4 wheezing episodes over the period of the preceding year, 95% made at least 1 primary care visit, 52% missed school or daycare, 40% made an emergency department visit, and 8% were hospitalized for wheezing illnesses. Atopic features were common, including eczema (37%), aeroallergen sensitization (46.8%), and positive asthma predictive index (59.7%). Oral corticosteroid use in the previous year (59.7% of the cohort) identified a subgroup with more severe disease documented by a higher incidence of urgent care visits (P = .0048), hospitalizations (P = .0061), aeroallergen sensitization (P = .047), and positive asthma predictive indices (P = .007). CONCLUSION Among preschool children enrolled in the Acute Intervention Management Strategies trial, a subgroup was identified with severe intermittent wheezing characterized by atopic features and substantial illness-related symptom burden despite prolonged periods of wellness. CLINICAL IMPLICATIONS Preschool children with recurrent severe wheezing episodes experience significant illness-related morbidity and exhibit features of atopic predisposition.
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Affiliation(s)
- Leonard B Bacharier
- Department of Pediatrics, Washington University, St Louis Children's Hospital, St. Louis, MOO 63110, USA.
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Korppi M. Are responses to treatment virus-specific in wheezing children? J Allergy Clin Immunol 2007; 119:1561-2. [PMID: 17412400 DOI: 10.1016/j.jaci.2007.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 02/09/2007] [Indexed: 11/25/2022]
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Abstract
A 6-year-old female in good health presented with no known drug allergies for dental treatment under general anesthesia. Following the preoperative evaluation, the patient received intramuscular premedication consisting of midazolam (1 mg) and Ketamine (60 mg) into the left deltoid muscle. During patient transfer, anesthesia personnel detected a hive developing in proximity to the patient's right ear lobe. The subject was directly placed into the operative chair, and a physical exam revealed urticaria on the neck, back, and torso. In addition, an audible wheeze was detected with lung auscultation. Investigations carried out after the incident revealed a positive reaction to ketamine
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Affiliation(s)
- Sean G Boynes
- University of Pittsburgh School of Dental Medicine, Department of Anesthesiology, PA 15216, USA.
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118
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Balli F, Bergamini B, Calistru P, Ciofu EP, Domenici R, Doros G, Dragomir D, Gherghina I, Iordachescu F, Murgoci G, Orasanu D, Plesca D, Vaccaro A, Assereto R. Clinical effects of erdosteine in the treatment of acute respiratory tract diseases in children. Int J Clin Pharmacol Ther 2007; 45:16-22. [PMID: 17256446 DOI: 10.5414/cpp45016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Erdosteine has positive effects on mucus rheology and transport due to the active metabolite (Metabolite I) which contains a free thiol group. Erdosteine inhibits bacterial adhesiveness and has antioxidant properties. A synergistic effect of erdosteine with various antibiotics has been demonstrated in pharmacological and clinical studies. The present study was multicenter, randomized, double-blind and placebo-controlled. The aims of the study were to compare a combination of erdosteine with amoxicillin against an amoxicillin-placebo combination in pediatric patients with acute lower respiratory tract disease. A total of 158 patients (78 in the erdosteine group and 80 in the placebo group) were treated for 7 +/- 2 days. The efficacy parameters were cough (primary), polypnea, rhonchi, rales and body temperature (all measured at baseline, on Day 3 and at the end of treatment). Safety was assessed by strictly monitoring the occurrence of adverse events and using standard laboratory parameters. The results of the intention-to-treat analysis showed that the severity of cough was decreased by 47% at Day 3 in the erdosteine group with a statistically significant difference compared to placebo, the difference was still significant at the final visit. The decrease in the severity of rales was significantly greater at Day 3 in the erdosteine group than in the placebo group. The incidence of polypnea and rhonchi in the two groups showed similar decreases, an improvement mainly due to the antibiotic. No adverse events occurred and no adverse changes in laboratory parameters were observed. It is concluded that the combination of erdosteine and amoxicillin is a safe medication which is clinically superior to that of the antibiotic combined with placebo, especially in regard to the effects on cough.
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Affiliation(s)
- F Balli
- Department of Gynecology, Obstetrics and Pediatry, University of Modena, Italy
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Gulcu N, Karaaslan K, Suslu AE, Kocoglu H. The treatment of postoperative inspiratory stridor with intraoral epinephrine. Paediatr Anaesth 2007; 17:297. [PMID: 17263751 DOI: 10.1111/j.1460-9592.2006.02081.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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121
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Blom D, Ermers M, Bont L, van Aalderen WMC, van Woensel JBM. Inhaled corticosteroids during acute bronchiolitis in the prevention of post-bronchiolitic wheezing. Cochrane Database Syst Rev 2007:CD004881. [PMID: 17253528 DOI: 10.1002/14651858.cd004881.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute bronchiolitis in infants and young children is associated with long-term airway disease also known as post-bronchiolitic wheezing. Two major hypotheses have been proposed to explain the association between bronchiolitis and PBW. The first hypothesis considers bronchiolitis to be the first manifestation of recurrent wheezing in infants and children who are susceptible to obstructive airway disease. The second hypothesis suggests that the infection and concomitant inflammatory reaction in the acute phase leads to airway epithelium injury resulting in long-term obstructive airway disease. In line with the latter hypothesis, corticosteroids may have a beneficial effect on the prevention of post-bronchiolitic wheezing. OBJECTIVES The objective of this review was to evaluate the effect of inhaled corticosteroids, started during the acute phase of bronchiolitis, on the prevention of post-bronchiolitic wheezing. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2006) which contains the Cochrane Acute Respiratory Infections Group's trials register, MEDLINE (1966 to September 2006), EMBASE (1980 to September 2006) and Current Contents (September 2006). Abstracts and reports of congresses (ERS 1999 to September 2005, ATS 1999 to September 2005) were obtained. We contacted experts in the field and pharmaceutical companies for ongoing or unpublished studies. SELECTION CRITERIA Randomised placebo-controlled trials studying the effect of inhaled corticosteroids in children younger than two years of age with the clinical diagnosis of acute bronchiolitis were included. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed trial quality using the Jadad 5-point scale. MAIN RESULTS Five studies matched the inclusion criteria, with a median Jadad score of 4 (Inter Quartile Range 3 to 4), involving 374 infants. Pooling of the data was limited, due to the clinical diversity of the studies. However, no effect of inhaled corticosteroids in the prevention of wheezing (diary records or GP diagnosed), hospital re-admissions or use of corticosteroids or bronchodilators could be demonstrated. Duration of therapy, length of follow up or causative agent (respiratory syncytial virus or not) did not influence the pooled effect. In the three studies that also evaluated the adverse events, none were reported. AUTHORS' CONCLUSIONS This review does not demonstrate an effect of inhaled corticosteroids given during the acute phase of bronchiolitis in the prevention of post-bronchiolitic wheezing. The small number of included participants and the inability to pool all clinical outcomes precludes us from making strong recommendations.
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Affiliation(s)
- D Blom
- Emma Children's Hospital, Pediatrics, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.
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Wang CL, Tsai YH, Huang CC, Wu YK, Ye MZ, Chou HM, Shu SC, Lin MC. The role of the cuff leak test in predicting the effects of corticosteroid treatment on postextubation stridor. Chang Gung Med J 2007; 30:53-61. [PMID: 17477030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND There is not enough evidence to determine the most appropriate treatment of postextubation stridor. Although the cuff leak test is a simple method to predict postextubation stridor, little is known about its use in monitoring the effects of steroid treatment for this complication. The aim of this study was to evaluate the effect of steroids on postextubation stridor based on the clinical response and the cuff leak test. METHODS A cohort of 110 translaryngeal intubated patients in the medical intensive care unit (ICU) were enrolled. A cuff leak test was conducted before extubation. Patients developing postextubation stridor were intravenously given 5 mgs of dexamethasone every 8 hours for 3 days. The clinical response and cuff leak volume before and after steroid treatment were gathered for analysis. RESULTS The incidence of postextubation stridor was 18.2% (20/110). Fifty-five percent of patients (11/20) with stridor needed reintubation. Overall, 80% of patients (16/20) with postextubation stridor improved with steroid treatment. The leak volume significantly increased after treatment (152.4 +/- 109.6 ml vs. 29.9 +/- 35.7 ml, p = 0.012); stridor did not recur in 64% of reintubated patients (7/11). A threshold leak volume of less than 88 ml predicted the occurrence of stridor (positive predictive value, 54.5%; negative predictive value, 90.9%). Postextubation stridor was associated with the female gender and lower leak volumes (p = 0.007 and 0.003, respectively). CONCLUSION Corticosteroids improve postextubation stridor. The cuff leak test accurately predicts the absence of stridor and is a non-invasive method of monitoring for regression of laryngeal edema after steroid treatment. Steroid treatment should be considered for patients developing postextubation stridor.
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Affiliation(s)
- Chih-Liang Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Niaosung Shiang, Kaohsiung, Taiwan, R.O.C
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Lehtinen P, Ruohola A, Vanto T, Vuorinen T, Ruuskanen O, Jartti T. Prednisolone reduces recurrent wheezing after a first wheezing episode associated with rhinovirus infection or eczema. J Allergy Clin Immunol 2006; 119:570-5. [PMID: 17196244 PMCID: PMC7173342 DOI: 10.1016/j.jaci.2006.11.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 11/06/2006] [Accepted: 11/09/2006] [Indexed: 11/16/2022]
Abstract
Background Rhinovirus-induced early wheezing has been suggested as a new important risk factor for recurrent wheezing. Objective We sought to investigate the risk factors for recurrent wheezing and to determine post hoc the efficacy of prednisolone in risk groups. Methods We followed for 1 year 118 children (median age, 1.1 years) who had had their first episode of wheezing and had participated in a trial comparing prednisolone with placebo in hospitalized children. Demographics and laboratory data were obtained at study entry. The follow-up outcome was recurrent wheezing (3 physician-confirmed episodes). Results Recurrent wheezing was diagnosed in 44 (37%) children. Independent risk factors were age < 1 year, atopy, and maternal asthma. The probability of recurrent wheezing was higher in rhinovirus than respiratory syncytial virus (RSV)–affected children among placebo recipients (hazard ratio, 5.05; 95% CI, 1.00-25.41). Prednisolone decreased the probability of recurrent wheezing in children with eczema (0.15; 95% CI, 0.04-0.63) but not in those without eczema (1.89; 95% CI, 0.83-4.29; P = .007 for interaction). Prednisolone was associated with less recurrent wheezing in the rhinovirus group (0.19; 95% CI, 0.05-0.71), but not in the RSV (2.12; 95% CI, 0.46-9.76) or in the RSV/rhinovirus-negative groups (2.03; 95% CI, 0.83-5.00; P = .017 for interaction). Conclusion Rhinovirus-induced early wheezing is a major viral risk factor for recurrent wheezing. Prednisolone may prevent recurrent wheezing in rhinovirus-affected first-time wheezers. The presence of eczema may also influence the response to prednisolone. Clinical implications A prospective trial is needed to test the hypothesis that prednisolone reduces recurrent wheezing in rhinovirus-affected wheezing children.
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Affiliation(s)
- Pasi Lehtinen
- From the Department of Pediatrics, Turku University Hospital
| | - Aino Ruohola
- From the Department of Pediatrics, Turku University Hospital
| | - Timo Vanto
- From the Department of Pediatrics, Turku University Hospital
| | | | - Olli Ruuskanen
- From the Department of Pediatrics, Turku University Hospital
| | - Tuomas Jartti
- From the Department of Pediatrics, Turku University Hospital
- Reprint requests: Tuomas Jartti, MD, Sirkkalankatu 4 C 59, FIN-20520 Turku, Finland.
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Lehmann S, Bakke PS, Eide GE, Gulsvik A. Bronchodilator response to adrenergic beta2-agonists: relationship to symptoms in an adult community. Respir Med 2006; 101:1183-90. [PMID: 17188486 DOI: 10.1016/j.rmed.2006.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Revised: 11/09/2006] [Accepted: 11/09/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Wheeze and chest tightness has traditionally been associated with enhanced bronchial responsiveness. However, no community studies are available on the associations between bronchodilator response and respiratory symptoms among adults. AIM To examine how respiratory symptoms predict bronchodilator response. METHODS An age and gender stratified random sample of all adults aged 47-48 and 71-73 years in Bergen, Norway, were invited. The 3506 participants (69%) filled in questionnaires including nine symptoms and performed bronchodilator reversibility tests. Subjects without current anti-asthmatic medication performing acceptable reversibility tests were included in the analyses (n=3088). RESULTS A reversibility with FEV(1) increase 12% and 200 ml was obtained in 2% of middle-aged and 4% of elderly subjects (p=0.001). In multiple linear regression analysis bronchodilatation was positively associated with wheezing without cold (FEV(1) increase of 1.5%, 95% CI: (0.9, 2.2)% in all participants and 31 ml, 95% CI: (1, 61)ml in men only) and dyspnoea climbing two flights of stairs (0.9%, 95% CI: (0.5,1.4)% and 12 ml, 95% CI: (1,23)ml). Chronic cough predicted the response negatively (-0.7%, 95% CI: (-1.3,-0.1)% and -17 ml, 95% CI: (-32,-2)ml). In multiple logistic regression analysis morning cough predicted an FEV(1) increase 12% and 200 ml (OR: 1.8, 95% CI: (1.1,2.8)). CONCLUSIONS A small fraction of adults in a general population has bronchodilatation after salbutamol inhalation. "Wheezing without cold", "dyspnoea climbing two flights of stairs", and "morning cough" predict an increased bronchodilator response among subjects without current anti-asthmatic medications.
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Affiliation(s)
- Sverre Lehmann
- Section for Thoracic Medicine, Institute of Medicine, University of Bergen, 5021 Bergen, Norway.
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Fonseca-Aten M, Okada PJ, Bowlware KL, Chavez-Bueno S, Mejias A, Rios AM, Katz K, Olsen K, Ng S, Jafri HS, McCracken GH, Ramilo O, Hardy RD. Effect of clarithromycin on cytokines and chemokines in children with an acute exacerbation of recurrent wheezing: a double-blind, randomized, placebo-controlled trial. Ann Allergy Asthma Immunol 2006; 97:457-63. [PMID: 17069099 DOI: 10.1016/s1081-1206(10)60935-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clarithromycin is postulated to possess immunomodulatory properties in addition to its antimicrobial activity. OBJECTIVE To evaluate the effect of clarithromycin on serum and nasopharyngeal cytokine and chemokine concentrations in children with an acute exacerbation of recurrent wheezing. METHODS Children with a history of recurrent wheezing or asthma and who presented with an acute exacerbation of wheezing were enrolled in a double-blind, randomized trial of clarithromycin vs placebo. Concentrations of tumor necrosis factor alpha (TNF-alpha), interferon-gamma (IFN-gamma), interleukin-1beta (IL-1beta), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating factor, RANTES, eotaxin, macrophage inflammatory protein 1alpha, macrophage inflammatory protein 1beta, and monocyte chemoattractant protein 1 were measured in serum and/or nasopharyngeal aspirates before, during, and after therapy. Mycoplasma pneumoniae and Chlamydophila pneumoniae infection were evaluated for by polymerase chain reaction and serologic testing. RESULTS Nasopharyngeal concentrations of TNF-alpha, IL-1beta, and IL-10 were significantly and persistently lower in children treated with clarithromycin compared with placebo. There tended to be a greater effect of clarithromycin on nasopharyngeal cytokine concentrations in patients with evidence of M. pneumoniae or C. pneumoniae infection. No significant differences were detected in serum cytokines for children treated with clarithromycin compared with placebo. CONCLUSION Clarithromycin therapy reduces mucosal TNF-alpha, IL-1beta, and IL-10 concentrations in children with an acute exacerbation of recurrent wheezing.
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Affiliation(s)
- Monica Fonseca-Aten
- Departments of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9063, USA
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Baraldi E, Filippone M. Inhaled corticosteroids and children. N Engl J Med 2006; 355:625; author reply 625-6. [PMID: 16903019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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127
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128
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Bont L, Kimpen JLL, Ermers MJJ. Inhaled corticosteroids and children. N Engl J Med 2006; 355:624-5; author reply 625-6. [PMID: 16906644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Abstract
Congress and the FDA have strongly suggested that tranquilizers and antipsychotics not be used in agitated demented frail elderly patients. The medical profession has not moved away from the tradition of antipsychotic sedation of such patients. Use of 'modern second generation low dose' antipsychotics continue to be the standard of care. Propranolol, a non-selective beta-blocker with good penetration of the CNS, is a reasonable and safe alternative to sedatives and antipsychotics. Anti-dementia drugs are complementary to propranolol. A case study which contrasts the two pharmacologic approaches is detailed. A method of estimating delirium-agitation risk in dementia patients (DRN method) is described.
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Affiliation(s)
- William K Summers
- Alzheimer's Corporation, 6000 Uptown Blvd, Suite 308, Albuquerque, NM 87110-4148, USA.
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131
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Pisarik P. Reversibility of forced expiratory volume in 1 second (FEV1) by albuterol. Fam Med 2006; 38:463-4. [PMID: 16823665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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132
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Peng QY, Chen AH. [Advances in studies on leukotrienes and their role in infantile wheezing diseases]. Zhonghua Er Ke Za Zhi 2006; 44:553-6. [PMID: 17044989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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133
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Salam MT, Wenten M, Gilliland FD. Endogenous and exogenous sex steroid hormones and asthma and wheeze in young women. J Allergy Clin Immunol 2006; 117:1001-7. [PMID: 16675325 DOI: 10.1016/j.jaci.2006.02.004] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Revised: 01/30/2006] [Accepted: 02/01/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emerging evidence suggests that both endogenous and exogenous sex steroid hormones may influence the occurrence of asthma and wheeze among women. OBJECTIVE We investigated the associations between exogenous sex hormone (oral contraceptive [OC]) use and wheezing in young women with and without asthma history. To investigate the role of endogenous sex hormones, we examined the association between age at menarche and the development of asthma after puberty. METHODS We conducted a study among 905 women who had undergone menarche. Subjects were between 13 and 28 years of age and had participated in the Children's Health Study. RESULTS In women without asthma, OC use was associated with higher risk of current wheeze (odds ratio [OR], 1.75; 95% CI, 1.15-2.65). In contrast, OC use was associated with a markedly reduced prevalence of current wheeze in women with a history of asthma (OR, 0.18; 95% CI, 0.06-0.56; P value for interaction = .003). These associations showed significant trends with duration of OC use. Age at menarche was associated with new-onset asthma after puberty. Compared with women who had menarche after age 12 years, women with menarche before age 12 years had a 2.08-fold (95% CI, 1.05-4.12) higher risk of asthma after puberty. CONCLUSION Both endogenous and exogenous sex steroid hormones affect asthma and wheeze occurrences in young women. CLINICAL IMPLICATIONS Because women have higher asthma risk after puberty, and OC use is common among young women, clinicians may inform women with asthma about the potential effects of OC on asthma-related respiratory symptoms.
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Affiliation(s)
- Muhammad T Salam
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles 90033, USA
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Jartti T, Lehtinen P, Vanto T, Hartiala J, Vuorinen T, Mäkelä MJ, Ruuskanen O. Evaluation of the efficacy of prednisolone in early wheezing induced by rhinovirus or respiratory syncytial virus. Pediatr Infect Dis J 2006; 25:482-8. [PMID: 16732144 DOI: 10.1097/01.inf.0000215226.69696.0c] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of systemic corticosteroids in the treatment of early childhood wheezing in children is not clear. OBJECTIVE We sought to determine whether prednisolone is effective in rhinovirus-induced early wheezing. METHODS We conducted a controlled trial comparing oral prednisolone (2 mg/kg per day in three divided doses for 3 days) with placebo in 78 hospitalized children (mean age, 1.1 year; standard deviation, 0.7) experiencing their first or second episode of wheezing induced by rhinovirus or respiratory syncytial virus. Mixed viral infections were excluded. Our primary end point was the time until the patient was ready for discharge; secondary end points included oxygen saturation during hospitalization, duration of symptoms, occurrence of relapses during the next 2 months and blood eosinophil counts at discharge and 2 weeks later. RESULTS In multivariate regression analysis, prednisolone did not influence the time until ready for discharge, but it decreased relapses during the subsequent 2-month period in rhinovirus-affected children (prednisolone versus placebo, 22% versus 56%; odds ratio, 19.06; 95% confidence interval, 2.52-144.03; P = 0.004) and in children with blood eosinophils > or = 0.2 x 10/L (respectively, 24% versus 71%; odds ratio, 10.57; 95% confidence interval, 1.99-56.22; P = 0.006). Rhinovirus-affected children had more blood eosinophils on admission (mean, 0.44 versus 0.086 x 10/L), had a higher prevalence of atopy (44% versus 8%) and were older (mean, 1.4 versus 0.9 years, P < 0.001 for all) than respiratory syncytial virus-infected children. CONCLUSION Prednisolone reduced relapses during a 2-month period after first episodes of wheezing associated with rhinovirus infection or blood eosinophils > or = 0.2 x 10/L.
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Affiliation(s)
- Tuomas Jartti
- Department of Pediatrics, Turku University Hospital, Turku, Finland.
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135
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Carlsen KCL, Stick S, Kamin W, Cirule I, Hughes S, Wixon C. The efficacy and safety of fluticasone propionate in very young children with persistent asthma symptoms. Respir Med 2006; 99:1393-402. [PMID: 15916891 DOI: 10.1016/j.rmed.2005.04.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2005] [Indexed: 11/28/2022]
Abstract
We aimed to evaluate the efficacy and safety of fluticasone propionate (FP) in children aged 12-47 months with recurrent/persistent asthma symptoms. One hundred and sixty children (12-47 months) were randomised into this multicentre, double-blind, placebo-controlled, parallel-group study, and treated with either FP (100 microg bd) or placebo (2 puffs bd), both administered by metered-dose-inhaler and Babyhaler for 12 weeks. The primary endpoint was percentage of symptom-free 24h periods. Over weeks 1-12, FP-treated patients had significantly more percentage symptom-free 24-h periods compared with placebo (odds ratio 0.53; 95% CI 0.29-0.95; P = 0.035). Relative to baseline, where all patients were symptomatic for at least 21/28 days of the run-in, the improvement equated to one additional symptom-free 24 h period per week. FP patients also had a significantly higher percentage of 24 h periods with no wheeze or cough, the odds ratio for treatment difference corresponding to two additional wheeze-free and one additional cough-free periods per week. FP was well-tolerated, with similar reported adverse events in both groups. Urinary cortisol-creatinine ratio was slightly decreased among FP patients after 12 weeks, but with no clinical correlates. FP is effective for the treatment of chronic persistent asthma symptoms in very young children.
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Affiliation(s)
- Karin C Lødrup Carlsen
- Department of Paediatrics, Woman-Child Division, Ullevål University Hospital, Oslo, Norway.
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136
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Abstract
Although chronic obstructive pulmonary disease (COPD) patients frequently report symptoms, it is not known which factors determine the course of symptoms over time and if these differ according to the sex of the patient. The current study investigated predictors for presence, development and remission of COPD symptoms in 816 males and 312 females completing 3-yr-follow-up in the European Respiratory Society Study on Chronic Obstructive Pulmonary Disease (EUROSCOP). The following were included in generalised estimating equations logistic regression analyses: explanatory variables of treatment; pack-yrs smoking; age, forced expiratory volume in one second % predicted (FEV1 % pred); annual increase in FEV1 and number of cigarettes smoked; body mass index; and phadiatop. Interaction terms of sex multiplied by explanatory variables were tested. Over 3 yrs, similar proportions of males and females reported symptoms. In males only, higher FEV1 % pred was associated with reduction in new symptoms of wheeze and dyspnoea, and symptom prevalence was reduced with annual FEV1 improvement and phlegm prevalence reduced with budesonide treatment (odds ratio 0.66; 95% confidence interval 0.52-0.83). Additionally an increase in the number of cigarettes smoked between visits increased the risk of developing phlegm (1.40 (1.14-1.70)) and wheeze (1.24 (1.03-1.51)) in males but not females. The current study shows longitudinally that symptom reporting is similar by sex. The clinical course of chronic obstructive pulmonary disease can differ by sex, as males show greater response to cigarette exposure and treatment.
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Affiliation(s)
- L Watson
- Dept of Epidemiology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9731 GZ Groningen, The Netherlands
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137
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Abstract
BACKGROUND We hypothesized that asthma is preceded by a stage of recurrent episodes of wheezing during the first years of life and that inhaled corticosteroid therapy during symptomatic episodes in this early phase may delay progression to persistent wheezing. METHODS We assigned one-month-old infants to treatment with two-week courses of inhaled budesonide (400 mug per day) or placebo, initiated after a three-day episode of wheezing, in this single-center, randomized, double-blind, prospective study of three years' duration. The primary outcome was the number of symptom-free days; key secondary outcomes were the time to discontinuation due to persistent wheezing and safety, as evaluated by height and bone mineral density at the end of the study. RESULTS We enrolled 411 infants and randomly assigned 294 to receive budesonide at a first episode of wheezing. The proportion of symptom-free days was 83 percent in the budesonide group and 82 percent in the placebo group (absolute difference, 1 percent; 95 percent confidence interval, -4.8 to 6.9 percent). Twenty-four percent of children in the budesonide group had persistent wheezing, as compared with 21 percent in the placebo group (hazard ratio, 1.22; 95 percent confidence interval, 0.71 to 2.13)--a finding that was unaffected by the presence or absence of atopic dermatitis. The mean duration of the acute episodes was 10 days in both groups and was independent of respiratory viral status. Height and bone mineral density were not affected by treatment. CONCLUSIONS Intermittent inhaled corticosteroid therapy had no effect on the progression from episodic to persistent wheezing and no short-term benefit during episodes of wheezing in the first three years of life. (ClinicalTrials.gov number, NCT00234390.).
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Affiliation(s)
- Hans Bisgaard
- Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Copenhagen
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138
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139
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Guilbert TW, Morgan WJ, Zeiger RS, Mauger DT, Boehmer SJ, Szefler SJ, Bacharier LB, Lemanske RF, Strunk RC, Allen DB, Bloomberg GR, Heldt G, Krawiec M, Larsen G, Liu AH, Chinchilli VM, Sorkness CA, Taussig LM, Martinez FD. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med 2006; 354:1985-97. [PMID: 16687711 DOI: 10.1056/nejmoa051378] [Citation(s) in RCA: 765] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unknown whether inhaled corticosteroids can modify the subsequent development of asthma in preschool children at high risk for asthma. METHODS We randomly assigned 285 participants two or three years of age with a positive asthma predictive index to treatment with fluticasone propionate (at a dose of 88 mug twice daily) or masked placebo for two years, followed by a one-year period without study medication. The primary outcome was the proportion of episode-free days during the observation year. RESULTS During the observation year, no significant differences were seen between the two groups in the proportion of episode-free days, the number of exacerbations, or lung function. During the treatment period, as compared with placebo use, use of the inhaled corticosteroid was associated with a greater proportion of episode-free days (P=0.006) and a lower rate of exacerbations (P<0.001) and of supplementary use of controller medication (P<0.001). In the inhaled-corticosteroid group, as compared with the placebo group, the mean increase in height was 1.1 cm less at 24 months (P<0.001), but by the end of the trial, the height increase was 0.7 cm less (P=0.008). During treatment, the inhaled corticosteroid reduced symptoms and exacerbations but slowed growth, albeit temporarily and not progressively. CONCLUSIONS In preschool children at high risk for asthma, two years of inhaled-corticosteroid therapy did not change the development of asthma symptoms or lung function during a third, treatment-free year. These findings do not provide support for a subsequent disease-modifying effect of inhaled corticosteroids after the treatment is discontinued. (ClinicalTrials.gov number, NCT00272441.).
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Affiliation(s)
- Theresa W Guilbert
- Division of Pediatric Pulmonary Medicine, Arizona Respiratory Center, University of Arizona, Tucson, AZ 85724, USA.
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140
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Hyvärinen MK, Kotaniemi-Syrjänen A, Reijonen TM, Korhonen K, Kiviniemi V, Korppi M. Responses to inhaled bronchodilators in infancy are not linked with asthma in later childhood. Pediatr Pulmonol 2006; 41:420-7. [PMID: 16547959 DOI: 10.1002/ppul.20360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Many doctors consider wheezing infants and young children who respond to beta-adrenergic agents to be asthmatics, or at least at risk for later asthma. The aim of this study was to compare responses to inhaled albuterol and racemic epinephrine in infancy between children with and without asthma later in childhood. In a crossover study setting, 100 acutely wheezing infants aged less than 24 months were randomized to receive inhalations of either racemic epinephrine and placebo, or albuterol and placebo. Clinical evaluation consisted of measurements of respiratory rate, heart rate, and oxygen saturation, and clinical assessment of the respiratory distress assessment instrument (RDAI) score, consisting of wheezing and chest indrawings. The asthma status of the children was evaluated at three clinical follow-up visits, at 4.0, 7.2, and 12.3 (median) years of age. Responses to bronchodilating agents, when respiratory rates and RDAI scores were used as outcome measures, were not different in future asthmatics compared to nonasthmatics. However, oxygen saturation was significantly higher after albuterol inhalation in children who had asthma at all three visits (92.67% confidence interval (CI), 91.39-93.96) than in those without asthma at these visits (92.52% CI, 91.79-93.25), but lower, correspondingly, after racemic epinephrine (91.97% CI, 90.74-93.19 vs. 93.04% CI, 92.29-93.79) and placebo (91.38% CI, 90.49-92.28 vs. 93.12% CI, 92.60-93.65) inhalations (P = 0.04). In conclusion, we were not able to confirm that future asthmatics respond better than future nonasthmatics to bronchodilating agents during wheezing in infancy. More studies are needed to characterize the subset of infants who benefit from bronchodilating treatment in infancy.
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Affiliation(s)
- Mari K Hyvärinen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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141
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Kompanje EJO. 'Death rattle' after withdrawal of mechanical ventilation: practical and ethical considerations. Intensive Crit Care Nurs 2006; 22:214-9. [PMID: 16551501 DOI: 10.1016/j.iccn.2005.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 05/23/2005] [Accepted: 06/13/2005] [Indexed: 11/20/2022]
Abstract
The noise produced by oscillatory movements of secretions in oropharynx, hypopharynx and trachea during inspiration and expiration in unconscious terminal patients is often described as 'the death rattle'. The reported incidence of death rattle in terminally ill patients varied between six and 92%. It is most commonly reported in patients dying from pulmonary malignancies, primary brain tumours or brain metastases, and predicts death within 48 hours in 75% of the patients. Clinical studies demonstrate that hyoscine hydrobromide is effective at improving symptoms. After withdrawal of artificial ventilation on the intensive care unit, excessive respiratory secretions resulting in rattling breathing, during the last hours of life, is not uncommon. Physicians and nurses experience considerable difficulties and frustrations in treating the death rattle. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient. This article provides practical and ethical considerations in the management of this near-death symptom. The fact that relatives were relieved in almost all cases, in which a positive effect was obtained, makes treatment in anticipation of death rattle an ethical demand. In practice, injectable scopolamine is the reference drug for symptomatic treatment of death rattle.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care and Department of Medical Ethics, Erasmus MC University Medical Center, Room V-208, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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Lee SKW, Wong CK, Sung RYT, Leung TF, Fung KP, Leung PC, Lam CWK. In vitro anti-allergic activities of a newly concocted traditional Chinese medicine--the wheeze-relief formula. J Ethnopharmacol 2006; 103:406-12. [PMID: 16169693 DOI: 10.1016/j.jep.2005.08.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 08/09/2005] [Accepted: 08/16/2005] [Indexed: 05/04/2023]
Abstract
Asthma is one of the most common chronic diseases worldwide. Western medications such as glucocorticoids are effective therapeutic agents but may be associated with side effects. Traditional Chinese medicine (TCM) has been used for treating allergic diseases with observable clinical benefits. The present study investigated whether a novel TCM concoction, the wheeze-relief formula (WRF), possesses in vitro anti-allergic activities. We measured the effects of WRF on the release of eosinophil cationic protein (ECP) by human eosinophils using fluorescence enzyme immunoassay, expression of chemokine receptor CCR3 and adhesion molecule CD49d on eosinophils using immunophenotyping, cytokine induction from peripheral blood mononuclear cells (PBMC) using cytometric bead array (CBA), and the gene expression of cytokines and cytokine receptors using cDNA expression array. Results demonstrated that WRF dose-dependently and significantly: (1) suppressed ECP release from eosinophils activated with granulocyte macrophage-colony stimulating factor (GM-CSF) and platelet activating factor (PAF); (2) inhibited the expression of CCR3 and CD49d on PAF-activated eosinophils; and (3) attenuated the production of tumor necrosis factor alpha and gene expression of IL-2 receptor chain alpha (CD25) on house dust mite (Der p 1) activated PBMC. The above results suggest a possible anti-allergic role of WRF and provide a biochemical basis for further clinical trial on human subjects.
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Affiliation(s)
- S K W Lee
- Department of Chemical Pathology, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Jones TM, Ho MS, Earis JE, Swift AC, Charters P. Acoustic parameters of snoring sound to compare natural snores with snores during 'steady-state' propofol sedation. Clin Otolaryngol 2006; 31:46-52. [PMID: 16441802 DOI: 10.1111/j.1749-4486.2006.01136.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the acoustic similarity between natural and sedation-induced snores. DESIGN Prospective observational study. SETTING University Hospital Aintree, Liverpool, UK. PARTICIPANTS Twenty-one patients, who had already had overnight snore recordings, completed a pre-operative sleep nasendoscopic examination. Endoscopic examination of the upper aero-digestive tract was performed at sequentially increasing, steady-state sedation levels, using intravenous propofol administered according to a weight/time-based algorithm to predict blood and effect site (tissue) concentrations. At each sedation level at which snoring occurred, snoring sound was recorded. From these samples, snore files, comprising the inspiratory sound of each snore were created. Similarly, from natural snores recorded pre-operatively, snore files, comprising the inspiratory sounds of the first 100 snores with the patient sleeping in a supine position, were also created. MAIN OUTCOME MEASURES Snore duration (s), loudness (dBA), periodicity (%) and energy ratios for the frequency sub-bands 0-200, 0-250 and 0-400 Hz. RESULTS Snore loudness increased significantly (P < 0.0001), whilst energy ratios for frequency bands 0-200, 0-250 and 0-400 Hz all decreased significantly as sedation level increased (P < 0.001). A significant difference between natural snoring and snoring induced at the lowest sedation level was shown (P < 0.0001). Endoscopic examination was not tolerated at this sedation level. CONCLUSIONS The acoustic characteristics of sedation-induced and natural snores are sufficiently different to recommend the need for further research to determine whether the technique of sleep nasendoscopy is, in fact, a valid predictor of outcome of snoring surgery.
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Affiliation(s)
- T M Jones
- Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK.
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Sunyer J, Torrent M, Muñoz-Ortiz L, Ribas-Fitó N, Carrizo D, Grimalt J, Antó JM, Cullinan P. Prenatal dichlorodiphenyldichloroethylene (DDE) and asthma in children. Environ Health Perspect 2005; 113:1787-90. [PMID: 16330365 PMCID: PMC1314922 DOI: 10.1289/ehp.8127] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Prevalence of asthma increases with increasing dichlorodiphenyldichloroethylene (DDE) levels. However, the effect of early-life exposure, the fundamental window of exposure, is unknown. We assessed the association between prenatal DDE and other organochlorine compounds, and atopy and asthma during infancy. All women presenting for antenatal care in Menorca (Spain) over 12 months starting in mid-1997 were invited to take part in a longitudinal study; 482 children were subsequently enrolled, and 468 (97.1%) provided complete outcome data up to the fourth year of study. Prenatal exposure of organochlorine compounds was measured in cord serum in 405 (83%) children. Asthma was defined on the basis of wheezing at 4 years of age, persistent wheezing, or doctor-diagnosed asthma. We measured specific immunoglobulin-E (IgE) against house dust mite, cat, and grass in sera extracted at 4 years of age. DDE (median = 1.03 ng/mL) was detected in all children, as well as hexachlorobenzene (0.68 ng/mL) and polychlorobiphenyls (0.69 ng/mL). Wheezing at 4 years of age increased with DDE concentration, particularly at the highest quartile [9% in the lowest quartile (< 0.57 ng/mL) vs. 19% in the highest quartile (1.90 ng/mL); relative risk = 2.63 (95% confidence interval 1.19-4.69), adjusting for maternal asthma, breast-feeding, education, social class, or other organochlorines]. The association was not modified by IgE sensitization and occurred with the same strength among nonatopic subjects and among those with persistent wheezing or diagnosed asthma. DDE was not associated with atopy alone. Prenatal exposure to DDE residues may contribute to development of asthma.
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Affiliation(s)
- Jordi Sunyer
- Unitat Recerca Respiratòria i Ambiental, Institut Municipal d'Investigació Mèdica, Barcelona, Spain.
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Abstract
OBJECTIVE Lung sounds analysis has been used for clinical care. Our objectives were to characterize the spectral pattern of lung sounds and their relation to bronchodilator effects in acute bronchiolitis (AB). We hypothesized that patients with sinusoidal wheezes (SW) would show a more significant bronchodilator response. METHODOLOGY We studied 22 asleep hospitalized infants (14 boys, eight girls), aged 5.2 +/- 1 months, 16 with a positive respiratory syncytial virus test, during their first 3 days after admission. Patients breathed spontaneously through a face mask connected to a pneumotachograph during normal breathing, and only target flows of 0.1 +/- 0.02 L/s were analyzed. Sounds were obtained using two contact sensors attached over both posterior lower lobes. For inspiratory and expiratory sounds, we determined the frequencies below which 25% (F25), 50% (F50), 75% (F75) and 99% (SEF99) of the spectral power between 100 and 1000 Hz was contained. We repeated the measurements 20 min after bronchodilator therapy in all patients. RESULTS We found classic SW in 11 patients, while the other 11 had complex wheezes (CW). There were positive bronchodilator responses in 9/11 with SW and 3/11 with CW (P < 0.01). Patients who responded to salbutamol showed an increase in power at low frequencies after medication (P < 0.01), and a positive correlation between wheezing and the increase in the power spectra measured by F50 and SEF99 (P < 0.001). CONCLUSIONS We conclude that sinusoidal and complex wheezes occur in patients with AB, that a positive response to bronchodilator is significantly more common in those with classic SW and that lung sounds analysis is a reproducible, safe and non-invasive method for assessing wheeze in infants.
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Affiliation(s)
- Ignacio Sánchez
- Section of Pediatric Respirology, Department of Pediatrics, Catholic University of Chile, Santiago, Chile.
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Taşar MA, Bostanci I, Atli O, Dallar Y. Effect of short-acting inhaler beta2-agonists on serum cardiac troponin in wheezy infant. Allergy Asthma Proc 2005; 26:477-82. [PMID: 16541973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Cardiac troponin (cTn) is highly specific for myocardial injury. However, effect of beta2-agonist therapy on cTn in wheezy infants is unknown. We aimed to assess serum troponin in children with wheezy infant treated by short-acting inhaler beta2-agonists. Twenty-four children, under 5 years old, with the diagnosis of wheezy infant with acute exacerbation were enrolled in the study. Subjects were treated three times by a standard dose of nebulized salbutamol (0.15 mg/kg per dose; maximum, 3 mg; Ventolin Nebules Ampule) therapy. The heart rate, respiratory rate, cTnI, creatine kinase (CK), CK-MB levels, and electrocardiogram were measured in wheezy infant before and after 60-minute nebulized salbutamol. In the control group the heart rate, respiratory rate, cardiac troponin I (cTnI), CK, CK-MB levels, and electrocardiogram were recorded at admission. For Seventeen boys (70.8%) and seven girls (29.2%) with wheezy infant, the mean age of the patients was 21.4 +/- 18.13 months and for control groups the mean age was 17.28 +/- 16.09 months (p = 0.419). There was no significant difference in serum troponin in patients before treatment, after treatment period, and in controls (mean +/- SD, 0.049 +/- 0.03, 0.043 +/- 0.048, and 0.044 +/- 0.034, respectively; p = 0.14, p = 0.72, and p = 0.35, respectively). Short-acting inhaler 32-agonists do not influence circulating troponin levels in wheezy infant with acute attack.
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Affiliation(s)
- M Ayşin Taşar
- Departments of Pediatrics, Ministry of Healthy Ankara Education and Research Hospital, Ankara, Turkey
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Ponsioen BP, Bohnen AM, Dekhuijzen PNR. Efficacy of Fluticasone Propionate on Lung Function and Symptoms in Wheezy Infants. Am J Respir Crit Care Med 2005; 172:930; author reply 930-1. [PMID: 16183714 DOI: 10.1164/ajrccm.172.7.950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
The 'death rattle' is a common symptom among dying people, and causes a great deal of anxiety and upset to relatives and carers, including nurses. A mini-review was carried out to evaluate the effectiveness of two drugs--hyoscine hydrobromide and glycopyrronium--in drying up respiratory secretions in terminally ill patients. Searches were made of the Cochrane Library, Medline, Embase, Cinahl and Pharmline. Reference lists, trial databases and professional colleagues were also consulted. There was a scarcity of research material directly comparing the effects of the two drugs in the clinical setting. Two papers were used for comparison in the review but these produced conflicting results. Many discrepancies existed in terms of research methods, and in results. One paper demonstrated that hyoscine hydrobromide was the more effective drug; the other favoured glycopyrronium. There is no clear evidence to support the choice of one drug over the other, based on the clinical outcome selected for this review. Although clinical trials are difficult to conduct in this vulnerable patient group, more research is needed to facilitate the best management of this distressing symptom and allow clinical guidelines to be produced.
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Affiliation(s)
- Helen Lawrey
- Palliative Care, Queen Mary's Hospital, Sidcup, UK.
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Abstract
BACKGROUND Wheeze in infancy and early childhood is common and appears to be increasing though the magnitude of any increase is unclear. Most wheezing episodes in infancy are precipitated by respiratory viral infections. Treatment of very young children with wheeze remains controversial. Anti-cholinergics are often prescribed but practice varies widely and the efficacy of this form of therapy remains the subject for debate. OBJECTIVES Wheeze in infancy and early childhood is common and appears to be increasing. Most wheezing episodes in infancy are a result of viral infection. Bronchodilator medications such as beta2-agonists and anti-cholinergic agents are often used to relieve symptoms, but patterns of use vary. The objective of this review was to assess the effects of anti-cholinergic therapy in the treatment of wheezing infants. This is a second update of this review. SEARCH STRATEGY We searched the Cochrane Airways Group Specialised Register of trials and the reference lists of articles. We contacted researchers in the field and industry sources. Searches were current as of June 2004. SELECTION CRITERIA Randomised trials that compared anti-cholinergic therapy with placebo or beta2-agonists in wheezing children under two years of age. Children with acute bronchiolitis and chronic lung disease were excluded. DATA COLLECTION AND ANALYSIS Eligibility for inclusion and quality of trials were assessed independently by two reviewers. MAIN RESULTS Six trials involving 321 infants in three different settings were included. Compared with beta2-agonist alone, the combination of ipratropium bromide and beta2-agonist was associated with a reduced need for additional treatment, but no difference was seen in treatment response, respiratory rate or oxygen saturation improvement in the emergency department. There was no significant difference in length of hospital stay between ipratropium bromide and placebo; or between ipratropium bromide and beta2-agonist combined compared with beta2-agonist alone. However, combined ipratropium bromide and beta2-agonist compared to placebo showed significantly improved clinical scores at 24 hours. Parents preferred ipratropium bromide over nebulised water or placebo for relief of their children's symptoms at home. A further updated search conducted in June 2004 did not yield any new studies. AUTHORS' CONCLUSIONS There is not enough evidence to support the uncritical use of anti-cholinergic therapy for wheezing infants, although parents using it at home were able to identify benefits.
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Affiliation(s)
- Mark Everard
- Sheffield Children's HospitalDepartment of PaediatricsWestern BankSheffieldUKS10 2TH
| | - Anna Bara
- Clinical Trials UnitMedical Research UnitOther Diseases Group222 Euston RoadLondonUKNW1 2DA
| | - Matthew Kurian
- Sheffield Children's HospitalSheffieldSouth YorkshireUKS10 2TH
| | - Tracy N'Diaye
- Sheffield Children's HospitalResearch Office16 Northumberland RoadSheffieldSouth YorkshireUKS10 2TH
| | - Francine Ducharme
- CHU Sainte‐JustineDirection de la Recherche/ Research Centre3175 Cote Sainte‐CatherineMontrealQuébecCanadaH3T 1C5
| | - Varaidzo Mayowe
- Sheffield Children's NHS TrustResearch and Development OfficeThe WhitehouseWestern BankSheffieldUKST10 2TH
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