Hypoxaemia after nebulised salbutamol in wheezy infants: the importance of aerosol acidity

The effect of nebulised iso-osmolar, preservative free, but acidic salbutamol solution was studied in 34 acutely wheezing infants aged 1-17 months. Transcutaneous oxygen pressure (TcPO2) and oxygen saturation (SO2) fell significantly during the first five minutes after nebulisation with further deterioration at 15-20 minutes. Ten of these infants were followed up for another two hours and showed slight improvement. Even after the second hour TcPO2 had not reached baseline values. Three months later the response to salbutamol and a placebo of equal acidity (pH 3.9) was studied in 11 infants from the same group, now free of symptoms. Lung function tests were included and showed no significant changes in specific conductance and volume corrected maximum expiratory flows (Vmax at functional residual capacity/thoracic gas volume). However, hypoxaemia occurred after the acidic placebo with a significant drop of TcPO2 (mean 0.9 kPa); SO2 decreased similarly but this did not reach significance. After salbutamol there was a further significant deterioration of mean TcPO2 (1.4 kPa) and of SO2. These results show that beside a possible pharmacological effect of salbutamol the acidity of the aerosol also induces hypoxaemia in infants.

Ipratropium bromide delivered by metered-dose aerosol to infant wheezers

Two methods of administration of ipratropium bromide (Atrovent; Boehringer Ingelheim) to wheezing children less than 25 months of age were compared: (i) the conventional nebulisation (15 children); and (ii) a metered-dose aerosol plus spacer and mask (MDA group, 17 children). The drug induced a significant and similar fall in respiratory rate in both groups. Transcutaneous carbon dioxide pressure was also reduced significantly but was more marked in the MDA group. This increase in alveolar ventilation was similar in those less than 12 months as in older children; in those with recurrent or with first time wheezing; and in those with radiological evidence of pneumonia. Clinical assessment of bronchospasm and recession was recorded as improved in over 80% of both groups. The MDA delivery of ipratropium bromide was as effective as nebulisation and was more convenient, since it required less time and equipment. It was also well accepted by the small patients.

Randomized trial of salbutamol in acute bronchiolitis

To test whether nebulized salbutamol (albuterol) is safe and efficacious for the treatment of young children with acute bronchiolitis, we enrolled 83 children (median age 6 months, range 1 to 21 months) in a randomized, double-blind clinical trial. Participants received two treatments at 30-minute intervals of either nebulized salbutamol (0.10 mg/kg in 2 ml 0.9% saline solution) or a similar volume of 0.9% saline solution placebo. Outcome measures were the respiratory rate, pulse oximetry, and a clinical score based on the degree of wheezing and retractions. Patients in the salbutamol arm had significantly greater improvement in clinical scores after the initial treatment (p = 0.04). There was no difference between the groups in oxygen saturation (p = 0.74); patients treated with salbutamol had a small increase in heart rate after two treatments (159 +/- 16 vs 151 +/- 16; p = 0.03). We conclude that salbutamol is safe and effective for the initial treatment of young children with acute bronchiolitis.

Effect of salbutamol on specific airway resistance in infants with a history of wheezing

The purpose of this study was to assess the effectiveness of nebulized salbutamol in infants with a history of wheezing. Eighty-eight children aged 3-24 months with a history of wheezing were studied, in seven groups: I (n = 15) and I/A (n = 17) with elevated specific airway resistance (SRaw); II (n = 17) with normal SRaw; III (n = 23), III/A (n = 17), and IV (n = 18) with normal SRaw exposed to carbachol bronchial challenge (CBC); and V (n = 13) serving as control. Infants for groups I/A and III/A were selected to match by age and by baseline and post-carbachol SRaw values, respectively. Baseline airway resistance and thoracic gas volume (TGV) were measured plethysmographically. Specific airway resistance was selected as an index of bronchial function. Thereafter every child in groups I, I/A and II inhaled 200 micrograms of salbutamol by tidal breathing, and the children in groups III, III/A, and IV were exposed to CBC. Following positive reaction to carbachol, children of groups III and III/A inhaled salbutamol (200 micrograms, tidal breathing), and those of group IV received no drug. Controls from group V with normal SRaw received placebo (phosphate-buffered saline). Plethysmography was repeated in all children at 5 minute intervals. Following salbutamol SRaw was reduced in children with elevated and normal SRaw. In contrast, children not receiving salbutamol had unchanged SRaw value. The response to salbutamol measured by SRaw, Raw, and TGV was not significantly different in the spontaneously obstructed infants compared to those who received carbachol. In conclusion, infants with a history of wheezing do respond to inhaled salbutamol.

Inhaled budesonide for treatment of recurrent wheezing in early childhood

77 children, aged 11 to 36 months (mean 24) with moderately severe recurrent wheezing, were treated with budesonide pressurised aerosol 400 micrograms twice daily or placebo for 12 weeks in a double-blind, parallel-group trial. Aerosols were inhaled from a spacer with a facemask. Budesonide significantly improved symptom scores of wheezing, sleep disturbance, and patient happiness. The frequency of severe exacerbations that required a course of oral prednisolone was also significantly reduced. The treatment effect appeared to be fully established after 6-8 weeks and no side-effects could be ascribed to the active treatment. The findings indicate that young children below 3 years of age can inhale a pressurised aerosol from a spacer with a facemask. Use of topically active glucocorticosteroids with this simple device may reduce symptoms and distress in young children with moderately severe recurrent wheeze and dyspnoea, and possibly reduce their requirement for oral steroids.

Effective bronchodilator treatment by a simple spacer device for wheezy premature infants

Ten preterm infants with recurrent respiratory symptoms (median gestational age 30 weeks) were entered into a non-randomised placebo controlled trial of bronchodilator treatment at 12.5 months of age. The infants had coughed or wheezed, or both, on at least four days a week for the past month. The infants received either placebo or 500 micrograms terbutaline from an inhaler using a coffee cup as a spacer device. Each treatment was maintained for two weeks, first placebo then active drug. The symptom score was reduced by 65% during the active treatment period compared with the placebo period and this was associated with a 32% improvement in lung function, reflected in an increase in functional residual capacity. We conclude that inhaled bronchodilator treatment given with a simple spacer device is useful for preterm infants with recurrent respiratory symptoms in the first two years of life.

Clinical efficacy and tolerance of two new macrolides, clarithromycin and josamycin, in the treatment of patients with acute exacerbations of chronic bronchitis

The efficacy and safety of oral 500 mg clarithromycin given twice daily and 500 mg josamycin given three times daily were compared for up to 14 days in the treatment of 103 out-patients with acute exacerbations of chronic bronchitis in an open, randomized study. The predominant pathogens isolated were Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. Clinical cures were experienced by 85% of the clarithromycin-treated patients, with an additional 10% showing improvement. In josamycin-treated patients, 76% of the patients experienced clinical cures and an additional 19% showed improvement. Eradication of the causative pathogen occurred in approximately 95% of the patients in both treatment groups. Adverse events, which all involved the gastro-intestinal tract and were mild, transient and probably related to therapy, were experienced by 5.8% and 7.8%, respectively, of the clarithromycin- and josamycin-treated patients. It is concluded that clarithromycin given twice daily is as effective as josamycin given three times daily.

Efficacy and safety of clarithromycin versus josamycin in the treatment of hospitalized patients with bacterial pneumonia

The efficacy and safety of 500 mg clarithromycin and 1000 mg josamycin both given twice daily for a maximum of 14 days were compared in the treatment of 72 hospitalized patients with bacterial pneumonia. The predominant pathogens isolated were Streptococcus pneumoniae and Staphylococcus aureus. Clinical success was reported for 91.5% of patients treated with clarithromycin and for 87.0% of those treated with josamycin. Eradication of the causative pathogen was noted in 85.7% of patients receiving clarithromycin and in 90% of those receiving josamycin. Adverse events considered probably to relate to therapy were experienced by 2% of patients treated with clarithromycin and by 12.5% of those treated with josamycin; one patient treated with josamycin was withdrawn because of severe nausea and moderate vomiting. Treatment with clarithromycin at half the dosage of josamycin was found to have comparable efficacy and to be associated with a lower incidence of adverse events.

Tuberculosis presenting as corticosteroid responsive wheezing in infancy

A nine-month-old child received intermittent oral prednisolone over a 6 month period because of persistent wheezing. This therapy had appeared to improve his symptoms. At 15 months of age, a chest X-ray and culture of tracheal aspirate revealed disseminated pulmonary tuberculosis. Response to antituberculous therapy was slow, and withdrawal of steroids produced marked worsening of wheeze and respiratory distress. Corticosteroids are recognised adjuncts in the management of bronchial-lymph node tuberculosis. Responsiveness of wheezing to prednisolone does not imply that its cause is hyperreactive airways disease, and other causes should be sought particularly in developing countries.

Characterization of abnormal respiratory movements in schizophrenic, bipolar and mentally handicapped patients with typical tardive dyskinesia

A population of 76 patients with typical tardive orofacial dyskinesia, and from which cases of respiratory disease had been excluded, were evaluated for abnormal respiratory movements. Such abnormality was present in 34 patients (45%), and was unrelated to age, sex or smoking habits. However, patients with respiratory movement disorder showed more severe orofacial dyskinesia and higher blood pressure. Putative pathophysiological processes implicated in this often unappreciated component of the tardive dyskinesia syndrome are discussed.

Retrospective studies in scleroderma: pulmonary findings and effect of potassium p-aminobenzoate on vital capacity

The principal clinical pulmonary findings were extracted from University of Michigan Hospital records of 390 patients with scleroderma. Dyspnea was the most frequent symptom and strongly correlated with pulmonary fibrosis and with decreased vital capacity (FVC) and CO diffusing capacity (DLCO). The mean value for FVC was 84% of the predicted normal for 326 patients, and that of the initial DLCO 56.8% of the predicted normal (323 patients). Pulmonary fibrosis was diagnosed on first chest X-ray in 80 of 382 patients. An additional 48 patients developed fibrosis detected on subsequent X-rays. Analyses were performed to determine whether the deterioration of pulmonary function over time was less for scleroderma patients who were adequately treated with potassium p-aminobenzoate (KPAB) than for those inadequately or never treated with KPAB, The average decrease for both FVC and DLCO was found to be less for KPAB-treated patients. However, only in the case of vital capacity was the difference significant. In the presence of radiological evidence of pulmonary fibrosis FVC decreased more rapidly (p = 0.002), but the decline in DLCO was not affected. When adjusting for the presence or absence of fibrosis the average slopes of the logarithm of vital capacity were significantly less negative (p = 0.003) for patients on KPAB.

[Bronchodilator effect of fenoterol in asthma]

For a sympathomimetic bronchodilator to be effective, it should be transported in an active form, from the place of administration to the receptor site, as well as the kind of medication and its route of administration. It has been shown both in the laboratory as well as in clinical studies that the intensity and duration of the sympathomimetic bronchodilator effect keeps decreasing although the tolerance does not seem to be clinically so important for the new bronchodilators. The beta 2 agonists are used via oral, parenteral and inhalatory route. The rapidity of the action by inhalation makes this method effective to treat intermittent symptoms or during acute exacerbations in bronquial asthma. In this study, 29 patients were included, of which 18 were symptomatic and 11 were asymptomatic asthmatics. Those patients with symptomatic and asymptomatic asthmatics were included in the first and second group respectively. The criteria of exclusion for both groups were: patients with restrictive or non-reversible bronchopulmonary disease, cardiovascular disease, thyrotoxicosis, patients under treatment with steroids and acute infection. The age was lower than 6 years and more than 15 years. A clinical history and a spirometric study (without medication) were performed to determine the basal line values of the forced spirometry volume one second (VEF1) and the vital capacity (CV). An inhalation of fenoterol in aerosol was administered immediately afterwards. At 3, 20, 30 and 60 minutes new spirometries were carried out to determine the initial and the therapeutic effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Forced random noise resistance determination in childhood asthma

The forced random noise method for measuring respiratory resistance was studied in terms of reproducibility and correlation with spirometry and flow volumes in 30 older children (four to 17 years) with asthma and in 16 infants and children below three years of age. In the 30 older children, the mean value of individual coefficient of variations for three repeated measurements was 7.4 percent. Resistance parameters correlated well with spirometric parameters with all but three correlation coefficients greater than 0.7. In 20 older asthmatic patients, 180 micrograms albuterol caused a significant reduction in resistance in 11 subjects. At the same time, FEV1 increased significantly in nine subjects but showed a paradoxic decrease in five. This paradoxic response is attributed to complex reflexes caused by the maximum inspiration and forced expiration and did not occur with resistance measurements. This method requires little subject cooperation, and therefore, is well suited for infants and children.