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Dobler CC, Morrow AS, Beuschel B, Farah MH, Majzoub AM, Wilson ME, Hasan B, Seisa MO, Daraz L, Prokop LJ, Murad MH, Wang Z. Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis. Ann Intern Med 2020; 172:413-422. [PMID: 32092762 DOI: 10.7326/m19-3007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations. PURPOSE To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD. DATA SOURCES English-language searches of several bibliographic sources from database inception to 2 January 2019. STUDY SELECTION 68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions. DATA EXTRACTION Two reviewers independently extracted data and rated study quality and strength of evidence (SOE). DATA SYNTHESIS Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and short-acting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function. LIMITATION Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs. CONCLUSION Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42018111609).
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Affiliation(s)
- Claudia C Dobler
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, and Institute for Evidence-Based Healthcare, Bond University and Gold Coast University Hospital, Gold Coast, Queensland, Australia (C.C.D.)
| | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Bradley Beuschel
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Magdoleen H Farah
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Abdul M Majzoub
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Michael E Wilson
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Bashar Hasan
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Lubna Daraz
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, Minnesota (L.J.P.)
| | - M Hassan Murad
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
| | - Zhen Wang
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota (A.S.M., B.B., M.H.F., A.M.M., M.E.W., B.H., M.O.S., L.D., M.H.M., Z.W.)
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Janssen WJ, Stefanski AL, Bochner BS, Evans CM. Control of lung defence by mucins and macrophages: ancient defence mechanisms with modern functions. Eur Respir J 2016; 48:1201-1214. [PMID: 27587549 DOI: 10.1183/13993003.00120-2015] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 06/12/2016] [Indexed: 12/14/2022]
Abstract
Owing to the need to balance the requirement for efficient respiration in the face of tremendous levels of exposure to endogenous and environmental challenges, it is crucial for the lungs to maintain a sustainable defence that minimises damage caused by this exposure and the detrimental effects of inflammation to delicate gas exchange surfaces. Accordingly, epithelial and macrophage defences constitute essential first and second lines of protection that prevent the accumulation of potentially harmful agents in the lungs, and under homeostatic conditions do so effectively without inducing inflammation. Though epithelial and macrophage-mediated defences are seemingly distinct, recent data show that they are linked through their shared reliance on airway mucins, in particular the polymeric mucin MUC5B. This review highlights our understanding of novel mechanisms that link mucus and macrophage defences. We discuss the roles of phagocytosis and the effects of factors contained within mucus on phagocytosis, as well as newly identified roles for mucin glycoproteins in the direct regulation of leukocyte functions. The emergence of this nascent field of glycoimmunobiology sets forth a new paradigm for considering how homeostasis is maintained under healthy conditions and how it is restored in disease.
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Affiliation(s)
- William J Janssen
- Dept of Medicine, National Jewish Health, Denver, CO, USA Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Bruce S Bochner
- Dept of Medicine, Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher M Evans
- Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Bennett WD, Daviskas E, Hasani A, Mortensen J, Fleming J, Scheuch G. Mucociliary and cough clearance as a biomarker for therapeutic development. J Aerosol Med Pulm Drug Deliv 2011; 23:261-72. [PMID: 20804426 DOI: 10.1089/jamp.2010.0823] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A workshop/symposium on “Mucociliary and Cough Clearance (MCC/CC) as a Biomarker for Therapeutic Development” was held on October 21–22, 2008, in Research Triangle Park, NC, to discuss the methods for measurement of MCC/CC and how they may be optimized for assessing new therapies designed to improve clearance of airway secretions from the lungs. The utility of MCC/CC as a biomarker for disease progression and therapeutic intervention is gaining increased recognition as a valuable tool in the clinical research community. A number of investigators currently active in using MCC/CC for diagnostic or therapeutic evaluation presented details of their methodologies. Attendees participating in the workshop discussions included those interested in the physiology of MCC/CC, some of who use in vitro or animal methods for its study, pharmaceutical companies developing muco-active therapies, and many who were interested in establishing the methods in their own clinical laboratory. This review article summarizes the presentations for the in vivo human MCC/CC methods and the discussions both at and subsequent to the workshop between the authors to move forward on a number of questions raised at the workshop.
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Affiliation(s)
- William D Bennett
- Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina 27599-7310, USA.
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Hasani A, Chapman TH, McCool D, Smith RE, Dilworth JP, Agnew JE. Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis. Chron Respir Dis 2008; 5:81-6. [PMID: 18539721 DOI: 10.1177/1479972307087190] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Inspired air humidification has been reported to show some benefit in bronchiectatic patients. We have investigated the possibility that one effect might be to enhance mucociliary clearance. Such enhancement might, if it occurs, help to lessen the risks of recurrent infective episodes. Using a radioaerosol technique, we measured lung mucociliary clearance before and after 7 days of domiciliary humidification. Patients inhaled high flow saturated air at 37 degrees C via a patient-operated humidification nasal inhalation system for 3 h per day. We assessed tracheobronchial mucociliary clearance from the retention of (99m)Tc-labelled polystyrene tracer particles monitored for 6 h, with a follow-up 24-h reading. Ten out of 14 initially recruited patients (age 37-75 years; seven females) completed the study (two withdrew after their initial screening and two prior to the initial clearance test). Seven patients studied were non-smokers; three were ex-smokers (1-9 pack-years). Initial tracer radioaerosol distribution was closely similar between pre- and post-treatment. Following humidification, lung mucociliary clearance significantly improved, the area under the tracheobronchial retention curve decreased from 319 +/- 50 to 271 +/- 46%h (p < 0.07). Warm air humidification treatment improved lung mucociliary clearance in our bronchiectatic patients. Given this finding plus increasing laboratory and clinical interest in humidification mechanisms and effects, we believe further clinical trials of humidification therapy are desirable, coupled with analysis of humidification effects on mucus properties and transport.
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Affiliation(s)
- A Hasani
- Department of Medical Physics, Royal Free Hospital, London, UK.
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Abstract
Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.
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Affiliation(s)
- Mario Cazzola
- Department of Internal Medicine, Unit of Respiratory Diseases, University of Rome Tor Vergata, Rome, Italy.
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Hasani A, Toms N, Agnew JE, Lloyd J, Dilworth JP. Mucociliary clearance in COPD can be increased by both a D2/ β2 and a standard β2 agonists. Respir Med 2005; 99:145-51. [PMID: 15715181 DOI: 10.1016/j.rmed.2004.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In addition to breathlessness and cough, excessive mucus production is one of the main symptoms of chronic obstructive pulmonary disease (COPD). Excess mucus coupled with deteriorating mucociliary clearance is associated with a decline in lung function and an increased risk of death from pulmonary infection. The effect of Viozan (Sibenadet HCl, AR-C68397AA), a novel dual D2 dopamine receptor, beta2-adrenoceptor agonist, on mucociliary clearance was investigated together with that of a beta2-adrenoceptor agonist, salbutamol. Using a double blind, parallel group study design, 15 patients with COPD, all habitual smokers, were randomised to receive nebulised sidenadet (3mg tid; n = 7) or salbutamol (5mg tid; n = 8) for 10 days. Lung mucociliary clearance rates were measured, by a standard radioaerosol technique, before and after the treatment period, as were 24-h sputum volumes. Both sibenadet and salbutamol therapies resulted in significant (P<0.02) enhancement of lung mucociliary clearance. The 24-h sputum volume was significantly reduced following sibenadet therapy (P<0.03) whereas salbutamol therapy had no effect. Our results, in addition to illustrating the effects of a standard beta2 agonist on mucociliary clearance, strongly suggest the potential dual benefit of dual-agonist compounds in lessening sputum production whilst simultaneously enhancing mucociliary clearance. For reasons unconnected with the present study, development work on this specific formulation is no Longer proceeding.
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Affiliation(s)
- A Hasani
- Department of Medical Physics and Thoracic Medicine, Royal Free and University College Medical School, London, UK.
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