A single dose of nebulized budesonide decreases exhaled nitric oxide in children with acute asthma

Long-term PM2.5 exposure is associated with asthma prevalence and exhaled nitric oxide levels in children

BACKGROUND

Exhaled nitric oxide concentration (FENO) is a marker of airway inflammation. This study aimed to evaluate the association of air pollution exposure with FENO levels and asthma prevalence with respiratory symptoms in school children.

METHODS

We analyzed 4736 school children who reside in six townships near industrial areas in central Taiwan. We evaluated asthmatic symptoms, FENO, and conducted the environmental questionnaire. The personal exposure of PM2.5, NO, and SO2 was estimated using land-use regression models data on children's school and home addresses.

RESULTS

Annual exposure to PM2.5 was associated with increased odds of physician-diagnosed asthma (OR = 1.595), exercise-induced wheezing (OR = 1.726), itchy eyes (OR = 1.417), and current nasal problems (OR = 1.334) (P < 0.05). FENO levels in the absence of infection were positively correlated with age, previous wheezing, allergic rhinitis, atopic eczema, near the road, and for children with high exposure to PM2.5 (P < 0.05). An increase of 1 μg/m3 PM2.5 exposure was significantly associated with a 1.0% increase in FENO levels for children after adjusting for potential confounding variables, including exposures to NO and SO2.

CONCLUSIONS

Long-term exposures to PM2.5 posed a significant risk of asthma prevalence and airway inflammation in a community-based population of children.

IMPACT

Annual exposure to PM2.5 was associated with increased odds of physician-diagnosed asthma and nasal problems and itchy eyes. Long-term exposures to PM2.5 were significantly associated with FENO levels after adjusting for potential confounding variables. This is first study to assess the association between FENO levels and long-term air pollution exposures in children near coal-based power plants. An increase of 1 μg/m3 annual PM2.5 exposure was significantly associated with a 1.0% increase in FENO levels. Long-term exposures to PM2.5 posed a significant risk of asthma prevalence and airway inflammation in a community-based population of children.

Nebulized budesonide combined with systemic corticosteroid vs systemic corticosteroid alone in acute severe asthma managed in the emergency department: a randomized controlled trial

Background

The additive benefit of inhaled corticosteroid when used with systemic corticosteroid in acute asthma is still unclear. The objective of this study was to assess the effect of high and repeated doses of inhaled budesonide when combined with the standard treatment of adult acute asthma.

Methods

It was a prospective double-blind randomized controlled study performed in the emergency department (ED) from May 1, 2010 to February 28, 2011 (ClinicalTrials.gov, NCT04016220). Fifty patients were included and were randomized to receive intravenous hydrocortisone hemisuccinate in association with nebulized budesonide (n = 23, budesonide group) or normal saline (n = 27, control group). Nebulization of budesonide or saline was done in combination with 5 mg of terbutaline every 20 min the first hour, then at 2 h (H2), and 3 h (H3). All patients received standard treatment. Efficacy and safety of inhaled budesonide were evaluated every 30 min for 180 min.

Results

A significant increase in peak expiratory flow (PEF) was observed in both treatment groups at evaluation times. The increase in PEF persisted significantly compared to the previous measurement in both groups. There was no significant difference in the PEF between the two groups at evaluation times. There was no significant difference between the two groups in the evolution in the respiratory rate and heart rate. There was also no statistically significant difference between the two groups in the rate of hospitalization, the discharge criteria before the end of the protocol.

Conclusions

Considering its limited power, our study suggests that the association of nebulized budesonide with hydrocortisone hemisuccinate has no additional effect over the use of hydrocortisone alone in adults’ acute asthma managed in the ED.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00691-9.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Effect of budesonide on hospitalization rates among children with acute asthma attending paediatric emergency department: a systematic review and meta-analysis

INTRODUCTION

The efficacy of inhaled budesonide for managing moderate-to-severe acute exacerbations in children is not clear. Therefore, this study aimed to evaluate hospital admission rates, need for use of systemic corticosteroids, length of hospital stay and adverse events when inhaled budesonide is added to standard pediatric emergency department management of moderate-to-severe acute exacerbations of asthma.

METHODS

A systematic search was conducted in PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases. Randomized controlled trials that evaluated the effect of nebulized budesonide in moderate-to-severe acute exacerbations of asthma in pediatric patients were included for this meta-analysis. Statistical analysis was done using STATA version 13.0.

RESULTS

A total of 16 RCTs were included. Children receiving nebulized budesonide had 43% lower risk of being hospitalized (RR 0.57; 95% CI, 0.39; 0.85) and 66% lower risk of requiring systemic corticosteroids (RR 0.34; 95 % CI, 0.21; 0.55) compared with those receiving placebo. There were no differences in the length of hospital stay (Hedges's g standardized mean difference - 1.53; 95% CI, - 3.64; 0.58) and risk of adverse events (RR 0.87, 95% CI; 0.65; 1.17) between the two groups. There was no evidence of publication bias for any of the outcomes considered.

CONCLUSION

The findings of this meta-analysis support the use of inhaled budesonide in reducing risk of hospitalization and the need for systemic corticosteroids among children with acute moderate-to-severe asthma exacerbation.

Efficacy and safety of inhalation budesonide in the treatment of pediatric asthma in the emergency department: a systematic review and meta-analysis

BACKGROUND

This study was aimed to evaluate the beneficial role of inhalation budesonide(BUD) in improving the pulmonary functions, and reducing the hospital admission rate, worsening of asthma and commonly encountered adverse events in pediatric asthma.

METHODS

The electronic search was performed using PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases to identify the randomized control trials(RCTs).

RESULTS

21 RCTs involving 12,787 subjects were included. The meta-analysis revealed that the BUD has reduced the hospitalization rate (Mantel-Haenszel (M-H), random effects odd ratio (RE-OR) of 0.34, p = 0.003, I² = 75%), and worsening of asthma (M-H, RE-OR 0.38, p = 0.001, I² = 73%); significantly improved the pulmonary functions such as FEV1 (Inverse variance (IV): 1.05, p < 0.0001, I² = 94%), PEFR (IV: 1.40, p < 0.0001, I² = 87%), morning PEF (IV: 1.04, p < 0.0001, I² = 91%), and evening PEF (IV: 1.29, p < 0.0001, I² = 92%) compared to control. Further, the incidences of adverse events like Pharyngitis (M-H, RE-OR 0.88, at 95% CI, p = 0.69, I² = 0%), Sinusitis (M-H, RE-OR 0.78, p = 0.79, I² = 0%), Respiratory infections (M-H, RE-OR 0.96, p = 0.46, I² = 0%), Otitis media (M-H, RE-OR 0.82, p = 0.32, I² = 12%) and Fever (M-H, RE-OR 0.78, p = 0.64, I² = 0%) were almost same between BUD and control.

CONCLUSION

The outcomes of the meta-analysis suggest that high-dose inhalation BUD could benefit the pediatric patients in minimizing the worsening of asthma and hospitalization rate, along with improving the pulmonary functions, with negligible adverse drug reactions.

Inhaled Corticosteroids in Acute Asthma: A Systemic Review and Meta-Analysis

BACKGROUND

Asthma exacerbations are a common and important cause of attendance at emergency departments (ED) and subsequent hospital admissions. Despite previous reviews reporting that in acute settings the risk of hospital admission is reduced with the use of high doses of inhaled corticosteroids (ICS), this evidence has not changed clinical practice.

OBJECTIVE

To estimate the efficacy of ICS in the treatment of acute asthma in ED.

METHODS

Randomized controlled trials were identified using PubMed, The Cochrane Library, and EMBASE. The primary outcome was hospital admission rates. The primary comparison was between administration of ICS in addition to systemic corticosteroids (SCS) and to SCS alone. Secondary comparisons were ICS alone compared with SCS alone and ICS compared with placebo.

RESULTS

There were 25 studies involving 2733 participants. For the primary comparison, ICS in addition to SCS reduced the risk of hospital admission compared with SCS; fixed-effects odds ratio (95% confidence interval) 0.73 (0.57-0.94). Lung function was poorly reported. There was moderate evidence of an improvement in clinical scores and vital signs with ICS in addition to SCS. Relatively few studies reported adverse events.

CONCLUSION

There is moderate evidence that high doses of ICS, in addition to SCS, reduce the risk of hospital admission in ED treatment of moderate-to-severe asthma exacerbations. Further research is required to determine their optimal role in both ED and outpatient settings.

Budesonide/formoterol maintenance and reliever therapy in asthma control: acute, dose-related effects and real-life effectiveness

BACKGROUND AND OBJECTIVE

The efficacy of budesonide/formoterol maintenance and reliever therapy (BFMRT) in asthma control is well documented in large randomized controlled trials. However, the acute reliever effects and real-life effectiveness are seldom reported.

METHODS

This multicenter trial enrolled steroid-naïve, symptomatic asthmatics with baseline exhaled nitric oxide (eNO) of ≥ 40 ppb. There were 120 eligible patients who were randomized and received a dose of inhaled budesonide/formoterol 320/9 μg (lower dose budesonide/formoterol), 640/18 μg (higher dose budesonide/formoterol (HDBF)), or terbutaline (TERB) 1 mg. Inflammatory cells and mediators in induced sputum, eNO and lung function were measured at baseline and 6 h (acute phase). Subsequently, all patients used BFMRT as real-life practice for 24 weeks (maintenance phase).

RESULTS

In the acute phase, the degree of post-treatment reduction in total eosinophil counts, interleukin-8 and matrix metalloproteinase-9 in induced sputum were significantly greater in group HDBF (vs TERB, P < 0.05). The increase in forced expiratory volume in first second (FEV1 ) in group HDBF was significantly higher (vs LDBF and TERB, P < 0.05) 3 h after dosing. In the maintenance phase, significant improvement of asthma control (presented by eNO, FEV1 and a five-item asthma control questionnaire) in real-life settings was observed at 4 weeks and sustained to the end of study. The rate of patients who followed scheduled visits declined over time (87% at week 4 and 42% at week 24).

CONCLUSIONS

Budesonide/formoterol as reliever exerts acute, dose-related anti-inflammatory effects and FEV1 improvement in symptomatic asthmatics. BFMRT is effective in asthma control. However, the decrease in long-term follow-up rate remains an issue to overcome in real-life settings.

Effects of nebulized high-dose budesonide on moderate-to-severe acute exacerbation of asthma in children: a randomized, double-blind, placebo-controlled study

BACKGROUND AND OBJECTIVE

The efficacy of inhaled corticosteroids (ICS) in asthma exacerbation are yet to be clarified. The aim of this study was to investigate the efficacy of nebulized ICS in children with moderate-to-severe acute exacerbation of asthma in an emergency room setting in order to elucidate the potential use of ICS as the first-line therapy in the management of acute exacerbation of asthma.

METHODS

This was a prospective, randomized, double-blind, placebo-controlled study. Paediatric patients with moderate-to-severe acute exacerbation of asthma in emergency room were randomized to receive nebulized salbutamol and ipratropium bromide, with the addition of nebulized high-dose budesonide (BUD group, n = 60) or normal saline (control group, n = 58), three doses in the first hour.

RESULTS

The improvement in forced expiratory volume in 1 s was similar in both groups at 0 h after three doses of nebulization, but there was significantly further improvement at 1 and 2 h in the BUD group (0.095 ± 0.062 L and 0.100 ± 0.120 L, respectively) compared with the control group (0.059 ± 0.082 L and 0.021 ± 0.128 L, respectively), P = 0.013 and 0.001, respectively. Complete remission rate was significantly higher (84.7% vs 46.3%, P = 0.004) and need for oral corticosteroids was significantly lower (16.9% vs 46.3%, P = 0.011) in BUD group than in control group.

CONCLUSION

On the basis of nebulized short-acting bronchodilators, addition of nebulized high-dose budesonide resulted in clinical improvement in children with moderate-to-severe acute exacerbation of asthma, suggesting that nebulized high-dose ICS can be used as first-line therapy for non-life-threatening acute exacerbation of asthma in children.

Increased IL-17A secreting CD4+ T cells, serum IL-17 levels and exhaled nitric oxide are correlated with childhood asthma severity

BACKGROUND

Measuring fractional exhaled nitric oxide (FeNO) is a simple and non-invasive method for assessing airway inflammation. IL-17 plays an important role in T cell-dependent inflammatory response that occurs in allergic asthma, it could act as a potent activator of inducible nitric oxide synthase (iNOS) to amplify FeNO levels.

OBJECTIVES

To evaluate the differences in the CD4(+) IL-17A(+) T cell counts, serum IL-17 levels, and FeNO levels in children with mild intermittent to moderate to severe persistent asthma classified by using the Global Initiative for Asthma (GINA).

METHODS

One hundred and twenty asthmatic children divided into the mild intermittent (n = 42), mild persistent (n = 42), and moderate to severe persistent (n = 36) groups, and 20 healthy controls were recruited for the study. Information obtained at visits included the assessment of asthma severity according to GINA guidelines and C-ACT, lung function parameters, FeNO levels, CD4(+) IL-17A(+) T cells counts from PBMCs, iNOS production by sputum cells and serum IL-17 levels.

RESULTS

Serum IL-17 and FeNO levels were significantly higher in mild to severe persistent asthmatic patients than in intermittent asthmatics or healthy controls (P < 0.05). The percentage of CD4(+) IL-17A(+) T cells was higher in moderate to severe persistent asthmatics than in mild asthmatics (P < 0.01). Moderate to severe asthmatics (n = 5) exhibited greater iNOS production in sputum cells than mild cases (n = 5). Decreased iNOS expression in sputum cells was noted in all subjects after IL-17 neutralizing antibody (P < 0.05). Serum IL-17 levels were positively correlated with FeNO (rho = 0.74; P < 0.01), negatively correlated with C-ACT (rho = -0.63; P < 0.01) in asthmatics.

CONCLUSION AND CLINICAL RELEVANCE

CD4(+) IL-17A(+) T cells counts and serum IL-17 levels in conjunction with augmented FeNO levels are systemic markers of childhood asthma, using these markers, prediction and potential therapeutics for persistent asthmatics may be developed.

Early use of inhaled corticosteroids in the emergency department treatment of acute asthma

BACKGROUND

Systemic corticosteroid therapy is central to the management of acute asthma. The use of inhaled corticosteroids (ICS) may also be beneficial in this setting.

OBJECTIVES

To determine the benefit of ICS for the treatment of patients with acute asthma managed in the emergency department (ED).

SEARCH METHODS

We identified controlled clinical trials from the Cochrane Airways Group specialised register of controlled trials. Bibliographies from included studies, known reviews, and texts also were searched. The latest search was September 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs. Studies were included if patients presented to the ED or its equivalent with acute asthma, and were treated with ICS or placebo, in addition to standard therapy. Two review authors independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two review authors. There were three different types of studies that were included in this review: 1) studies comparing ICS vs. placebo, with no systemic corticosteroids given to either treatment group, 2) studies comparing ICS vs. placebo, with systemic corticosteroids given to both treatment groups, and 3) studies comparing ICS alone versus systemic corticosteroids. For the analysis, the first two types of studies were included as separate subgroups in the primary analysis (ICS vs. placebo), while the third type of study was included in the secondary analysis (ICS vs. systemic corticosteroid).

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors if the authors were unable to verify the validity of extracted information. Missing data were obtained from the authors or calculated from other data presented in the paper. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) with 95% confidence intervals (CIs). Where appropriate, individual and pooled continuous outcomes were reported as mean differences (MD) or standardized mean differences (SMD) with 95% CIs. The primary analysis employed a fixed-effect model and a random-effects model was used for sensitivity analysis. Heterogeneity is reported using I-squared (I(2)) statistics.

MAIN RESULTS

Twenty trials were selected for inclusion in the primary analysis (13 paediatric, seven adult), with a total number of 1403 patients. Patients treated with ICS were less likely to be admitted to hospital (OR 0.44; 95% CI 0.31 to 0.62; 12 studies; 960 patients) and heterogeneity (I(2) = 27%) was modest. This represents a reduction from 32 to 17 hospital admissions per 100 patients treated with ICS in comparison with placebo. Subgroup analysis of hospital admissions based on concomitant systemic corticosteroid use revealed that both subgroups indicated benefit from ICS in reducing hospital admissions (ICS and systemic corticosteroid versus systemic corticosteroid: OR 0.54; 95% CI 0.36 to 0.81; 5 studies; N = 433; ICS versus placebo: OR 0.27; 95% CI 0.14 to 0.52; 7 studies; N = 527). However, there was moderate heterogeneity in the subgroup using ICS in addition to systemic steroids (I(2) = 52%). Patients receiving ICS demonstrated small, significant improvements in peak expiratory flow (PEF: MD 7%; 95% CI 3% to 11%) and forced expiratory volume in one second (FEV(1): MD 6%; 95% CI 2% to 10%) at three to four hours post treatment). Only a small number of studies reported these outcomes such that they could be included in the meta-analysis and most of the studies in this comparison did not administer systemic corticosteroids to either treatment group. There was no evidence of significant adverse effects from ICS treatment with regard to tremor or nausea and vomiting. In the secondary analysis of studies comparing ICS alone versus systemic corticosteroid alone, heterogeneity among the studies complicated pooling of data or drawing reliable conclusions.

AUTHORS' CONCLUSIONS

ICS therapy reduces hospital admissions in patients with acute asthma who are not treated with oral or intravenous corticosteroids. They may also reduce admissions when they are used in addition to systemic corticosteroids; however, the most recent evidence is conflicting. There is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function or clinical scores when used in acute asthma in addition to systemic corticosteroids. Also, there is insufficient evidence that ICS therapy can be used in place of systemic corticosteroid therapy when treating acute asthma. Further research is needed to clarify the most appropriate drug dosage and delivery device, and to define which patients are most likely to benefit from ICS therapy. Use of similar measures and reporting methods of lung function, and a common, validated, clinical score would be helpful in future versions of this meta-analysis.

A smarter way to manage asthma with a combination of a long-acting beta(2)-agonist and inhaled corticosteroid

Symbicort SMART® (Symbicort Maintenance and Reliever Therapy) represents a new and unique way of treating patients with moderate-to-severe asthma, ie, those patients who require combination treatment with an inhaled corticosteroid and a long-acting inhaled β₂-agonist. Symbicort SMART enables patients to use only one inhaler, the budesonide-formoterol combination inhaler, for both maintenance and reliever therapy. The maintenance dose is adjustable, but should be a minimum of two doses per day which can be administered as two doses once daily or as one dose twice daily. It is important that the temporary reliever medication includes not only a bronchodilator but also an antiinflammatory drug because worsening of asthma includes not only more airway narrowing, but also an increase in airway inflammation. The Symbicort SMART concept therefore ensures that the patient gets an antiinflammatory drug at the time of the first signs of asthma worsening. Clinical results show that Symbicort SMART prolongs the time to the first severe asthma exacerbation, reduces the rate of exacerbations, and maintains day-to-day asthma control at a reduced load of corticosteroids (inhaled plus systemic) when compared with higher fixed maintenance doses of combination inhalers. Symbicort SMART consequently offers a more effective and simple approach to asthma management for physicians and patients. Symbicort SMART is also easier for the patient as only one inhaler is required. The positive results with Symbicort SMART can be explained by the early as-needed use on the inhaled corticosteroid component, which puts out the early flames of inflammation, together with the interaction between the β₂-agonist, formoterol, and the inhaled corticosteroid, budesonide.

Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial

OBJECTIVES

The goal was to determine if adding inhaled budesonide to standard asthma therapy improves outcomes of pediatric patients presenting to the emergency department (ED) with acute asthma.

METHODS

The authors conducted a randomized, double-blind, placebo-controlled trial in a tertiary care, urban pediatric ED. Patients 2 to 18 years of age with moderate to severe acute asthma were randomized to receive either a single 2-mg dose of budesonide inhalation suspension (BUD) or normal sterile saline (NSS) placebo, added to albuterol, ipratropium bromide (IB), and systemic corticosteroids (SCS). The primary outcome was the difference in median asthma scores between treatment groups at 2 hours. Secondary outcomes included differences in vital signs and hospitalization rates.

RESULTS

A total of 180 patients were enrolled. Treatment groups had similar baseline demographics, asthma scores, and vital signs. A total of 169 patients (88 BUD, 81 NSS) were assessed for the primary outcome. No significant difference was found between groups in the change in median asthma score at 2 hours (BUD -3, NSS -3, p = 0.64). Vital signs at 2 hours were also similar between groups. Fifty-six children (62%) were admitted to the hospital in the BUD group and 55 (62%) in the NSS group (difference 0%, 95% confidence interval [CI] = -14% to 14%). Neither multivariate adjustment nor planned subgroup analysis by inhaled corticosteroids (ICS) use prior to the ED significantly altered the results.

CONCLUSIONS

For children 2 to 18 years of age treated in the ED for acute asthma, a single 2-mg dose of budesonide added to standard therapy did not improve asthma severity scores or other short-term ED-based outcomes.

Exhaled nitric oxide levels during treatment of pediatric acute asthma exacerbations and association with the need for hospitalization

OBJECTIVES

To examine how exhaled nitric oxide (eNO) levels measured before and after treatment of asthma exacerbations relate to emergency department (ED) disposition.

METHODS

We enrolled children 6 to 17 years old treated for asthma exacerbations in a pediatric ED. Using an offline single-breath eNO sampling technique, we collected replicate initial samples before treatment and replicate final samples when disposition was decided. We determined correlations and coefficients of variability of eNO values (parts per billion, ppb) of samples and compared by disposition (hospitalization or discharge) mean initial and final eNO levels and initial-to-final change.

RESULTS

Eighty-one subjects had initial and final eNO values; 24 subjects with more severe presentations had final values only. Replicate eNO samples were correlated (initial r = 0.98, final r = 0.99) and had low coefficients of variability (initial, 0.059 ± 0.057; final, 0.061 ± 0.070). For subjects with initial and final values, initial eNO levels were similar by disposition (mean difference, -8.0 ppb; 95% confidence interval [CI], -24.8 to 8.9 ppb), as were final levels (mean difference, -2.8 ppb; 95% CI, -23.8 to 18.2 ppb). Overall, final eNO was higher than initial (36.3 ± 29.7 vs 31.5 ± 23.9 ppb), but only 63% of subjects had any increase. Change in eNO was similar by disposition (mean difference, 4.6 ppb; 95% CI, -3.4 to 12.6). For more severe subjects with final eNO only, eNO was similar by disposition (P = 0.47).

CONCLUSIONS

For children aged 6 to 17 years with asthma exacerbations, eNO levels can be reliably measured. However, eNO levels measured before treatment or when disposition was determined did not distinguish children needing hospitalization.

Inhaled corticosteroids as rescue medication in acute severe asthma

Systemic corticosteroids (CS) should be considered as first-line treatment for acute asthma exacerbations, especially severe exacerbations. They may sometimes require a few hours or more to achieve their maximum effect. This time delay observed between administration of CS and improvement in lung function or hospital admissions is consistent with the belief that these effects of CS, involving the modification of gene expression, occur with a time lag of hours or days (genomic effect). On the other hand, CS also have effects initiated by specific interactions with membrane-bound or cytoplasmic receptors for CS, or nonspecific interactions with the cell membrane, with a much more rapid response (seconds or minutes; nongenomic effect). This review analyzes the clinical evidence regarding the use of inhaled CS in acute asthma patients, according to the characteristics of the nongenomic effect, and presents a proposal for the use of inhaled CS as a rescue medication in the emergency-department setting.

Effect of elevated exhaled nitric oxide levels on the risk of respiratory tract illness in preschool-aged children with moderate-to-severe intermittent wheezing

BACKGROUND

The fractional concentration of exhaled nitric oxide (FeNO) is a noninvasive marker for airway inflammation but requires further study in preschool-aged children to determine its clinical relevance.

OBJECTIVE

To determine whether the risk of respiratory tract illnesses (RTIs), disease burden, and atopic features are related to FeNO in preschool-aged children with moderate-to-severe intermittent wheezing.

METHODS

We determined FeNO using the off-line tidal breathing technique in 89 children, aged 12 to 59 months, with moderate-to-severe intermittent wheezing. The risk of RTI was determined by comparing participants with a baseline FeNO of greater than the 75th percentile (24.4 ppb) with those with a baseline FeNO at the 75th percentile or lower using Cox regression analysis.

RESULTS

The risk of RTI was significantly higher in children with an FeNO of greater than 24.4 ppb relative to those with lower FeNO values (adjusted relative risk, 3.80; 95% confidence interval, 1.74-8.22; P < .001). FeNO levels of greater than 24.4 ppb were associated with more positive skin test results to aeroallergens (P = .03) but not with other atopic characteristics or historic parameters of illness burden.

CONCLUSIONS

An elevated FeNO in preschool-aged children with moderate-to-severe intermittent wheezing was associated with an increased risk of RTI during a 1-year follow-up. In addition, a higher FeNO was associated with aeroallergen sensitization.

Offline exhaled nitric oxide in emergency department and subsequent acute asthma control

BACKGROUND

Few studies have evaluated exhaled NO measurement during acute asthma.

OBJECTIVES

To evaluate exhaled NO fraction (FE(NO)) and peak expiratory flow (PEF) time-courses during acute asthma treatment (beta 2-agonist plus systemic steroid) and to assess whether FE(NO) time-course predicts subsequent asthma control.

METHODS

Sixty-five asthmatic patients (mean +/- SD, 34 +/- 10 years) were prospectively enrolled in three Emergency Departments.

RESULTS

Sixteen patients were excluded (failure of offline FE(NO) measurement at 100 mL/s [FE(NO 0.1)], n = 4, and early discharge). The 49 remaining patients performed FE(NO 0.1) and PEF on admission, at the 2nd (H2) and 6th hour (H6). Follow-up using an Asthma Control Diary was obtained in 27 of 49 patients, whether they were hospitalized (n = 9) or discharged (n = 18). All but 2 patients had elevated FE(NO) on admission (median [interquartile], 49 [26-78] ppb). Unlike PEF, mean FE(NO 0.1) of our sample was not significantly modified by treatment. No significant relationship was evidenced between exhaled NO and PEF variations. The variation of FE(NO 0.1) [H0 minus H6] was different in patients who were hospitalized (decrease of 8 +/- 20 ppb) versus discharged (increase of 5 +/- 20 ppb, p = 0.04). This variation of FE(NO 0.1) was correlated with the Diary score (control of subsequent week), an initial increase in FE(NO 0.1) being associated with better asthma control. Nevertheless, neither exhaled NO nor PEFR were good predictors of asthma control.

CONCLUSIONS

An increase in FE(NO) is observed in almost all patients with acute asthma, and its subsequent increase within 6 hours is associated with a better degree of asthma control in the subsequent week.

The role of exhaled nitric oxide in evaluation of acute asthma in a pediatric emergency department

OBJECTIVES

Fractional excretion of nitric oxide (FE(NO)) has been used as a noninvasive marker to assess and manage chronic asthma in adults and children. The aim of this study was to determine the feasibility of obtaining FE(NO) concentrations in children treated in the emergency department (ED) for acute asthma exacerbation and to examine the association between FE(NO) concentrations and other measures of acute asthma severity.

METHODS

This was a cross-sectional study of a convenience sample of children 2-18 years old who were seen in an urban ED for acute asthma exacerbation. Using a tidal breathing method with real-time display, the authors measured FE(NO) concentrations before and 1 hour after the administration of corticosteroids and at discharge from the ED. Outcome measures included pulmonary index score (PIS), hospital admission, and short-term outcomes (e.g., missed days of school).

RESULTS

A total of 133 subjects were enrolled. Sixty-eight percent (95% confidence interval [CI] = 60% to 76%) of the subjects provided adequate breaths for FE(NO) measurement. There was no difference in the median initial FE(NO) concentration among subjects, regardless of the severity of their acute asthma. Most subjects showed no change in their FE(NO) concentrations from the start to the end of treatment. FE(NO) concentrations were not significantly associated with other short-term outcomes.

CONCLUSIONS

Measurement of FE(NO) is difficult for a large proportion of children with acute asthma exacerbation. FE(NO) concentration during an asthma exacerbation does not correlate with other measures of acute severity and has limited utility in the ED management of acute asthma in children.

Budesonide/formoterol for maintenance and reliever therapy in the management of moderate to severe asthma

The Global Initiative for Asthma (GINA) guidelines aim at improving asthma control and preventing future risk. For patients with moderate to severe asthma an inhaled corticosteroid (ICS) or an ICS/long-acting beta2-agonist (LABA) combination with a short-acting beta2-agonist (SABA) as reliever is recommended. Despite the availability of effective maintenance therapies, a large proportion of patients still fail to achieve guideline-defined asthma control, and overuse of SABA reliever medication at the expense of ICS is commonly observed. New simplified treatment approaches may offer a solution and assist physicians to achieve overall asthma control. One such treatment approach, which is recommended in the GINA guidelines, is budesonide/formoterol for both maintenance and reliever therapy. This treatment strategy significantly reduces the rate of severe asthma exacerbations compared with ICS/LABA plus SABA and achieves equivalent daily symptom control compared with higher doses of ICS/LABA plus separate SABA for relief. These benefits are achieved at a lower overall steroid load, and budesonide/formoterol maintenance and reliever therapy is well tolerated in patients with moderate to severe asthma. This review discusses current asthma management in patients with moderate to severe disease and examines the evidence for alternative asthma management approaches.

[Follow up of asthmatic children: definition and measurement tools]

The guidelines for the management of asthma currently emphasise the concept of monitoring that reflects the activity of the disease over a period of several weeks. This principle is valid whatever the severity of the asthma. The monitoring tools are essentially clinical and functional. The clinical parameters (daytime and/or nocturnal symptoms, discomfort on exercise, beta-2 agonist usage) should be evaluated systematically at each consultation just as at the onset of exacerbations. A number of questionnaires have been developed (ATAQ, ACT...). At the functional level every asthmatic child should have the benefit of a respiratory function assessment, the frequency of which depends on the therapeutic management programme. Among the non-invasive measurements of airway inflammation the measurement of expired nitric oxide (NO) is the best established. The measurement of expired NO could improve some paraclinical parameters that are not monitored routinely.

Comparison of single 2000-microg dose treatment vs. sequential repeated-dose 500-microg treatments with nebulized budesonide in acute asthma exacerbations

BACKGROUND

High repeated doses of inhaled corticosteroids (ICSs) are recognized as having a more rapid improvement of outcomes than a single dose of ICS in severe acute asthma. However, to our knowledge, there has been no direct comparison of the early effects of single or repeated administration of the same total dosage of ICS in children with moderate to severe exacerbations of asthma.

OBJECTIVE

To compare the efficacy of a single dose of 2000 microg of nebulized budesonide with 4 repeated doses of 500 microg of nebulized budesonide in 40 children with an acute asthma exacerbation.

METHODS

Randomized, double-blind, parallel study that compared the efficacy of 2000 microg of nebulized budesonide, administered in a single dose, with repeated doses (4 doses of 500 microg each) during the first 90 minutes in 40 children (mean [SD] age, 10.7 [2.4] years) with an acute asthma exacerbation that required treatment with an oral corticosteroid. Forced expiratory volume in 1 second, asthma attack score, and oxygen saturation were evaluated at 20, 40, 60, 90, 120, 180, and 240 minutes after initial treatment. Oral corticosteroids were given to all patients at 90 minutes.

RESULTS

There were no significant differences in forced expiratory volume in 1 second (P = .54) at any times between the groups. Also, asthma scores and oxygen saturation were not different in either group within 90 minutes (P = .51 and P = .64, respectively) and thereafter (P = .35 and P = .87, respectively).

CONCLUSION

The use of a single dose of nebulized budesonide is as effective as repeated administration of the same total dosage during the first 90 minutes before giving oral corticosteroids in children with moderate to severe exacerbations of asthma.

Exhaled nitric oxide distinguishes between subgroups of preschool children with respiratory symptoms

BACKGROUND

Respiratory symptoms are common in early childhood. The clinical characterization of disease presentation and hence its likely disease progression has so far been proven difficult.

OBJECTIVE

To investigate whether exhaled nitric oxide (NO) could be helpful to distinguish between subgroups of nonwheezy and wheezy young children less than 4 years of age.

METHODS

Exhaled NO was measured in 391 children (age 3-47 months) with nonwheezy and wheezy respiratory symptoms. Children were divided into 3 groups: children with recurrent cough but no history of wheeze (group 1), with early recurrent wheeze and a loose index for the prediction of asthma at school age (group 2), and with frequent recurrent wheeze and a stringent index for the prediction of asthma at school age (group 3).

RESULTS

Children from group 3 showed significantly higher median (interquartile range) fractional exhaled NO (FeNO) levels (11.7 [11.85]) than children from groups 1 (6.5 [5.5]; P < .001) and 2 (6.4 [6.5]; P < .001). No difference in FeNO levels was found between children from groups 1 and 2 (P = .91).

CONCLUSION

Wheezy young children less than 4 years of age with a stringent index for the prediction of asthma at school age have elevated levels of FeNO compared with children with recurrent wheeze and a loose index for the prediction of asthma at school age or children with recurrent cough.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Exhaled nitric oxide in childhood asthma: a review

As an 'inflammometer', the fraction of nitric oxide in exhaled air (Fe(NO)) is increasingly used in the management of paediatric asthma. Fe(NO) provides us with valuable, additional information regarding the nature of underlying airway inflammation, and complements lung function testing and measurement of airway hyper-reactivity. This review focuses on clinical applications of Fe(NO) in paediatric asthma. First, Fe(NO) provides us with a practical tool to aid in the diagnosis of asthma and distinguish patients who will benefit from inhaled corticosteroids from those who will not. Second, Fe(NO) is helpful in predicting exacerbations, and predicting successful steroid reduction or withdrawal. In atopic asthmatic children Fe(NO) is beneficial in adjusting steroid doses, discerning those patients who require additional therapy from those whose medication dose could feasibly be reduced. In pre-school children Fe(NO) may be of help in the differential diagnosis of respiratory symptoms, and may potentially allow for better targeting and monitoring of anti-inflammatory treatment.

Suppression of plasma matrix metalloproteinase-9 following montelukast treatment in childhood asthma

BACKGROUND

Montelukast and ketotifen are commonly prescribed anti-inflammatory medications used in the treatment of childhood asthma.

METHODS

To investigate the modulation effect of montelukast and ketotifen, the levels of exhaled nitric oxide (eNO) and plasma matrix metalloproteinase-9 (MMP-9) were analyzed in a group of 30 children with mild persistent asthma.

RESULTS

Patients on montelukast therapy for 8 weeks had significantly decreased levels of eNO and plasma MMP-9, which were associated with improved symptoms and enhanced peak expiratory flow but not significantly associated with increased level of tissue inhibitor metalloproteinase-1 (TIMP-1). In contrast, treatment with ketotifen produced no significant changes in these parameters until 4-6 weeks into the therapy and no effect on plasma MMP-9.

CONCLUSION

Leukotriene antagonists, such as montelukast, may be better non-steroidal anti-inflammatory drugs for preventing airway inflammation in mild childhood asthma.

Montelukast decreased exhaled nitric oxide in children with perennial allergic rhinitis

BACKGROUND

Measurement of exhaled nitric oxide (eNO) is a simple and noninvasive method for assessment of inflammatory airway diseases. eNO is elevated in adolescent patients with perennial allergic rhinitis and related to bronchial hyperresponsiveness. The aim of this study was to investigate whether oral loratadine, montelukast, nasal budesonide or nasal sodium cromoglycate could reduce airway inflammation as indicated by decrease of eNO in children with perennial allergic rhinitis as demonstrated by eNO levels.

METHODS

A randomized and investigator-blinded study was conducted in a hospital-based outpatient clinic. Children with perennial allergic rhinitis were divided into four groups and treated by loratadine, loratadine with nasal sodium cromoglycate, loratadine with oral montelukast, and loratadine with nasal budesonide, respectively. Allergic rhinitis scores, eNO and peak expiratory flow were measured before and 2, 4, 6 and 8 weeks after treatment.

RESULTS

Results showed that eNO in children with perennial allergic rhinitis was reduced by nasal budesonide and oral montelukast within 2 weeks (24.56 +/- 14.42 vs 18.42 +/- 12.48, P < 0.001, in budesonide group; 27.81 +/- 13.4 vs 19.09 +/- 10.45, P < 0.001, in montelukast group), but not in the loratadine and cromoglycate groups. In contrast, loratadine or sodium cromoglycate also did not decrease eNO levels although they could decrease the symptom scores.

CONCLUSIONS

It was concluded that four common treatment modalities could effectively release symptom scores, but decrease of airway inflammation as determined by decrease of eNO might be only achieved by nasal budesonide and montelukast, but not nasal sodium cromoglycate and loratadine. Children with perennial allergic rhinitis with high eNO levels may require oral montelukast or nasal budesonide treatment to prevent airway hyperresponsiveness.

[Inhaled corticosteroids in the treatment of asthma exacerbations: essential concepts]

The use of systemic corticosteroids reduces hospitalizations in patients suffering an asthma attack and improves lung function within 6 to 12 hours of administration. However, despite the considerable body of positive evidence published in the last decade, doubts remain in regard to the effectiveness of inhaled corticosteroids. Analysis of this evidence has been cursory; crucial data on the mechanism of action of corticosteroids have been overlooked and there has been a failure to distinguish between antiinflammatory effects and so-called nongenomic effects. This review considers the biological basis for the effects of inhaled corticosteroids and analyzes the best data available on the use and therapeutic implications of inhaled corticosteroids for the treatment of asthma exacerbations.

Rapid effects of inhaled corticosteroids in acute asthma: an evidence-based evaluation

BACKGROUND

Current reviews on the use of inhaled corticosteroids (ICS) for acute asthma underestimated their early (minutes) clinical impact and produced conclusions of questionable validity.

OBJECTIVE

The analysis of the best evidence available on the early (1 to 4 h) clinical impact of ICS for patients with acute asthma in the emergency department (ED) setting.

METHODS

Published (from 1966 to 2006) randomized controlled trials were retrieved using different databases (MEDLINE, EMBASE, Cochrane Controlled Trials Register), bibliographic reviews of primary research, review articles, and citations from texts. Primary outcome measures were admission and ED discharge rates.

RESULTS

Seventeen studies met criteria for inclusion in the review (470 adults and 663 children and adolescents). After 2 to 4 h of protocol, a greater reduction in admission rate was observed with trials that used multiple doses of ICS (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.16 to 0.55), especially when they were compared with placebo. Patients treated with ICS also displayed a faster clinical improvement compared with placebo or systemic corticosteroids (SCS), increasing the probability of an early ED discharge (OR, 4.70; 95% CI, 2.97 to 7.42; p = 0.0001). The advantage of the use of ICS was also demonstrated in spirometric and clinical measures as early as 60 min. These benefits were obtained only when patients received multiple doses of ICS along with beta-agonists compared with placebo or SCS.

CONCLUSIONS

Data suggests that ICS present early beneficial effects (1 to 2 h) when they were used in multiple doses administered in time intervals < or = 30 min over 90 to 120 min. The nongenomic effect is a possible candidate by covering the link between molecular pathways and the clinical effects of corticosteroids.

Inhaled budesonide in the management of acute worsenings and exacerbations of asthma: a review of the evidence

The use of systemic corticosteroids, together with bronchodilators and oxygen therapy, has become established for the management of acute asthma. These agents are undoubtedly effective, but are also associated with problems such as metabolic adverse effects. Inhaled corticosteroids (ICS) offer potential benefit in the acute setting because they are delivered directly to the airways. They are also likely to reduce systemic exposure, which would lead in turn to reductions in rates of unwanted systemic effects. In order to evaluate the role of budesonide in the management of acute asthma exacerbations we conducted a review of the literature and critically evaluated the rationale for the use of ICS in general in this setting. Trials in adults and children requiring treatment for acute exacerbation of asthma have shown clinical and/or spirometric benefit for budesonide when delivered via nebulizer, dry powder inhaler, or aerosol in the emergency department, hospital and follow-up settings. The efficacy seems to benefit from high doses given repeatedly during the initial phase of an acute exacerbation. These acute effects are likely to be linked to the drug's distinctive pharmacokinetic and pharmacodynamic profile. The current evidence base revealed encouraging results regarding the efficacy of the ICS budesonide in patients with wheeze and acute worsening of asthma. Future studies should focus on the efficacy of these agents in more severe asthma worsenings.

The effect of a single inhaled dose of a VLA-4 antagonist on allergen-induced airway responses and airway inflammation in patients with asthma

Adhesion molecule very late antigen-4 (VLA-4) is implicated in the recruitment and activation of inflammatory cells in asthma, including eosinophils, T cells and mast cells. VLA-4 antagonists have been proposed as a new anti-inflammatory treatment modality for asthma. Therefore, we investigated whether a single inhaled dose of VLA-4 antagonist GW559090X could protect against allergen-induced changes in airway responses and airway inflammation in patients with asthma. We performed a randomized, double-blind, three-way crossover study with single inhaled doses of 3 mg of GW559090X, 500 microg of fluticasone propionate (FP) or placebo in 15 patients with mild intermittent asthma, controlled with short-acting beta(2)-agonists only. All patients developed a late asthmatic response (LAR) after allergen inhalation during screening. Study medication was administered 30 min prior to allergen challenge. Pre-dose and 24 h post-dose PC20 methacholine and levels of exhaled nitric oxide (eNO) were determined. At the given dose, VLA-4 antagonist GW559090X did not attenuate the early asthmatic response (EAR) when compared with placebo: mean AUC0-2 h(+/-SEM) (%fall h): 27.2+/-3.7 and 21.9+/-3.0 respectively (P=0.33); nor the LAR: mean AUC3-8 h(+/-SEM) (%fall h): 98.8+/-12.9 and 94.8+/-6.8 respectively (P=0.84). However, pretreatment with FP did attenuate both EAR and LAR when compared with placebo: mean AUC0-2 h11.6+/-3.3 (P=0.024) and mean AUC3-8 h 6.3+/-7.6 (P<0.001). None of these treatments had an effect on allergen-induced changes in airway hyper-responsiveness or eNO levels. These findings suggest that VLA-4 may not play a major role in allergen-induced airway responses and inflammation in asthma.

Daily ambulatory exhaled nitric oxide measurements in asthma

Exhaled NO (FENO) is a non-invasive, validated marker for asthmatic airway inflammation. Recently, a new hand-held NO-analyzer has been developed which makes it possible to monitor FENO at home. We assessed feasibility and analyzed variability of daily FENO home measurements. Twenty-one asthmatics (mean age 14.5 yr; range 8-25 yr) participated. Nineteen used a stable dose of inhaled corticosteroids and all of them were in a stable clinical condition. FENO was measured twice daily for 14 consecutive days. Measurements and symptom scores were recorded on a smart card in the analyzer. Symptom score items included well-being, wheeze, activity, and nocturnal symptoms. Measurements showed a success rate of 93%. We found a significant diurnal variation in FENO with geometric mean morning levels 14% higher than evening levels (95% CI: 4%-25%; p = 0.013). Individual subjects showed marked fluctuation of FENO. The mean intrasubject coefficient of variation of FENO was 40% for morning and 36% for evening values. FENO and cumulative symptom scores did not correlate. Home FENO measurements are feasible, and offer the possibility to asses airway inflammation on a daily basis. Further study is needed to interpret and evaluate possible benefits of FENO home monitoring.

Regulation of stromal cell-derived factor-1 and exhaled nitric oxide in asthmatic children following montelukast and ketotifen treatment

BACKGROUND

Montelukast and ketotifen are oral anti-allergy medications in asthmatic children. This study investigates the modulation effect of montelukast and ketotifen on children with intermittent to mild persistent asthma as demonstrated by the levels of peak expiratory flow (PEF), asthma scores (AS), exhaled nitric oxide (eNO) and plasma stromal cell-derived factor-1 (SDF-1) concentration in a randomized, prospective study.

METHODS

Fifty asthmatic children were enrolled and received 8 weeks of treatment with oral montelukast sodium 5mg chewable tablet administered once daily, or 1mg ketotifen, and were followed for a 4-week post-treatment washout period. ENO concentration, AS and PEF were measured before, 2, 4, 6 and 8 weeks after initial treatment, and 4 weeks after cessation of treatment.

RESULTS

Montelukast therapy was showed to improve AS, PEF and eNO within 2 weeks and remained the improvement during the treatment period. Montelukast also significantly decreased plasma SDF-1 levels after 8 weeks of treatment. In contrast, the ketotifen treatment revealed no significant effects in these clinical parameters until 4 and 6 weeks of the therapy, and did not suppress plasma SDF-1 levels after 8 weeks of treatment. To prove whether montelukast directly suppressed SDF-1 induction, we studied effects of montelukast on the LPS-induced SDF-1 expression and SDF-1-induced chemotaxis of monocytic (THP-1) cells. Montelukast, but not ketotifen, could suppress SDF-1 expression and its related chemotaxis on THP-1 monocytic cells.

CONCLUSIONS

Leukotriene receptor antagonist, such as montelukast, may be a better non-steroid anti-inflammatory drug for mild childhood asthma in preventing airway inflammation.

Relationship between exhaled nitric oxide levels and compliance with inhaled corticosteroids in asthmatic children

Levels of exhaled nitric oxide (eNO) are elevated in subjects with asthma and fall in response to oral or inhaled steroids. This study explored the possibility the measurement of eNO levels could be used to identify subjects who were not adhering to their treatment regimen. Twenty children with asthma attending the respiratory clinic were recruited. Each attended on four occasions 1 month apart when eNO levels were measured. A data logger attached to a pressurised metered dose inhaler was used to objectively monitor use of inhaled corticosteroids (ICSs). The correlation between day and dose compliance with eNO was assessed. The data demonstrated a weak but non-significant correlation between eNO and both day (r = 0.055, P = 0.67) and dose (r = 0.153, P = 0.23). A recorded value of eNO less than 12 was associated with day compliance rates of 3-97%. Of the 19 recorded eNO values greater than 12 ppb almost 80% were from subjects with a day compliance of less than 50% during the preceding month. Of the four values greater than 12 ppb and day compliance > 60% one subject had a poor inhaler technique, one had a mild viral exacerbation and one appeared to be associated with increase pollen exposure. The measurement of eNO may prove to be a useful tool in helping to manage children with asthma but further work is required to define its precise role. Elevated eNO levels in asthmatic children taking ICSs are likely to reflect poor compliance but confounding factors such as disease activity and inhaler technique need to be carefully considered.

High fractional concentration of nitric oxide in exhaled air despite steroid treatment in asthmatic children

BACKGROUND

The fractional concentration of nitric oxide in exhaled air (FENO) is elevated in atopic asthma and typically responds to treatment with inhaled corticosteroids (ICS). However, some patients have persistently high FENO levels despite treatment.

OBJECTIVE

We studied how optimizing the inhalation technique and increasing ICS doses would affect FENO in stable atopic asthmatic children who had elevated FENO while using ICS.

METHODS

In 41 stable asthmatic children who were treated with ICS (median daily dose 800 microg budesonide equivalent, range 100-1600 microg) and maintained FENO> or =20 p.p.b., we optimized the inhalation technique by thorough instruction and measured FENO 2 weeks later. Then, if FENO remained > or =20 p.p.b., we increased the ICS dose and reassessed FENO 2 weeks later.

RESULTS

Improving the inhalation technique did not reduce FENO. Increasing ICS from a daily median dose of 800 to 1200 microg budesonide had no significant effect on FENO. FENO correlated positively with symptom scores in the following 2 and 4 weeks (P=0.001, 0.002) and beta2-agonist use the 2 and 4 weeks following FENO measurement (P=0.02, 0.004).

CONCLUSION

We conclude that common steps in asthma treatment, i.e. inhalation instruction and increasing ICS dose, were both ineffective in reducing FENO in atopic asthmatic children with elevated FENO values despite treatment with ICS. This implies that FENO cannot simply be incorporated in current treatment guidelines.

Effects of montelukast on symptoms and eNO in children with mild to moderate asthma

BACKGROUND

Asthma is a chronic inflammatory airway disease. Exhaled nitric oxide (eNO) is a marker reflecting airway inflammation. This study was conducted to investigate whether montelukast, a leukotriene receptor antagonist, could be used for the management of asthma and how fast the montelukast sodium decreased airway inflammation as demonstrated by eNO levels.

METHODS

Twenty children aged 6-14 years (mean age: 9.2 +/- 2.4 years; mean weight 30 +/- 4.6 kg) with mild to moderate asthma were recruited for the study. They received montelukast plus an inhaled short-acting beta2 agonist as open and uncontrolled therapy. Asthma score (AS) and peak expiratory flow rate (PEFR) and eNO concentrations were measured at pretreatment (0 week) and post-treatment (1 and 2 weeks) as well as 2 weeks after withdrawal of therapy.

RESULTS

In one week, the eNO levels (33.3 +/- 15.5 p.p.b. vs 14.8 +/- 8.6 p.p.b.; P < 0.05), and AS (4.2 +/- 1.3 vs 1.8 +/- 1.3; P < 0.05) decreased rapidly, and PEFR (206.9 +/- 69.7 L/min vs 236.2 +/- 69.8 L/min; P < 0.05) increased. Concurrent beta2 agonist use decreased from a mean +/- SD of 2.2 +/- 0.4-1.3 +/- 0.3 puffs per weeks (P < 0.05). After the withdrawal of treatment for 2 weeks, the eNO levels (29.2 +/- 16.1 p.p.b) rebounded again, although the improvements in AS (1.1 +/- 1.3) and PEFR (245.0 +/- 91.3 L/min) persisted.

CONCLUSION

Oral montelukast sodium treatment of these children with mild to moderate asthma effectively improved asthmatic symptoms and suppressed airway inflammation in 1 week, suggesting that this leukotriene antagonist combined with short-acting beta2 agonists may provide effective treatment option in mild to moderate childhood asthma. Larger, controlled, and double-blinded studies are needed to confirm these preliminary open uncontrolled observations.

Induced apoptosis of TH2 lymphocytes in asthmatic children treated with Dermatophagoides pteronyssinus immunotherapy

Allergen-specific immunotherapy (IT) has been effectively used for the treatment of asthma. Allergen specific IT induced immune tolerance with induction of TH2 cells anergy remain to be clarified. The aim of this study was to evaluate whether the mite allergen Dermatophagoides pteronyssinus (Dpt) specific IT serially decreased IL-4+/CD4+ (TH2) lymphocytes and induced apoptosis of TH2 lymphocytes in asthmatic children. Sixty Dpt-sensitive asthmatic children were randomly assigned to a received IT and an untreated group. Dermatophagoides pteronyssinus specific IT treated patients were examined at three time points: before IT, after 6 months of an increased dose phase and with maximum tolerated doses after 1 yr. Peripheral blood mononuclear cells (PBMC) were isolated and cultured for 48 h for cellular staining with CD4+, CD45RO cell phenotypes and interleukin (IL)-4 and interferon-gamma expression by fluorescence monoclonal antibodies. Apoptosis was measured using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) method. A simultaneous flow cytometric study using the same permeabilized cell was examined to determine whether apoptosis occurred preferentially in TH2 lymphocytes. The data demonstrated that Dpt specific IT decreased Dpt-specific IgE levels (p < 0.01) after 1 yr of treatment. In addition, decreased CD4+IL-4+ TH2 cells with increased CD4+IFN-gamma+ TH(1) cells were observed at 6 months and 1 yr after IT treatment (p < 0.05). At the same time, apoptosis of CD4+IL-4+ TH2 lymphocytes in the IT group had increased after 1 yr of treatment when compared with the results before treatment (p < 0.001) and after 6 months of treatment (p = 0.046). In addition, CD45RO cells apoptosis mainly occurred after 6 months of IT treatment and after 1-year period of IT treatment (p < 0.05). All of the data suggested that Dpt specific IT decreased Dpt specific IgE and CD4+IL-4+ TH2 lymphocytes with induction apoptosis of CD4+IL-4+ TH2 lymphocytes subsets serially.

Asthma management issues in infancy and childhood

The prevalence of asthma has been increasing worldwide over the past 2 decades, especially the prevalence of childhood asthma. Currently, the prevalence of childhood asthma is around 3-20% in different countries based on the report from the International Study of Asthma and Allergies in Children (ISAAC). Asthma in childhood is predominantly an extrinsic asthma. In general, countries in the coastal, temperate, and subtropical zones have the highest prevalence of mite- and cockroach-sensitive asthma. Countries in the sub-arctic or semi-arid areas have a lower prevalence of childhood asthma, mostly associated with sensitization to pet dander, moulds, and pollens. Many genes have been linked to asthma in different ethnic populations. A global consensus for the management of asthma in adults and children >5 years of age has been made possible in the Global Initiative for Asthma (GINA) guidelines, where a step-wise management program using inhaled medication with and without oral anti-inflammatory drugs is recommended. The management of asthma in children <5 years of age remains inconclusive. Recent studies suggest that inherited susceptibility associated with risk factors from the prenatal and postnatal environment is likely to promote allergic sensitization and development of asthma. Consequently, early prevention of prenatal sensitization in utero and environmental control of early life exposure to various allergens may decrease the incidence of childhood asthma. In the management of moderate persistent asthma in infants and young children <5 years of age, airway resistance tests (FEV(1) or PEF) are not of significance, but assessment of respiratory rate and skin pulse oximeter measurements of arterial oxygen saturation are helpful. Moreover, recent advances in pharmacogenetics and pharmacogenomics may provide better individualized care for early pharmacological prevention of childhood asthma via selective modulation of airway remodeling.

Titrating steroids on exhaled nitric oxide in children with asthma: a randomized controlled trial

RATIONALE

Corticosteroids are the antiinflammatory treatment of choice in asthma. Treatment guidelines are mainly symptom-driven but symptoms are not closely related to airway inflammation. The fraction of nitric oxide in exhaled air (FENO) is a marker of airway inflammation in asthma.

OBJECTIVE

We evaluated whether titrating steroids on FENO improved asthma management in children.

METHODS

Eighty-five children with atopic asthma, using inhaled steroids, were allocated to a FENO group (n=39) in which treatment decisions were made on both FENO and symptoms, or to a symptom group (n=46) treated on symptoms only. Children were seen every 3 months over a 1-year period.

MEASUREMENTS

Symptoms were scored during 2 weeks before visits and 4 weeks before the final visit. FeNO was measured at all visits, and airway hyperresponsiveness and FEV1 were measured at the start and end of the study. Primary endpoint was cumulative steroid dose.

RESULTS

Changes in steroid dose from baseline did not differ between groups. In the FENO group, hyperresponsiveness improved more than in the symptom group (2.5 vs. 1.1 doubling dose, p=0.04). FEV1 in the FENO group improved, and the change in FEV1 was not significantly different between groups. The FENO group had 8 severe exacerbations versus 18 in the symptom group. The change in symptom scores did not differ between groups. FENO increased in the symptom group; the change in FENO from baseline differed between groups (p=0.02).

CONCLUSION

In children with asthma, 1 year of steroid titration on FENO did not result in higher steroid doses and did improve airway hyperresponsiveness and inflammation.

Discrepant clinical responses and blood chemokine profiles between two non-steroidal anti-inflammatory medications for children with mild persistent asthma

In a randomized study, two oral medications, ketotifen and montelukast, were compared for children with mild persistent asthma. Montelukast revealed faster clinical responses than ketotifen, showing improved exhaled nitric oxide, peak expiratory flow, and asthma scores in 1 wk. After 8-wk of medication, both ketotifen and montelukast revealed improved clinical responses. However, 8 wk of ketotifen, but not montelukast, decreased plasma serum thymus and activation-regulated chemokine (317.854 +/- 207.906 vs. 181.348 +/- 167.109, p < 0.05), macrophage-derived chemokine (355.11 +/- 174.30 vs. 169.19 +/- 62.42, p < 0.05) levels. In conclusion, different oral non-steroidal anti-inflammatory drugs revealed faster or slower treatment responses due to different mechanisms.

Budesonide and formoterol in a single inhaler controls asthma in adolescents

Despite the availability of effective treatments and national guidelines, morbidity from asthma remains high among adolescents. Adolescents need to be considered as a distinct group of individuals with different requirements to those of children and adults. In particular, their non-adherence to prescribed treatment regimens is of concern and is a significant factor contributing to the high rate of morbidity in adolescents. Studies in children aged 4 to 17 years suggest that the combination of an inhaled corticosteroid (ICS) and a long-acting beta2-agonist effectively controls asthma symptoms in patients who remain symptomatic on ICS alone. In order to improve adherence to therapy, the use of combined therapy with an ICS and a long-acting beta2-agonist in a single inhaler should be considered and the dosing frequency should be adjusted according to the severity of asthma symptoms. This should empower patients with a greater degree of self-management and may be important in helping adolescents feel responsible for the management of their asthma. Results from a recent subanalysis demonstrate that the combination of budesonide and formoterol administered twice daily via a single inhaler (Symbicort Turbuhaler) rapidly gains and maintains control of asthma in adolescents whose asthma is not controlled on ICS alone. It is anticipated that this will lead to improved adherence to therapy in this difficult-to-treat population.

Inhaled corticosteroids and leukotriene modifiers in the acute treatment of asthma exacerbations

Asthma exacerbation has a considerable impact on patients' quality of life and constitutes a challenging condition for primary health-care providers. Severe exacerbations are also an important cause of hospital admissions and require high costs. Despite this, a widely accepted definition is still lacking; etiologic and pathogenetic mechanisms are still incompletely defined. Although the efficacy of inhaled corticosteroids (ICS) and leukotriene modifiers in preventing mild to moderate asthma exacerbation is well recognized, their role within the context of an asthma action plan in general practice and in home-based early intervention for acute exacerbations is still controversial. Although systemic corticosteroids (CS) are standard care for severe exacerbation in the emergency department's (ED) management of asthma, published evidence suggests that high doses of ICS may be beneficial in the ED. The additive benefit of ICS when used with systemic CS is still debated. Data on leukotriene modifiers in the management of asthma exacerbation are limited. However, therapeutic strategies of this emergency including ICS and leukotriene modifiers seem logical and may be suitable, at least in certain patient groups. The availability of different drugs, active on different targets, can potentially contribute to a better management of asthma exacerbations.

Early use of inhaled corticosteroids in the emergency department treatment of acute asthma

BACKGROUND

Systemic corticosteroid therapy is central to the management of acute asthma The use of inhaled corticosteroids may also be beneficial in this setting.

OBJECTIVES

To determine the benefit of inhaled corticosteroids for the treatment of patients with acute asthma managed in the emergency department (ED).

SEARCH STRATEGY

Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews, and texts also were searched. The search is considered updated to February of 2003.

SELECTION CRITERIA

Only RCTs or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma to the ED or its equivalent, and were treated with inhaled corticosteroids or placebo, in addition to standard therapy. Two reviewers independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two reviewers.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers if the authors were unable to verify the validity of extracted information. Missing data were obtained from the authors or calculated from other data presented in the paper.

MAIN RESULTS

Eight trials were selected for inclusion, but data were not available for one of them. In the seven usable trials, (4 adult, 3 paediatric), a total of 376 patients were studied (191 with inhaled corticosteroids, 185 without). Patients treated with inhaled corticosteroids were less likely to be admitted to hospital (OR: 0.30; 95% CI: 0.16, 0.57). This benefit was evident in the subgroup of patients not receiving concomitant systemic steroids (OR 0.21; 95% CI: 0.08, 0.53). Patients receiving concomitant systemic steroids showed a similar, but non-significant, trend towards reduced admissions compared to placebo treatment (OR 0.45; 95% CI: 0.18, 1.12). Patients receiving inhaled corticosteroids also demonstrated small, significant improvements in peak expiratory flows (PEFR WMD: 8%; 95% CI: 3, 13 %) and forced expiratory volumes (FEV1 WMD: 5%; 95% CI: 0.4, 10 %). The treatment was well tolerated, with few reported adverse side effects. A secondary analysis compared inhaled corticosteroids alone vs systemic steroids alone; in the four trials included, there was significant heterogeneity between the study results for admission rates which precluded meaningful pooling of the study results.

REVIEWER'S CONCLUSIONS

Inhaled steroids reduced admission rates in patients with acute asthma, but it is unclear if there is a benefit of inhaled corticosteroids when used in addition to systemic corticosteroids. There is insufficient evidence that inhaled corticosteroids result in clinically important changes in pulmonary function or clinical scores when used in acute asthma. Similarly, there is insufficient evidence that inhaled corticosteroids alone are as effective as systemic steroids. Further research is needed to clarify if there is a benefit of inhaled corticosteroids when used in addition to systemic steroids.

The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis

STUDY OBJECTIVE

Inhaled corticosteroids (ICSs) are of proven benefit in the treatment of chronic asthma; however, their role in the management of acute asthma is unclear.

METHODS

We performed a systematic review of randomized controlled trials involving children or adults treated in the emergency department for acute asthma with or without the addition of ICSs. Outcome measures included hospital admission, pulmonary function tests, and side effects.

RESULTS

Seven trials were selected for inclusion in the primary analyses. ICSs versus placebo were compared; data were not available on 1 of these trials. In the remaining 6 trials, a total of 352 patients were studied (179 ICS-treated and 173 non-ICS-treated patients). Two trials compared ICSs plus systemic corticosteroids versus placebo plus systemic corticosteroids; 4 trials compared ICSs versus placebo. Patients treated with ICSs were less likely to be admitted to the hospital (odds ratio 0.30; 95% confidence interval [CI] 0.16 to 0.57) and showed small improvements in peak expiratory flows (weighted mean difference 8%; 95% CI 3% to 13%) Overall, the treatment was well tolerated, with few reports of adverse side effects. A secondary analysis compared ICSs alone versus systemic corticosteroids alone; in the 4 included trials, significant heterogeneity between the study results for admission rates precluded meaningful pooling of admission data.

CONCLUSION

There is evidence of decreased admission rates for patients with acute asthma treated with ICSs. However, there is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function when used in acute asthma, and there is insufficient evidence that ICSs alone are as effective as systemic corticosteroids.

Acute asthma: under attack

The burden of asthma (death, disability, and an increasing prevalence) makes it a major public health problem worldwide. In an effort to decrease this burden, investigators are studying many aspects of this disease. The role of race, ethnicity, infections, and pollutants as triggers, as well as the risk factors are now being defined. Research into methods to decrease acute exacerbations and improve emergency and in-hospital management, using standardized protocols and incentives for follow-up care, has yielded valuable information but has met with limited success. Adherence to the national guidelines has been poor and to some extent can be attributed to the lack of a practical method of measuring the degree of lung inflammation and cumbersome treatment protocols. Exhaled nitric oxide is a noninvasive marker of inflammation and may provide a rational method to titrate corticosteroid and leukotriene receptor antagonist therapy. The best route and dosing regimen for corticosteroid administration (oral vs intramuscular vs nebulized) are the subject of several studies, with no clear-cut winner. The burden of asthma in developing countries with limited financial resources has also triggered a search for simpler, cheaper, and practical methods for beta-agonist delivery using indigenous spacers. Recent research in asthma has unveiled our incomplete knowledge of the disease but has also provided a sense of where efforts should be expended. Research into the genetics and pharmacogenetics of asthma and into the societal factors limiting the delivery of optimal care is likely to yield useful and practical information.