Jet-nebulized beclomethasone dipropionate in the management of bronchial asthma. Topical steroids for asthmatic children younger than 4 years

Inhaled corticosteroid therapy with nebulized beclometasone dipropionate

Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents for the management of chronic persistent asthma and are therefore recommended as first-line antiasthmatic therapy in children and adults. In various settings, the administration of ICS via nebulizer rather than hand-held inhaler (HHI) may have certain advantages, as many patients with HHI fail to use these devices properly or efficiently. In particular, young children, the elderly, the acutely ill, and those with restricted dexterity may be unable to coordinate inhalation with actuation of the device or to generate sufficient inspiratory flow to operate breath-actuated devices effectively. Compliance with nebulized therapy may also be better than that with a pressurized metered-dose inhaler (pMDI) plus spacer. Systematic reviews conclude that there is no significant difference in clinical effects between nebulizers and HHI. Performance and clinical effect of nebulization are influenced by several technical aspects such as the nebulizer-drug combination, nebulizer type, output and lung deposition. Among the currently available ICS, nebulized beclometasone dipropionate (BDP) has been in clinical use for more than 35 years, and has demonstrated marked clinical efficacy and a favorable tolerability profile in children and adults with chronic persistent asthma. The clinical efficacy of nebulized beclometasone is discussed in the present review using data from 13 published studies, which included a total of 1250 patients. Three multicenter, randomized, double-blind studies showed that nebulized BDP is as effective as BDP via pMDI plus spacer in a 2:1 dose ratio. Controlled trials involving 497 adults and children demonstrated similar clinical efficacy between nebulized BDP and either nebulized fluticasone propionate or nebulized budesonide. In all these trials, treatment-related adverse effects were generally uncommon, most were mild-to-moderate in severity, and most were associated with the respiratory system. Meta-analyses show that BDP, like other inhaled corticosteroids, has no major influence on patient height, urinary cortisol concentration, or bone metabolism, thus suggesting the absence of growth retardation or any marked effect on adrenal function or the hypothalamic-pituitary-adrenal axis when used in the approved dose range. Overall, nebulized BDP appears to have a particularly important place in asthma therapy: as a general alternative to HHIs (e.g. in patients with poor HHI compliance); when patients such as children or the elderly are unable to operate HHIs because of poor hand-lung coordination, lack of cooperation, or low inspiratory flow rate; and when high dosages of ICS are required, such as in adults with severe, corticosteroid-dependent asthma.

The efficacy and safety of fluticasone propionate in very young children with persistent asthma symptoms

We aimed to evaluate the efficacy and safety of fluticasone propionate (FP) in children aged 12-47 months with recurrent/persistent asthma symptoms. One hundred and sixty children (12-47 months) were randomised into this multicentre, double-blind, placebo-controlled, parallel-group study, and treated with either FP (100 microg bd) or placebo (2 puffs bd), both administered by metered-dose-inhaler and Babyhaler for 12 weeks. The primary endpoint was percentage of symptom-free 24h periods. Over weeks 1-12, FP-treated patients had significantly more percentage symptom-free 24-h periods compared with placebo (odds ratio 0.53; 95% CI 0.29-0.95; P = 0.035). Relative to baseline, where all patients were symptomatic for at least 21/28 days of the run-in, the improvement equated to one additional symptom-free 24 h period per week. FP patients also had a significantly higher percentage of 24 h periods with no wheeze or cough, the odds ratio for treatment difference corresponding to two additional wheeze-free and one additional cough-free periods per week. FP was well-tolerated, with similar reported adverse events in both groups. Urinary cortisol-creatinine ratio was slightly decreased among FP patients after 12 weeks, but with no clinical correlates. FP is effective for the treatment of chronic persistent asthma symptoms in very young children.

Beclomethasone dipropionate and salbutamol by metered dose inhaler in infants and small children with recurrent wheezing

The efficacy of beclomethasone dipropionate (BDP) to control respiratory symptoms was evaluated in 31 children under age 2 years with recurrent wheezing. The study was conducted in a double-blind, parallel, and placebo-controlled fashion. The two study groups received either salbutamol plus BDP 200 microg bid by metered dose inhaler (MDI) with a spacer, or salbutamol MDI plus a placebo. Inhaled corticosteroid (IC) and placebo were administered for 8 weeks. Patients were seen every 2 weeks as outpatients, and their progress was evaluated by clinical examination and a daily symptom score card. At the end of the study, patients in both groups had significantly decreased symptoms. No significant difference was found between BDP and placebo groups regarding clinical score, number of salbutamol doses, sleep disturbances, number of symptom-free days, feelings of insecurity of mothers regarding the infants' life due to wheezing, and mothers' perceptions of progress in their infants' respiratory symptoms. We conclude that salbutamol plus 200 microg bid of BDP inhaled from an MDI with a spacer for 8 weeks is no better than salbutamol alone for decreasing recurrent wheezing in small children under age 24 months.

Neonatal Chronic Lung Disease

Chronic lung disease (CLD), formerly known as bronchopulmonary dysplasia, is presently defined as the need for oxygen therapy either at 28 days of age or greater than 36 weeks postmenstrual age. Clinical signs and symptoms include tachypnea, retractions, apnea, and radiographic findings of poorly inflated lungs with reticulogranular opacities. The disease develops as a result of chronic pulmonary inflammation and continuous lung injury induced by oxygen, positive pressure ventilation, and other causes. Fifty to sixty-five percent of neonates with CLD are rehospitalized with respiratory problems, and 21% of very low birth weight neonates are diagnosed with asthma or other respiratory disorders by the age of five. These infants are at risk of adverse neurodevelopmental sequelae as they have a more complicated neonatal course. Many studies have explored various preventive therapies including α1-proteinase inhibitors, superoxide dismutase, antioxidants, and ventilatory management. Although the results from these trials are promising, further studies are needed to define which patients are most likely to benefit from preventive therapy. Two preventive treatment approaches that have shown a decrease in morbidity and an improvement in mortality are antenatal steroids and surfactant therapy. Postnatal corticosteroid therapy continues to be the mainstay of treatment for CLD, however, there are a number of detrimental side effects associated with this treatment. Due to the increased incidence in periventricular leukomalacia, early treatment of steroid therapy cannot be recommended. The optimal time to start steroid therapy appears to be after the first week of life. In addition, the lowest dose and shortest duration of treatment needs to be implemented in order to minimize potential complications. Although bronchodilators and diuretics continue to be used extensively in infants with CLD, there are surprisingly few well-controlled studies that have evaluated the clinical impact of this therapy. Further trials are needed in order to support the routine use of these therapies in CLD. Unfortunately, inhaled steroids have not shown an improvement in long-term outcomes of CLD, however, they have shown a decrease in systemic steroid usage. CLD is a complex disease with many unanswered questions. Further studies are needed to evaluate the effects of various treatment modalities with particular focus on the long-term outcomes such as oxygen and ventilator dependency as well as the incidence of CLD.

Once-daily inhaled corticosteroids in children with asthma: nebulisation

Current guidelines on the management of childhood asthma have emphasised the important preventive role of inhaled corticosteroids, which should be used at the lowest possible doses that are compatible with good disease control. However, some children do not respond to inhaled corticosteroids, the most common reasons for which are inability to use conventional hand-held inhalers (plus spacers and face masks) effectively or lack of cooperation with them, particularly among infants and young children. In these patients, nebulisers have proved effective in administering corticosteroids, and this form of delivery is often preferred by both the children and their parents, despite their longer administration times (commonly around 10 minutes). Compliance with these devices may therefore be better than with a conventional pressurised metered-dose inhaler plus spacer and face mask. Recent studies with nebulised budesonide have demonstrated that once-daily administration is as effective in maintaining control of asthma symptoms in children as the usual twice-daily administration. In children with moderately severe persistent asthma, the improvement provided by once-daily nebulised doses of 1.0 mg budesonide has been found to be equivalent to that with twice-daily doses of 0.25 or 0.5 mg, indicating that once-daily therapy is an effective option that can be considered in many patients. In view of the time-consuming nature of nebuliser administration, reduction of the frequency of corticosteroid administration from twice to once daily may be useful in simplifying the treatment programme and improving compliance with it. This may be beneficial in reducing under-utilisation of inhaled corticosteroids in children with asthma and improving long term control of the disease.

Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children

STUDY OBJECTIVE

To compare nebulized dexamethasone with oral prednisone in the treatment of children with asthma.

DESIGN

A randomized, double-blind, double-placebo study.

SETTING

An urban pediatric emergency department.

PARTICIPANTS

Patients aged 1 to 17 years with acute asthma.

INTERVENTIONS

Patients with moderate asthma exacerbation received frequent aerosolized albuterol and either 1.5 mg/kg of nebulized dexamethasone or 2 mg/kg of oral prednisone.

RESULTS

A total of 111 children was evaluated; 21% of those treated with dexamethasone required hospitalization, compared with 31% of those treated with prednisone (P = .26). A significantly greater proportion of dexamethasone-treated children were discharged home within 2 hours (23% versus 7%, P = .02). In the dexamethasone group, 8% who received the drug by mouthpiece were hospitalized compared with 33% who received it by face mask (P = .06). Fewer children treated with dexamethasone vomited (0% versus 15%, P = .001) and fewer relapsed within 48 hours of ED discharge (0% versus 16%, P = .008).

CONCLUSION

Nebulized dexamethasone was as effective as oral prednisone in the ED treatment of moderately ill children with acute asthma and was associated with more rapid clinical improvement, more reliable drug delivery, and fewer relapses.

Treatment of severe steroid dependent preschool asthma with nebulised budesonide suspension

The steroid sparing effect of nebulised budesonide suspension was assessed in a double blind placebo controlled parallel group study of 36 preschool children with severe asthma who were dependent on treatment with oral steroids. Nebulised budesonide suspension significantly reduced the requirement for treatment with oral steroids, and produced a marked improvement in overall health as scored on a visual analogue scale during the clinic visits. This study shows a significant step forward in the prophylactic treatment of asthma in children under the age of 3 years, in whom the efficacy of many other nebulised treatments has been questioned.

Nebulized steroid therapy in bronchopulmonary dysplasia

The effect of inhaled beclomethasone dipropionate (BEC) was studied in seven infants between 7 and 18 months of age with glucocorticoid-dependent bronchopulmonary dysplasia. Oral glucocorticoid therapy, pulmonary function, growth, daily caloric consumption, blood pressure, blood sugar, blood gases, and immunoglobulins were monitored for 3 months before (control period) and 3 months after (intervention period) instituting inhaled beclomethasone dipropionate (25 micrograms/kg/day divided tid) delivered by Pulmoaide with a DeVilbiss nebulizer. Acute BEC inhalation produced no change in pulmonary function. During BEC treatment, oral glucocorticoid therapy was decreased in all infants, stopped in four infants within 3 months and in the other three infants in 4-5 months. Within 1 month of inhaled BEC the rate of linear growth and weight increased markedly (2.2 +/- 1.8 vs 6.4 +/- 2.4 cm/month - mean +/- SD and 9.3 +/- 6.5 vs 18.2 +/- 7.4 g/day, respectively without change in average daily caloric consumption (113 +/- 16 vs. 110 +/- 15 cal/kg/day). Immunoglobulins also significantly increased during BEC therapy (IgG(Total) 246 +/- 74 vs 463 +/- 111 mg/dL). Pulmonary function revealed moderate obstructive pulmonary disease before BEC. After 3 months of BEC inhalation no significant change occurred although respiratory system resistance decreased and the flow at 25% of tidal volume to peak flow ratio increased more than predicted by intersession variability. In no infant did pulmonary function decline after BEC, nor were any apparent adverse effects noted in this small group of patients. In conclusion, inhaled BEC was effective in decreasing oral glucocorticoid therapy and in modifying glucocorticoid-induced growth suppression in a very small, highly select group of infants with bronchopulmonary dysplasia.

Controlled trial of beclomethasone dipropionate by nebulization in oxygen- and ventilator-dependent infants

Parenteral glucocorticoids have been shown to be effective in the treatment of oxygen- and ventilator-dependent bronchopulmonary dysplasia. We conducted a randomized, prospective study using a nebulized, water-soluble form of beclomethasone dipropionate for the treatment of infants with oxygen- and ventilator-dependent lung disease. Newborn infants with chest x-ray changes consistent with bronchopulmonary dysplasia at 14 days of age were randomly assigned, in a paired sequential fashion by birth weight, to treatment (beclomethasone) or placebo (saline solution) groups. Treatment included three nebulized doses of beclomethasone (50 micrograms) or saline solution per day for 28 days. Measured variables included tidal volume, total dynamic compliance, and airway resistance. Weight gain, gender, and incidence of infection during therapy were also recorded. Pulmonary functions were measured before initiation of therapy and weekly thereafter. Thirteen infants, seven in the saline solution group and six in the beclomethasone group, met study criteria and completed treatment. Infants treated with beclomethasone had reductions in airway resistance that were significant in weeks 2, 3, and 4 (p < 0.05, p < 0.02, and p < 0.001, respectively). Dynamic lung compliance increased at weeks 3 and 4 (p < 0.01 and p < 0.05, respectively). As expected, tidal volume increased with weight and time, but there were no significant differences between groups. There were no differences between the groups in weight gain, gender, or infection. This study demonstrates that beclomethasone by nebulization (1) reduced airway resistance in oxygen-dependent neonates with bronchopulmonary dysplasia, (2) improved dynamic lung compliance, as reported with parenterally administered glucocorticoids, and (3) produced no apparent increase in the incidence of infection.

The use of inhaled steroids in young children

There are apparently irreversible inflammatory changes in the airways of young adults with chronic asthma so a strong case can be made for starting anti-inflammatory treatment early. Corticosteroids have potent and diverse anti-inflammatory activity. High efficacy is established in school age children. Trials in pre-school children and infants have given more mixed results perhaps because of problems with administration. No clinically important systemic effects have been observed in children taking conventional doses of inhaled steroids.

Clinical observations of nebulized flunisolide in infants and young children with asthma and bronchopulmonary dysplasia

Severe bronchopulmonary dysplasia (BPD) is frequently associated with asthma. The combination is often severe enough to necessitate corticosteroid therapy. There are no commercially available nebulizer solutions of corticosteroids for use in infants and young children. Seven infants and small children with very severe BPD and asthma aged 6-24 months, were treated with flunisolide, 187-250 micrograms q.i.d. in the form of nasal spray delivered by nebulizer. After treatment for 2.5-20 months, four patients showed clinical improvement, one initially improved but later deteriorated and died of cardiac failure, and two patients showed no improvement and died within 3 months. The number of days of hospitalization was significantly reduced from 8.4/month to 2.5/month (P less than 0.05). No side-effects were detected and it was felt that the three patients who died, did so as a consequence of very severe BPD and its cardiac consequences. The suspension remained stable for 80 min when mixed with normal saline, cromolyn sodium, albuterol, or acetylcysteine. It is concluded that nebulized flunisolide is a potentially useful treatment for infants and young children with asthma and BPD.

Suppression of adrenal function in children on inhaled steroids

Inhaled steroid therapy is one of the mainstays of treatment of asthma in children. Side effects, including suppression of the hypothalamic-pituitary-adrenal (HPA) axis, have been noted with high doses of inhaled steroids. Most studies concerning side effects have been done with mechanical nebulization devices or hand-held metered-dose inhalers. The present study attempts to ascertain if dry powder inhalation of beclomethasone dipropionate is associated with any significant suppression of the HPA axis. Fifteen children (10 male and 5 female) between the ages of 4 and 14 years were followed for several years in our outpatient department. They were on inhaled beclomethasone dipropionate at dosages ranging from 6.9 to 25 micrograms/kg per day for 4-24 months. The short adrenocorticotrophic hormone (ACTH) test was used to evaluate function of the HPA axis. Mild suppression of the HPA axis was noted in one of the cases. The study therefore concludes that at therapeutic doses of dry powder beclomethasone dipropionate, suppression of the HPA axis can occur. However, the extent of this complication does not appear to be greater than with hand-held or mechanical nebulization devices.

Aerosolized budesonide in asthmatic infants: a double blind study

The efficacy of nebulized budesonide (0.5 mg b.i.d.) against placebo was evaluated in the management of asthma in 23 infants, aged 3 to 17 months, using a double blind crossover design. After an initial treatment period of 2 weeks placebo and budesonide were randomly administered during two consecutive treatment periods of 1 month. The progress of the patients was monitored using diary score cards, the number of salbutamol doses needed during the treatment periods, clinical examinations using standardized scoring cards, and registration of parents' preference period. Although there was a tendency toward fewer wheezing periods during budesonide, the results of the diary score cards were not significantly different between the budesonide period and the placebo period. The number of salbutamol doses used was also the same during both periods. Clinical examination after budesonide revealed less rhinitis and a less pathological lung auscultation, but the difference between the two periods was also not significant. Furthermore, the parents' preference could not distinguish between budesonide and placebo. We conclude that the trends in favor of nebulized budesonide are not significant and do not suggest that the suspension is effective in severe infantile asthma.

Use of steroids in pediatric asthma

Steroids are necessary for treatment of chronic asthma. They are life-saving in many acute exacerbations and enable daily functioning free of wheezing and disability for the chronic asthmatic. The beneficial effect of steroids for asthma is increasingly thought to be due to their anti-inflammatory effect on hyperreactive airways. Attempts have been made to develop synthetic steroids to maximize the anti-inflammatory effect on the target tissue while decreasing adverse effects on other tissues. Inhaled steroids with potent topical and minimal systemic effects have been the most important breakthrough in this regard. Long-term follow-up studies for over ten years of beclomethasone have not shown serious local or systemic side effects. Intravenous or oral steroids are still needed for acute exacerbations, and prednisone may be needed in combination with inhaled steroids for the severe asthmatic. Treatment of this complex, variable disease with any type of steroid should be accompanied by objective measurements of benefit (pulmonary function) and risk (steroid side effects).

Nebulised beclomethasone dipropionate in recurrent obstructive episodes after acute bronchiolitis

Forty four children with recurrent obstructive episodes after acute bronchiolitis in infancy were treated with nebulised beclomethasone dipropionate or placebo for eight weeks in a randomised double-blind study. They were seen monthly for a year afterwards, and also if they had acute respiratory illnesses with or without bronchopulmonary obstruction. The two treatment groups were well matched. The children receiving active treatment had significantly fewer symptomatic respiratory illnesses and fewer episodes of bronchopulmonary obstruction during the follow up period. The children given placebo had significantly higher obstructive scores during the study period, and they were treated with inhaled beta 2 agonists and theophylline for longer periods of time during the follow up period. The results suggest that nebulised beclomethasone dipropionate may have prolonged effects on subsequent asthmatic symptoms after termination of treatment in children with recurrent obstructive episodes after acute bronchiolitis.