The role of selective beta2-adrenoceptor stimulants in the control of ciliary activity

Airway clearance in patients with neuromuscular disease

Airway clearance is a critical component of both maintenance of respiratory health and management of acute respiratory illnesses. The process of effective airway clearance begins with the recognition of secretions in the airway and culminates in expectoration or swallowing. There are multiple points on this continuum at which neuromuscular disease causes impaired airway clearance. This can result in an otherwise mild upper respiratory illness progressing unabated from an easily managed condition to a severe, life-threatening lower respiratory illness requiring intensive therapy for patient recovery. Even during periods of relative health, airway protective mechanisms can be compromised, and patients may have difficulty managing average quantities of secretions. This review summarizes airway clearance physiology and pathophysiology, mechanical and pharmacologic treatment modalities, and provides a practical approach for managing secretions in patients with neuromuscular disease. Neuromuscular disease is an umbrella term used to describe disorders that involve dysfunction of peripheral nerves, the neuromuscular junction, or skeletal muscle. Although this paper specifically reviews airway clearance pertaining to those with neuromuscular diseases (e.g., muscular dystrophy, spinal muscular atrophy, myasthenia gravis), most of its content is relevant to the management of patients with central nervous system disorders such as chronic static encephalopathy caused by trauma, metabolic or genetic abnormalities, congenital infection, or neonatal hypoxic-ischemic injury.

Mucociliary dysfunction in HIV and smoked substance abuse

Impaired mucociliary clearance (MCC) is a hallmark of acquired chronic airway diseases like chronic bronchitis associated with chronic obstructive pulmonary disease (COPD) and asthma. This manifests as microbial colonization of the lung consequently leading to recurrent respiratory infections. People living with HIV demonstrate increased incidence of these chronic airway diseases. Bacterial pneumonia continues to be an important comorbidity in people living with HIV even though anti-retroviral therapy has succeeded in restoring CD4+ cell counts. People living with HIV demonstrate increased microbial colonization of the lower airways. The microbial flora is similar to that observed in diseases like cystic fibrosis and COPD suggesting that mucociliary dysfunction could be a contributing factor to the increased incidence of chronic airway diseases in people living with HIV. The three principal components of the MCC apparatus are, a mucus layer, ciliary beating, and a periciliary airway surface liquid (ASL) layer that facilitates ciliary beating. Cystic fibrosis transmembrane conductance regulator (CFTR) plays a pivotal role in regulating the periciliary ASL. HIV proteins can suppress all the components of the MCC apparatus by increasing mucus secretion and suppressing CFTR function. This can decrease ASL height leading to suppressed ciliary beating. The effects of HIV on MCC are exacerbated when combined with other aggravating factors like smoking or inhaled substance abuse, which by themselves can suppress one or more components of the MCC system. This review discusses the pathophysiological mechanisms that lead to MCC suppression in people living with HIV who also smoke tobacco or abuse illicit drugs.

Liposomal corticosteroids for the treatment of inflammatory disorders and cancer

Glucocorticoids (GC) are known for their potent immunosuppressive and anti-inflammatory properties. As a consequence, they have been extensively used for the treatment of many different diseases. Prolonged and/or high-dose GC therapy, however, generally comes with severe side effects, resulting not only from their very diverse mechanism(s) of action, but also from their relatively poor biodistribution. Drug delivery systems, and in particular liposomes, have been extensively used to enhance the biodistribution and the target site accumulation of GC, and to thereby improve the balance between their efficacy and their toxicity. Many different types of liposomes have been employed, and both local and systemic treatments have been evaluated. We here summarize the progress made in the use of liposomal GC formulations for the treatment of asthma, rheumatoid arthritis, multiple sclerosis and cancer, and we show that the targeted delivery of GC to pathological sites holds significant clinical potential.

Pharmacotherapy challenges of Fontan-associated plastic bronchitis: a rare pediatric disease

Pediatric pharmacotherapy is often challenging due to the paucity of available clinical data on the safety and efficacy of drugs that are commonly used in children. This quandary is even more prevalent in children with rare diseases. Although extrapolations for dosing and administration are often made from available adult data with similar disease states, this translation becomes even more problematic in rare pediatric diseases. Understanding of rare disease pathophysiology is typically poor, and few, if any, effective therapies have been studied and identified. One condition that illustrates these issues is plastic bronchitis, a rare, most often pediatric disease that is characterized by the production of obstructive bronchial airway casts. This illness primarily occurs in children with congenital heart disease, often after palliative surgery. Plastic bronchitis is a highly clinically relevant and therapeutically challenging problem with a high mortality rate, and, a generally accepted effective pharmacotherapy regimen has yet to be identified. Furthermore, the disease is ill defined, which makes timely identification and treatment of children with plastic bronchitis difficult. The pharmacotherapies currently used to manage this disease are largely anecdotal and vary between the use of macrolide antibiotics, mucolytics, bronchodilators, and inhaled fibrinolytics in a myriad of combinations. The purpose of this review is 2-fold: first, to highlight the dilemma of treating plastic bronchitis, and second, to bring attention to the continuing need for studies of drug therapies used in children so safe and effective drug regimens can be established, particularly for rare diseases.

Comparison of tracheal aspirates before and after high-speed treadmill exercise in racehorses

OBJECTIVE

To determine whether percentages of neutrophils in tracheal aspirate (TA) samples collected from racehorses are increased after exercise and whether interpretation of results from TA samples taken before and after exercise agree.

DESIGN

Case series of 40 young Thoroughbred and Standardbred racehorses in race training presented for evaluation of poor performance.

PROCEDURE

TA samples were collected endoscopically from racehorses presented for poor performance 24 h before and 1 to 2 h after high speed treadmill exercise testing. Aliquots of the retrieved fluid were cytocentrifuged and smears were stained with Diff-Quik. Mean neutrophil counts were expressed as percentages of the total number of inflammatory cells counted and subsequently were categorised as either above or below an accepted cut-off of 20%. Comparisons between percentages of neutrophils before and after exercise were made.

RESULTS

Percentage of neutrophils from TA samples obtained from racehorses after exercise was significantly higher than neutrophil percentages from TA samples collected from the same horse before exercise. In horses with TA specimens that were categorised as having < or = 20% neutrophils before treadmill exercise, the percentage of neutrophils in their TA specimens after exercise was, on average, significantly higher and was greater than the cut-off value of 20%.

CONCLUSION

Recent strenuous exercise may change the proportion of neutrophils in lower airways of racehorses and practitioners should be aware of this when collecting and interpreting the results from TA samples. The most practical time for collection of a TA sample to obtain the most diagnostically useful information might be after a suitable washout period of at least 1 to 2 h post-exercise.

Effect of beta-adrenergic agonists on mucociliary clearance

The mucociliary clearance apparatus, an important defense mechanism for clearing the lung of bacteria and foreign particulate matter, is a well-coordinated system consisting of airway secretory cells that produce a sol and gel (or mucus) fluid layer on the airway surface and ciliated cells that propel the mucus out of the lung towards the mouth. In vivo mucociliary clearance rates can be measured by following the rate of egress of deposited, radiolabeled markers by gamma camera. Short-acting beta-adrenergic agonists have been shown to enhance mucociliary clearance rates to varying degrees in patients with various lung diseases (eg, asthma, chronic bronchitis, and cystic fibrosis), although the enhancement is generally less than that seen in the normal lung. Limited data on the in vivo dose-response relationships of these mucociliary clearance effects suggest that larger doses are required for enhancement of mucociliary clearance than are needed for bronchodilatation. Little is known about chronic effects, but studies with dosing for up to a week also suggest an enhancement of mucociliary clearance, primarily by agonists that are lipophilic. Issues for future research include the effects of the newer long-acting beta-agonists, large versus small airway effects, and combination effects with other inhaled therapeutic agents (eg, steroids and ion-channel blockers).

Possibilities of formoterol to enhance the peripheral lung deposition of the inhaled liposome corticosteroids

The pulmonary distribution and clearance of 99m-Tc-labelled beclomethasone dipropionate (Bec)--dilauroylphosphatidylcholine (DLPC) were compared in nine asthmatic patients on inhaled steroids after a 1-week medical treatment period of long-acting beta2-agonist formoterol. The patients were given formoterol 12 microg (OxisTurbuhaler) twice daily in addition to their own regular inhaled corticosteroid therapy. Gamma lung scintigraphy and lung function tests were performed before and after formoterol treatment. The bronchodilating effect ofthe combined therapy was significant: 1-week usage of inhaled formoterol enhanced peripheral lung deposition of beclomethasone liposome and thus diminished central/peripheral deposition ratio (C/P ratio). All measured lung function values except FEV1/FVC% improved after the medication period, although statistically significant levels were not reached. A systemic positive connection was seen between enhanced lung functions and greater lung deposition measured as AUC(0-24h)/24 Beclomethasone liposome formulation maintained its long-lasting effect in connection with formoterol treatment. At the 4-h measurement, 76% of the liposome-entrapped radioactivity still remained in the lungs before and 75% after the medication period.

Cholinergic and adrenergic stimulation of mucociliary transport in the rat trachea

Mucociliary transport in the rat trachea was monitored through a surgical window for approximately one hour. Rates were grouped according to 5-min intervals which were examined with analyses of variance. Rates were consistent within each rat, although inter-animal variability was pronounced. Unstimulated transport involved minimal amounts of mucus and averaged 4.5 +/- 1.4 mm/min. Pilocarpine, presumably a secretagogue, caused a sustained (55 +/- 10 min) increase to 5.7 +/- 1.6 mm/min. Isoproterenol, presumably a cilioexcitatory agent, caused a brief (14 +/- 6 min) peak in transport at 6.4 +/- 2.1 mm/min. There were slow and fast animals which remained relatively slow or fast during and after treatment, indicating that each rat had an individual base-line determined by factors other than those susceptible to stimulation. Transport ceased almost at once throughout the airway, as mucus became scanty although ciliary activity was wide-spread. It was concluded that both types of response revealed different mechanisms for the physiological modulation of mucociliary transport.

Factors affecting ciliary function in vitro: a preliminary study

Nasal ciliary function forms an important defence mechanism within the upper respiratory tract which has largely been ignored in recent years. The effects of various drugs used extensively in the treatment of diseases of the nose have not been fully established. Furthermore, the physiological control of ciliary activity is unclear. The aim of this study was therefore to investigate the effects of drugs on ciliary beat frequency in vitro using a photometric technique. A dose-dependent response to alpha and beta receptor drugs was found, cocaine hydrochloride achieved ciliostasis even at 40-fold dilution, and potassium ions, except at the limits of tolerance for excitable tissue, did not affect ciliary function. In conclusion, we suggest that alpha and beta receptors may be present on ciliated epithelium and be involved in the control of ciliary function in vivo. Ion fluxes across the ciliary cell membrane may also be important in ciliary activity akin to nervous tissue.

Effect of terbutaline on mucociliary clearance in asthmatic and healthy subjects after inhalation from a pressurised inhaler and a dry powder inhaler

BACKGROUND

beta Agonists have been shown to increase mucociliary clearance in some studies but not all. Whether the formulation of beta agonists affects mucociliary clearance is not known but may be important as the use of dry powder inhalers increases.

METHODS

The effect of different methods of administration of inhaled terbutaline on mucociliary clearance and forced expiratory volume in one second (FEV1) was assessed in 10 patients with asthma and 10 healthy subjects. Terbutaline (1 mg) was administered through a metered dose inhaler with a spacer (Nebuhaler) or a dry powder inhaler (Turbuhaler), or both treatments were given, in a four way double blind, double dummy trial. Mucociliary clearance was measured by bronchoscintigraphy.

RESULTS

Clearance of radioactivity from the lobar bronchi increased in the asthmatic patients by a median of 32% after terbutaline was given by metered dose inhaler and 55% after a combined dose of 2 mg from both inhalers (1 mg from each) compared with placebo but by only 9% after 1 mg of terbutaline was given by a dry powder inhaler. In the healthy subjects mucociliary clearance increased by 51% when terbutaline was given by a dry powder inhaler, by 66% when given by a metered dose inhaler, and by 66% when given by both inhalers combined. The effect of terbutaline on FEV1 was the same with each of the inhalers.

CONCLUSION

Despite similar changes in FEV1 with the two formulations terbutaline increased mucociliary clearance significantly in asthmatic and healthy subjects when inhaled from a metered dose inhaler whereas when it was inhaled from a dry powder inhaler its effect was significant only in healthy subjects. The reason for the difference in asthmatic subjects is unclear, but may be associated with differences in the deposition of terbutaline.

Tumor necrosis factor attenuates beta agonist-evoked Cl- secretion in canine tracheal epithelium

We examined the effect of human recombinant TNF alpha on the potential difference (PD) and short circuit current (SCC) of canine tracheal epithelium using an Ussing chamber. Luminal or submucosal TNF (2 to 200 U/ml) produced no significant alterations in the basal PD or SCC values. Pretreatment with luminal TNF significantly reduced isoproterenol (ISOP, 10(-6) M)-evoked increases in SCC and PD to 57% and 66% of that with ISOP alone, respectively, with a significant decrease in conductance (G) to 87% of that with ISOP alone in a dose-dependent fashion, from 10 to 200 U/ml. Even after ISOP (10(-6) M)-evoked PD and SCC had reached a plateau, TNF produced significant decreases in PD and SCC up to 79% and 83% of that with ISOP alone, respectively, in a dose-dependent fashion, from 50 to 200 U/ml. Amiloride did not alter the inhibitory action of TNF on ISOP-evoked SCC and PD values. Antiserum against TNF abolished the inhibitory action of TNF on ISOP-evoked response. In contrast, submucosal TNF did not alter PD, SCC or G. These findings indicate that TNF attenuates beta agonist-evoked increases in chloride secretion across airway epithelium.

Suitability of cryopreserved samples for pharmacological studies of ciliary activity

The effect of terbutaline sulfate on the ciliary activity of fresh and cryopreserved human nasal epithelium was evaluated. Cryopreservation had no effect on baseline ciliary beat frequency. Both fresh and cryopreserved samples exposed to 10(-4) M terbutaline showed a statistically significant increase in ciliary beat frequency (27 and 25%, respectively). When the percentage changes after drug challenge for fresh and cryopreserved samples were compared no statistical difference emerged. It is concluded that cryopreservation in liquid nitrogen at -196 degrees C does not affect membrane receptors, at least beta-adrenergic receptors, and therefore cryopreserved samples are suitable for pharmacological studies of ciliary activity.

Does a beta 2-stimulator really facilitate mucociliary transport in the human lungs in vivo? A study with procaterol

The purpose was to study whether procaterol, a beta 2-stimulator, facilitated mucociliary transport on the ciliated airways in the human lungs. From immediately after inhalation of [99mTc]albumin aerosol, radioactivity of the thorax was continuously measured anteriorly by a gamma camera with the examinee in the supine position; the data were sequentially stored in a computer in 10-s frame mode. Three puffs (30 micrograms) of procaterol were inhaled from a metered dose inhaler at 60 min in the same supine position, and measurement of radioactivity was continued for 30 min more. Spirometry was performed before and after the measurement of radioactivity. A group of 8 normal subjects and 34 patients with various lung diseases, including 6 with bronchial asthma in remission, were studied. In addition to observation of mucus transport on the large airways by radioaerosol inhalation lung cinescintigraphy, the time-activity curve from the right lung was evaluated and the quantitative parameters for evaluating mucociliary clearance were calculated for the right lung. Following inhalation of procaterol, there were neither significant acceleration in mucus transport on the large airways by cinescintigraphy nor significant changes in the slope of time-activity curves. Quantitative parameters did not show any significant changes either, although spirometry indicated significant bronchodilation. We conclude that three puffs of inhaled procaterol neither necessarily accelerate mucus transport nor facilitate mucociliary clearance in the human lung.

Ciliary beating frequency of frog palate and rat trachea explants under continuous perfusion

Rat trachea and frog palate explants were continuously perfused for 2 hr with 199 tissue culture medium. The ciliary beating frequency of the frog palate exhibited fluctuations twice as large as compared to the rat trachea. The rat trachea model should be preferred to the frog palate for long-term studies on ciliary beat frequency.

Autonomic regulation of mucociliary transport rate in the oesophagus of the frog, Rana temporaria

Transport of lead particles along the mucosal surface of the frog oesophagus has been measured by direct observation with the aid of video recording. Electrical stimulation of the vagus nerve increased the rate of particle transport. This acceleration was suppressed by atropine or by hexamethonium. Acetylcholine and other parasympathomimetic agents accelerated particle transport rate. Such acceleration was abolished by atropine. Nicotine increased the rate of particle transport and this effect was suppressed by hexamethonium or by atropine. Atropine did not significantly alter basal particle transport rate. Neither basal particle transport rate nor the response to vagal nerve stimulation were affected by eserine. Adrenaline, noradrenaline or isoprenaline did not affect basal particle transport rate. Adrenaline or noradrenaline were without effect on the increased particle transport rate due to electrical stimulation of the vagus.

Albuterol: an adrenergic agent for use in the treatment of asthma pharmacology, pharmacokinetics and clinical use

Albuterol is a long-acting beta 2-adrenergic receptor-selective drug that relaxes airway smooth muscle. It is currently available in the United States in oral and metered-dose inhaler forms. Nebulizer solutions and parenteral preparations are likely to be marketed here in the future. The chemical modifications that make albuterol beta 2-selective also promote oral bioavailability and increased duration of action by decreasing sensitivity to degradative enzymes. Albuterol can also produce undesirable dose-related effects: metabolic effects including decreased levels of plasma potassium, phosphate, calcium and magnesium; increased levels of plasma glucose, insulin, renin, lactate and ketones; peripheral vasodilation and perhaps some direct cardiac stimulation resulting in decreased systemic and pulmonary vascular resistance, increased pulse pressure and tachycardia; and skeletal muscle tremor. These side effects are most common with parenteral administration and much less prominent with aerosol administration, which yields lower systemic concentrations. Limited pharmacokinetic data suggest a long distribution phase, a terminal half-life of 3-8 hours, and 10-20% oral bioavailability. Aerosolization of albuterol or a similar agent with a compressed-air nebulizer appears to be best first-line management of the patient with acute dyspneic asthma, but appropriate preparations for this kind of therapy are currently missing from the United States market. Intravenous albuterol has also been employed in acutely dyspneic patients, but produces more side effects than carefully administered intravenous theophylline, is impaired by lack of sufficient pharmacokinetic information to guide dosing, and is of uncertain efficacy in the asthmatic with respiratory failure. However, it appears to lack the potentially life-threatening side effects that can result when theophylline is used carelessly . In the ambulatory patient, aerosolized albuterol (or a similar agent) administered by metered-dose inhaler is an excellent agent for treatment as needed and/or for prevention of acute bronchospasm triggered by exercise or other predictable cause. Advantages include a high degree of efficacy, rapid onset and long duration of effect, and minimal side effects. Regularly scheduled administration of albuterol by metered-dose inhaler is a widely used and effective maintenance medication for patients requiring long-term prophylactic therapy. However comparisons of the ability of this regimen and the other common maintenance regimens (cromolyn and theophylline) to control chronic symptoms of asthma are needed.

An in vitro model for studying the effects of pharmacological agents on human ciliary beat frequency: effects of lignocaine

1 The effects of lignocaine hydrochloride on ciliary beat frequency (CBF), measured photometrically in vitro, using human epithelium obtained by nasal brushing was studied in 20 healthy subjects. Above lignocaine concentrations of 2.5 x 10(-3) g/ml cilio-inhibition occurred in a dose-dependent manner. Concentrations greater than 2 x 10(-2) g/ml caused ciliostasis. 2 Lignocaine aerosol was sprayed in vivo on the mucosa of one nasal cavity in five healthy subjects and five patients premedicated for bronchoscopy. CBF, measured in vitro in nasal brushings, was not different for treated and untreated sides. 3 Variation of intrinsic CBF with time after nasal brushings were taken was studied in ten normal subjects. No significant change in CBF was found until after 24 h. 4 We conclude that lignocaine hydrochloride, at concentrations three orders of magnitude above drug levels encountered in clinical practice, inhibits human CBF in a dose-dependent manner. Aerosolised lignocaine hydrochloride in doses which produce local nasal mucosal anaesthesia, does not inhibit CBF subsequently measured in vitro. Lignocaine is a suitable local anaesthetic for use at fibreoptic bronchoscopy when samples are being obtained for study of ciliary function. 5 The measurement of CBF in nasal mucosal brushings provides an in vitro model suitable for studying the effects of pharmacological agents on human ciliary activity.

The role of mucociliary dysfunction in bronchial asthma

Abnormalities of mucociliary function in the airways of patients with bronchial asthma are suggested by the clinical observation of excessive tracheobronchial secretions which are difficult to expectorate and may contribute to bronchial obstruction. Pathologic and functional studies in animals and patients have demonstrated an impairment of mucociliary transport mechanisms, but the pathogenesis of this abnormality is still poorly understood. In patients with allergic asthma, the elaboration of chemical mediators in the lung seems to depress mucociliary function. Although pharmacologic agents which increase mucous transport rates have been identified, more potent stimulators will probably be needed to produce a clinical improvement in patients with bronchial asthma.

Effect of beta-adrenergic agonists aerosolized by freon propellant on tracheal mucous velocity and cardiac output

The present study was designed to assess the effects of two beta-adrenergic agonists, isoproterenol sulfate and carbuterol hydrochloride, and aerosolized Freon propellant (a mixture of Freon II, Freon 12, and Freon 114) on tracheal mucous velocity and cardiac output in anesthetized dogs. Five groups of ten animals each received the following dosages of aerosols: Freon, 20 puffs; isoproterenol, four puffs; carbuterol, four puffs; isoproterenol, 20 puffs; and carbuterol, 20 puffs. The puff was delivered by a standard metered aerosol; each puff of isoproterenol spray contained 75 mug of isoproterenol sulfate, and each puff of carbuterol spray contained 100 mug of carbuterol hydrochloride. Tracheal mucous velocity was not changed by receiving Freon, but administration of both isoproterenol and carbuterol caused a significant increase in this measurement, with peak increases ranging from 74 to 111 percent above control values. The duration of action for four and 20 puffs of isoproterenol and for four puffs of carbuterol was two hours. Twenty puffs of carbuterol increased tracheal mucous velocity for three hours. Administration of carbuterol effected a slightly larger increase in cardiac output than isoproterenol. The duration of action for the increased cardiac output was shorter than the duration of action for the increased tracheal mucous velocity. These studies indicate that beta-adrenergic agonists may have an important role in improving mucous transport in patients with chronic obstructive pulmonary disease in whom mucociliary clearance is depressed.