Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

Optimization of Nebulized Budesonide in the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background

Clinical studies have suggested nebulized budesonide (NB) as an alternative to systemic corticosteroids for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, the optimal budesonide dose for AECOPD remains unclear.

Objectives

To compare the efficacy and safety of different doses of NB in the management of AECOPD.

Patients and Methods

A total of 321 AECOPD patients with moderate-to-severe exacerbation were randomly divided into three groups and treated with NB. The low dose group (L) was given 4 mg/day (n=95, 1 mg Q6h), while high-dose group 1 (H1, n=111, 2 mg Q6h) and high-dose group 2 (H2, n=115, 4 mg Q12h) were given 8 mg/day. Patients also received routine treatment including oxygen therapy, expectorant, nebulization bronchodilators, antibiotics, and fluid rehydration. The COPD assessment test (CAT), lung function, and artery blood gas were evaluated before and after 3 hrs and 5 days of treatment. In addition, hospital stay, frequency of acute exacerbations within 3 months of discharge, and adverse events during treatment were compared.

Results

H1 and H2 showed improved spirograms and CAT score faster than L. In H2, forced expiratory volume in 1 s (FEV₁%) at 3 hrs and FEV₁%, forced expiratory flow after 50% of the forced vital capacity has been exhaled (FEF_50%), mean forced expiratory flow between 25% and 75% of forced vital capacity (FEF_25-75%) and CAT score at 5 days were significantly improved compared to L. FEV₁% improved most in H2, moderately in H1, and least in L, with significant differences between groups at 5 days. No differences between groups were observed in adverse effects, hospital stay, and frequency of exacerbations within 3 months of discharge.

Conclusion

Compared to the conventional dose (4 mg/day), a high dose (8 mg/day) of NB improved pulmonary function and symptoms more effectively in the early treatment of AECOPD, especially when given as 4 mg twice daily.

Comparative efficacies of nebulized budesonide and systemic corticosteroids in the treatment of exacerbations of chronic obstructive pulmonary disease: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Corticosteroids are recommended by almost all international guidelines for the management of exacerbations of chronic obstructive pulmonary disease (COPD). Nevertheless, due to their side effects, there are still concerns regarding the use of systemic corticosteroids (SCs). The Global Initiative for Chronic Obstructive Lung Disease guideline states nebulized budesonide (NB) may be a suitable alternative to SCs for treating COPD exacerbations. We conducted this study to systematically compare the efficacies of NB and SCs by using a meta-analysis.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched from database inception to 10 October 2019. Our main end points were change in pulmonary function and blood gas analysis. Secondary end points were numbers of exacerbations and hyperglycaemia.

RESULTS AND DISCUSSION

Of 645 identified studies, 6 were eligible and were included in our analysis (N = 867 participants). Compared with SCs, NB was non-inferior on the change in FEV₁ %predicted at 24 hours, 48-72 hours and 5-7 days; FEV₁ at 5-7 days; FEV₁ /FVC at 7 days. For blood gas analysis, our meta-analysis indicated that PaO₂ , PaCO₂ at 24 hours, 48-72 hours and 7-10 days and SaO₂ at 24 hours and 7-10 days showed a non-significant difference in both groups, whereas the SaO₂ was significant higher in NB group at 48-72 hours after treatment. Hyperglycaemia was less frequent with NB (odds ratio, 0.1; 95% CI, 0.01-0.85; P = .04).

WHAT IS NEW AND CONCLUSION

Based on our meta-analysis, NB was not inferior to SCs when used in the treatment of COPD exacerbations. However, additional well-designed prospective studies are needed to identify the optimal dose of nebulized budesonide and the effects of nebulized budesonide in outpatients, or patients in ICU settings.

Clinical Outcomes Of Using Nebulized Budesonide As The Initial Treatment For Acute Exacerbations Of Chronic Obstructive Pulmonary Disease: A Post-Hoc Analysis

Purpose

The current guidelines recommend the use of systemic corticosteroids (SCS) as the optimal treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of this real-world study was to evaluate whether nebulized budesonide (NBS) could also be used as an initial treatment for AECOPD.

Patients and methods

AECOPD patients initially treated with NBS or SCS (oral/intravenous) were enrolled. A large-scale, long-term multicenter cohort study of AECOPD patients was performed to analyze outcomes for each treatment (NCT02051166).

Results

Initial NBS and SCS treatment resulted in similar outcomes in terms of improvements in FEV₁, PaO₂, SaO₂, and PaCO₂. Disease severity affected outcome similarly in both groups. When the groups were stratified according to whether the initial treatment was subsequently intensified or reduced, more intubation was seen in the groups in which initial treatment was intensified. NBS escalation and SCS reduction groups spent more days in the hospital. The NBS escalation group was associated with the highest medical expenditure and a relatively higher rate of new-onset pneumonia. The NBS maintenance/reduction group showed the lowest mortality rate between groups. Stratification according to initial PaCO₂ level showed more intubation in the groups with high initial PaCO₂ concentrations.

Conclusion

These results indicate that NBS may be used as an initial treatment in certain AECOPD patients, and further studies are needed to better define those most likely to benefit.

Comparison of Nebulized Budesonide and Intravenous Dexamethasone Efficacy on Tracheal Tube Cuff Leak in Intubated Patients admitted to Intensive Care Unit

Background:

Tracheal intubation is a common action in intensive care unit (ICU); however, it may cause laryngeal edema or laryngotracheal injury which leads to edema. The cuff-leak test is usually done to define the upper airway patency. Considering the point that laryngeal edema would be treated by anti-inflammatory agents, our aim was to evaluate the impact of nebulized budesonide on ICU patients’ relief and comparison between nebulized budesonide efficacy and intravenous (IV) dexamethasone.

Materials and Methods:

In our clinical trial, 270 intubated patients from ICU were randomly selected and divided into three groups (each group was included 90 patients) as follows: IV dexamethasone, nebulized budesonide, and placebo group. All the patients were monitored at 0, 12, 24, 36, and 48 h of starting follow-up. Hemodynamic parameters and cuff-leak ratio were measured and data were analyzed using SPSS (ver. 20).

Results:

Our findings revealed that dexamethasone and budesonide treatment approaches were beneficial for an increase of cuff-leak volume (P < 0.001). Furthermore, the superiority of mentioned methods in patients’ relief was significant compared with placebo group (P < 0.001). Moreover, hemodynamic parameters were not altered and were within the normal range in both dexamethasone and budesonide groups (P > 0.05).

Conclusion:

Our findings demonstrated that the use of budesonide and dexamethasone is beneficial in intubated ICU patients, and the above-mentioned approaches can reduce the complications of tracheal intubation. Furthermore, budesonide could be a trustworthy substitute treatment strategy instead of IV dexamethasone.

Effect of nebulized budesonide on respiratory mechanics and oxygenation in acute lung injury/acute respiratory distress syndrome: Randomized controlled study

Background:

We tested the hypothesis that nebulized budesonide would improve lung mechanics and oxygenation in patients with early acute lung injury (ALI) and/or acute respiratory distress syndrome (ARDS) during protective mechanical ventilation strategy without adversely affecting systemic hemodynamics.

Methods:

Patients with ALI/ARDS were included and assigned into two groups; budesonide group (30 cases) in whom 1 mg–2 ml budesonide suspension was nebulized through the endotracheal tube and control group (30 cases) in whom 2 ml saline (placebo) were nebulized instead of budesonide. This regimen was repeated every 12 h for three successive days alongside with constant ventilator settings in both groups. Hemodynamics, airway pressures, and PaO₂/FiO₂ were measured throughout the study period (72 h) with either nebulized budesonide or saline. Furthermore, tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6) were analyzed serologically as markers of inflammation at pre- and post-nebulization sessions.

Results:

We found a significant difference between the two groups regarding PaO₂/FiO₂ (P = 0.023), peak (P = 0.021), and plateau (P = 0.032) airway pressures. Furthermore, TNF-α, IL-1β, and IL-6 were significantly reduced after budesonide nebulizations. No significant difference was found between the two groups regarding hemodynamic variables.

Conclusion:

Nebulized budesonide improved oxygenation, peak, and plateau airway pressures and significantly reduced inflammatory markers (TNF-α, IL-1β and IL-6) without affecting hemodynamics.

Trial Registry:

Australian New Zealand Clinical Trial Registry (ANZCTR) at the number: ACTRN12615000373572.

Comparison of the efficacy of nebulized budesonide and intravenous dexamethasone administration before extubation in prevention of post-extubation complications among patients admitted in intensive care unit

Background:

Narrowing of the airway caused by tracheolaryngeal edema is one of the most common complications of endotracheal intubation particularly among patients requiring mechanical ventilation longer than 36 h that can cause other complications and increase mortality rate. The aim of this study was to investigate the efficacy of nebulized budesonide in comparison with intravenous (IV) dexamethasone administration before extubation in prevention of post-extubation complications.

Materials and Methods:

This double-blind clinical trial was carried out at the intensive care unit (ICU) of a tertiary care center (Alzahra Hospital in Isfahan). The study's population was comprised of 90 patients who had been admitted in the ICU and required intubation at least for 48 h. All patients were between 18 and 65 years of age. Having randomly divided the patients into two equal groups, the first group received nebulized budesonide while the second group was treated by IV dexamethasone 1 h before extubation. The treatment continued up to 48 h after extubation. The collected data from both groups was then subjected to statistical analyses to come to results.

Results:

There was no significant difference between the two groups; hence, both drugs were found to be effective in prophylaxis of the complications due to tracheal extubation. According to the findings of the current study, since nebulized budesonide has no systemic complications of IV corticosteroid, it can be used as the first choice in reducing the complications attributed to extubation.

Conclusion:

Considering the very low systemic absorption of nebulized budesonide; however, we recommend it for prevention of post-extubation complications instead of IV dexamethasone.