Saturday, March 17, 2018

Exacerbations of COPD: prevention is still actual in 2018!!

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. While COPD is a mainly chronic disease, a substantial number of patients suffer from exacerbations. Severe exacerbations are related to a significantly worse survival outcome. This review summarises the current knowledge on the different aspects of COPD exacerbations. The impact of risk factors and triggers such as smoking, severe airflow limitation, bronchiectasis, bacterial and viral infections and comorbidities is discussed. More severe exacerbations should be treated with β-agonists and anticholinergics as well as systemic corticosteroids.
Antibiotic therapy should only be given to patients with presumed bacterial infection. Noninvasive ventilation is indicated in patients with respiratory failure. Smoking cessation is key to prevent further COPD exacerbations. Other aspects include choice of pharmacotherapy, including bronchodilators, inhaled corticosteroids, phosphodiesterase-4 inhibitors, long-term antibiotics and mucolytics. Better education and self-management as well as increased physical activity are important. Influenza and pneumococcal vaccination is recommended. Treatment of hypoxaemia and hypercapnia reduce the rate of COPD exacerbations, while most interventional bronchoscopic therapies increase exacerbation risk within the first months after the procedure.
The prevention of exacerbations is one of the most important treatment goals. To achieve that goal, patient education and smoking cessation programmes as well as patient-tailored pharmacological and nonpharmacological treatments are mandatory.
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Friday, March 9, 2018

2018 New approach for the treatment of severe uncontrolled asthma

New updated approach to severe uncontrolled asthma was presented by Greek team in ERJ Open research!!!
Asthma is a common, chronic and heterogeneous disease, affecting people of all ages. It may be mild, barely noticed by the patient, or it may range all the way to very severe disease, causing constant symptoms greatly affecting the life of the patient, and may result in poor quality of life and severe, life-threatening attacks. 
A small subgroup of patients with asthma suffers from severe disease that is either partially controlled or uncontrolled despite intensive, guideline-based treatment. These patients have significantly impaired quality of life and although they constitute <5% of all asthma patients, they are responsible for more than half of asthma-related healthcare costs. Here, we review a definition for severe asthma and present all therapeutic options currently available for these severe asthma patients. Moreover, we suggest a specific algorithmic treatment approach for the management of severe, difficult-to-treat asthma based on specific phenotype characteristics and biomarkers.
The diagnosis and management of severe asthma requires specialised experience, time and effort to comprehend the needs and expectations of each individual patient and incorporate those as well as his/her specific phenotype characteristics into the management planning. Although some new treatment options are currently available for these patients, there is still a need for further research into severe asthma and yet more treatment options.
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Thursday, March 8, 2018

New study contradicts Asthma Guidelines: How efficient is escalating inhaled glucocorticoids for prevention of asthma exacerbations?

Evidence indicates that substantial escalation of regularly used inhaled glucocorticoids, fails to prevent most asthma exacerbations. A small subgroup of adults and adolescents with asthma may have a response to an escalation strategy; however, their baseline and exacerbation characteristics remain to be defined.
New study was published in NEJM on Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.

In children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth.
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Saturday, March 3, 2018

More evidences for ban of e-cigarettes: prolonged exposure might result in asthma, COPD and inflammation

A critical review outlining the toxicological profile and immunological consequences of e-cigarette use was published these days in European Respiratory Review
Knowledge of the long-term toxicological and immunological effects of e-cigarette (e-cig) aerosols remains elusive due to the relatively short existence of vaping. Therefore, we performed a systematic search of articles published in public databases and analysed the research evidence in order to provide critical information regarding e-cig safety. Electronic nicotine delivery systems (or e-cigs) are an alternative to traditional cigarettes for the delivery of nicotine and are typically filled with glycerol or propylene glycol-based solutions known as e-liquids. Though present in lower quantities, e-cig aerosols are known to contain many of the harmful chemicals found in tobacco smoke.
However, due to the paucity of experimental data and contradictory evidence, it is difficult to draw conclusive outcomes regarding toxicological, immunological and clinical impacts of e-cig aerosols. Excessive vaping has been reported to induce inflammatory responses including mitogen-activated protein kinase, Janus tyrosine kinase/signal transducer and activator of transcription and nuclear factor-κB signalling, similar to that induced by tobacco smoke.  
Based on recent evidence, prolonged exposure to some constituents of e-cig aerosols might result in respiratory complications such as asthma, chronic obstructive pulmonary disease and inflammation. 
Future studies are warranted that focus on establishing correlations between e-cig types, generations and e-liquid flavours and immunological and toxicological profiles to broaden our understanding about the effects of vaping.
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Saturday, February 24, 2018

2018 Update: Acute Respiratory Distress Syndrome Advances in Diagnosis and Treatment

Importance  Acute respiratory distress syndrome (ARDS) is a life-threatening form of respiratory failure that affects approximately 200 000 patients each year in the United States, resulting in nearly 75 000 deaths annually. Globally, ARDS accounts for 10% of intensive care unit admissions, representing more than 3 million patients with ARDS annually.
Objective  To review advances in diagnosis and treatment of ARDS over the last 5 years.
Evidence Review  We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 2012 to 2017 focusing on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines. Articles were identified for full text review with manual review of bibliographies generating additional references.
Findings  After screening 1662 citations, 31 articles detailing major advances in the diagnosis or treatment of ARDS were selected. The Berlin definition proposed 3 categories of ARDS based on the severity of hypoxemia: mild (200 mm Hg<Pao2/Fio2≤300 mm Hg), moderate (100 mm Hg<Pao2/Fio2≤200 mm Hg), and severe (Pao2/Fio2 ≤100 mm Hg), along with explicit criteria related to timing of the syndrome’s onset, origin of edema, and the chest radiograph findings. The Berlin definition has significantly greater predictive validity for mortality than the prior American-European Consensus Conference definition. Clinician interpretation of the origin of edema and chest radiograph criteria may be less reliable in making a diagnosis of ARDS. The cornerstone of management remains mechanical ventilation, with a goal to minimize ventilator-induced lung injury (VILI). Aspirin was not effective in preventing ARDS in patients at high-risk for the syndrome. Adjunctive interventions to further minimize VILI, such as prone positioning in patients with a Pao2/Fio2 ratio less than 150 mm Hg, were associated with a significant mortality benefit whereas others (eg, extracorporeal carbon dioxide removal) remain experimental. Pharmacologic therapies such as β2 agonists, statins, and keratinocyte growth factor, which targeted pathophysiologic alterations in ARDS, were not beneficial and demonstrated possible harm. Recent guidelines on mechanical ventilation in ARDS provide evidence-based recommendations related to 6 interventions, including low tidal volume and inspiratory pressure ventilation, prone positioning, high-frequency oscillatory ventilation, higher vs lower positive end-expiratory pressure, lung recruitment maneuvers, and extracorporeal membrane oxygenation.

Conclusions and Relevance  The Berlin definition of acute respiratory distress syndrome addressed limitations of the American-European Consensus Conference definition, but poor reliability of some criteria may contribute to underrecognition by clinicians. No pharmacologic treatments aimed at the underlying pathology have been shown to be effective, and management remains supportive with lung-protective mechanical ventilation. Guidelines on mechanical ventilation in patients with acute respiratory distress syndrome can assist clinicians in delivering evidence-based interventions that may lead to improved outcomes.

Friday, February 23, 2018

Impact of obstructive sleep apnea on chronic obstructive pulmonary disease: prospective, consecutive study

What is not known yet, about the topic
Coexistent chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are insufficiently studied in terms of prevalence, frequency and spectrum of complications, health risks and impact on quality of life.
Research hypothesis
Certain clinical and demographic parameters or data obtained from nocturnal polysomnography can have significant predictive value for overlap syndrome, induced by coexistent obstructive sleep apnea and chronic obstructive pulmonary
Article’s added novelty on this scientific topic
It was established that increased body mass index and high Epworth sleepiness score have significant predictive value for coexistent OSA and COPD.

Sunday, February 18, 2018

Dual LABA/LAMA bronchodilators in COPD: why? when? and how?

Dual LABA/LAMA bronchodilators in COPD: why? when? and how?
Still many questions in our real everyday practice!
Read Editorial in Expert Review of Respiratory Medicine by great Italian team conducted by professor Mario Cazzola. 
LABA/LAMA combinations induce bronchorelaxant synergistic interaction when the drugs mixture is well-balanced and administered at low isoeffective concentrations.
The overall approach of Drug Companies has been to combine in a FDC a LABA and a LAMA at the same doses for which the monocomponents were previously approved. Indeed, this practice does not permit to optimize the synergy in the final
LABA/LAMA FDCs. Conversely, dose-finding studies are required to identify the correct dose-ratio and establish the minimal doses for each monocomponent in the FDC leading to the greater synergism with regard to the improvement in lung
function, symptoms, and exacerbations.
Furthermore, although LABA/LAMA FDCs are characterized by an acceptable safety profile, the cardiovascular toxicity of LABAs and LAMAs may overlap. Thus, postmarketing surveillance and observational studies are needed to assess the real risk of rare, but potentially serious, cardiovascular adverse events associated with the dual bronchodilation therapy in COPD patients.
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