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Emergency endotracheal intubation-related adverse events in bronchial asthma exacerbation: can anesthesiologists attenuate the risk?

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Emergency endotracheal intubation-related adverse events in bronchial asthma exacerbation: can anesthesiologists attenuate the risk?

J Anesth. 2015 Mar 24;

Authors: Ono Y, Kikuchi H, Hashimoto K, Sasaki T, Ishii J, Tase C, Shinohara K

Abstract
PURPOSE: Airway management in severe bronchial asthma exacerbation (BAE) carries very high risk and should be performed by experienced providers. However, no objective data are available on the association between the laryngoscopist's specialty and endotracheal intubation (ETI)-related adverse events in patients with severe bronchial asthma. In this paper, we compare emergency ETI-related adverse events in patients with severe BAE between anesthesiologists and other specialists.
METHODS: This historical cohort study was conducted at a Japanese teaching hospital. We analyzed all BAE patients who underwent ETI in our emergency department from January 2002 to January 2014. Primary exposure was the specialty of the first laryngoscopist (anesthesiologist vs. other specialist). The primary outcome measure was the occurrence of an ETI-related adverse event, including severe bronchospasm after laryngoscopy, hypoxemia, regurgitation, unrecognized esophageal intubation, and ventricular tachycardia.
RESULTS: Of 39 patients, 21 (53.8 %) were intubated by an anesthesiologist and 18 (46.2 %) by other specialists. Crude analysis revealed that ETI performed by an anesthesiologist was significantly associated with attenuated risk of ETI-related adverse events [odds ratio (OR) 0.090, 95 % confidence interval (CI) 0.020-0.41, p = 0.001]. The benefit of attenuated risk remained significant after adjusting for potential confounders, including Glasgow Coma Score, age, and use of a neuromuscular blocking agent (OR 0.058, 95 % CI 0.010-0.35, p = 0.0020).
CONCLUSIONS: Anesthesiologist as first exposure was independently associated with attenuated risk of ETI-related adverse events in patients with severe BAE. The skill and knowledge of anesthesiologists should be applied to high-risk airway management whenever possible.

PMID: 25801541 [PubMed - as supplied by publisher]

CSACI position statement: systemic effect of inhaled corticosteroids on adrenal suppression in the management of pediatric asthma.

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CSACI position statement: systemic effect of inhaled corticosteroids on adrenal suppression in the management of pediatric asthma.

Allergy Asthma Clin Immunol. 2015;11(1):9

Authors: Issa-El-Khoury K, Kim H, Chan ES, Vander Leek T, Noya F

Abstract
Asthma is a chronic inflammatory disease of the airways that affects a growing number of children and adolescents. Inhaled corticosteroids (ICS) are the mainstay of treatment in persistent asthma, with a stepwise approach to increasing doses of ICS depending on asthma severity and control. ICS have known local and systemic side effects, of which adrenal suppression is still under-recognized. The latter is associated with chronic exposure and higher doses, although it has rarely been reported in children receiving low doses for a short period of time. The Canadian Society of Allergy and Clinical Immunology (CSACI) therefore recommends that physicians screen for adrenal suppression in children receiving high doses for more than 6 months and to consider screening those on medium dose if the risk is deemed higher by factors that increase an individual's systemic corticosteroid exposure. Morning serum cortisol level can be used as a screening tool and abnormal results or normal results with a high index of suspicion should be confirmed with low-dose ACTH stimulation tests.

PMID: 25802532 [PubMed]

The value of spirometry and exercise challenge test to diagnose and monitor children with asthma.

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The value of spirometry and exercise challenge test to diagnose and monitor children with asthma.

Respirol Case Rep. 2015 Mar;3(1):25-8

Authors: van den Wijngaart LS, Roukema J, Merkus PJ

Abstract
Asthma is defined as a chronic inflammatory disease of the airways with characteristic symptoms including recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. It may result in abnormalities of ventilator function, which can be assessed by different pulmonary function tests. In this case report, we present a 15-year-old boy with asthma and illustrate the value and limitations of spirometry and exercise challenge test in daily practice.

PMID: 25802746 [PubMed]

Inhaled corticosteroids: potency, dose equivalence and therapeutic index.

Glucocorticosteroids are a group of structurally related molecules that includes natural hormones and synthetic drugs with a wide range of anti-inflammatory potencies. For synthetic corticosteroid analogues it is commonly assumed that the therapeutic index cannot be improved by increasing their glucocorticoid receptor binding affinity. The validity of this assumption particularly for inhaled corticosteroids has not been fully explored.

Inhaled corticosteroids exert their anti-inflammatory activity locally in the airways and hence this can be dissociated from their potential to cause systemic side-effects. The molecular structural features that increase glucocorticoid receptor binding affinity and selectivity drive topical anti-inflammatory activity. But in addition, these structural modifications also result in physicochemical and pharmacokinetic changes that can enhance targeting to the airways and reduce systemic exposure. As a consequence potency and therapeutic index can be correlated. However, this consideration is not reflected in asthma treatment guidelines that classify inhaled corticosteroid formulations as low, mid and high doses and imbed a simple dose equivalence approach where potency is not considered to affect the therapeutic index. This article describes the relationship between potency and therapeutic index and concludes that higher potency can potentially improve the therapeutic index. Therefore both efficacy and safety should be considered when classifying inhaled corticosteroid regimens in terms of dose equivalence.

The historical approach to dose equivalence in asthma treatment guidelines is not appropriate for the wider range of molecules, potencies and device/formulations now available. A more robust method is needed that incorporates pharmacological principles.

Pharmacokinetics and pharmacodynamics of an extrafine fixed pMDI combination of beclometasone dipropionate/formoterol fumarate in adolescent asthma.

AIM: To investigate the pharmacokinetics and pharmacodynamics of an extrafine pressurized metered-dose inhaler (pMDI) fixed combination of beclometasone-dipropionate (BDP)/formoterol-fumarate (FF) in adolescent and adult asthma.

METHODS: Three-way crossover study, on 30 asthmatic adolescents receiving BDP/FF-pMDI with or without valved holding chamber (VHC) or a free licenced combination of BDP-pMDI and FF-pMDI; plus a parallel arm of 30 asthmatic adults receiving BDP/FF-pMDI. All patients received a single dose of BDP and FF of 400 µg and 24 µg, for each treatment, respectively. Assessments were performed over 8 hours.

RESULTS: In adolescents, the 90% confidence intervals (CIs) for the systemic exposure (AUC0-t ) geometric mean ratio of the fixed combination with or without VHC versus the free combination were within the bioequivalence range 0.80-1.25, both for beclometasone-17-monopropionate (B17MP, active metabolite of BDP) and formoterol. Pharmacodynamic variables for plasma potassium and glucose, pulse rate and pulmonary function in adolescents were equivalent between treatments; 95%CI within 0.94-1.09. The upper level of 90%CIs for AUC0-t geometric mean ratio adolescents/adults of B17MP and formoterol after treatment with BDP/FF-pMDI were lower than 1.25; 90%CI 0.78-1.04 and 0.86-1.17, respectively.

CONCLUSIONS: In adolescents the pharmacodynamics and the overall systemic exposure to the active ingredients of an extrafine fixed combination of BDP/FF-pMDI with or without VHC was equivalent to that of a free licenced combination pMDIs of established safety and efficacy profiles. The systemic exposure in adolescents was not higher than in adults. These results support the indication for use of inhaled-corticosteroids/long acting β2-agonists pMDIs in adolescents at the same dosage as in adults.

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