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Respiratory Reviews in Asthma 2013.

Tuberc Respir Dis (Seoul). 2014 Mar;76(3):105-113

Authors: Kim TH

Abstract
From January 2012 up until March 2013, many articles with huge clinical importance in asthma were published based on large numbered clinical trials or meta-analysis. The main subjects of these studies were the new therapeutic plan based on the asthma phenotype or efficacy along with the safety issues regarding the current treatment guidelines. For efficacy and safety issues, inhaled corticosteroid tapering strategy or continued long-acting beta agonists use was the major concern. As new therapeutic trials, monoclonal antibodies or macrolide antibiotics based on inflammatory phenotypes have been under investigation, with promising preliminary results. There were other issues on the disease susceptibility or genetic background of asthma, particularly for the "severe asthma" phenotype. In the era of genome and pharmacogenetics, there have been extensive studies to identify susceptible candidate genes based on the results of genome wide association studies (GWAS). However, for severe asthma, which is where most of the mortality or medical costs develop, it is very unclear. Moreover, there have been some efforts to find important genetic information in order to predict the possible disease progression, but with few significant results up until now. In conclusion, there are new on-going aspects in the phenotypic classification of asthma and therapeutic strategy according to the phenotypic variations. With more pharmacogenomic information and clear identification of the "severe asthma" group even before disease progression from GWAS data, more adequate and individualized therapeutic strategy could be realized in the future.

PMID: 24734097 [PubMed - as supplied by publisher]

Official american thoracic society technical standards: spirometry in the occupational setting.

Am J Respir Crit Care Med. 2014 Apr 15;189(8):983-93

Authors: Redlich CA, Tarlo SM, Hankinson JL, Townsend MC, Eschenbacher WL, Von Essen SG, Sigsgaard T, Weissman DN, American Thoracic Society Committee on Spirometry in the Occupational Setting

Abstract
Purpose: This document addresses aspects of the performance and interpretation of spirometry that are particularly important in the workplace, where inhalation exposures can affect lung function and cause or exacerbate lung diseases, such as asthma, chronic obstructive pulmonary disease, or fibrosis. Methods: Issues that previous American Thoracic Society spirometry statements did not adequately address with respect to the workplace were identified for systematic review. Medline 1950-2012 and Embase 1980-2012 were searched for evidence related to the following: training for spirometry technicians; testing posture; appropriate reference values to use for Asians in North America; and interpretative strategies for analyzing longitudinal change in lung function. The evidence was reviewed and technical recommendations were developed. Results: Spirometry performed in the work setting should be part of a comprehensive workplace respiratory health program. Effective technician training and feedback can improve the quality of spirometry testing. Posture-related changes in FEV1 and FVC, although small, may impact interpretation, so testing posture should be kept consistent and documented on repeat testing. Until North American Asian-specific equations are developed, applying a correction factor of 0.88 to white reference values is considered reasonable when testing Asian American individuals in North America. Current spirometry should be compared with previous tests. Excessive loss in FEV1 over time should be evaluated using either a percentage decline (15% plus loss expected due to aging) or one of the other approaches discussed, taking into consideration testing variability, worker exposures, symptoms, and other clinical information. Conclusions: Important aspects of workplace spirometry are discussed and recommendations are provided for the performance and interpretation of workplace spirometry.

PMID: 24735032 [PubMed - in process]

Immediate Anti-Inflammatory Effects of Inhaled Budesonide in Patients with Asthma.

Ann Am Thorac Soc. 2014 Apr 15;

Authors: Mendes ES, Rebolledo P, Campos M, Wanner A

Abstract
Background: In patients with asthma, single doses of inhaled glucocorticosteroids (ICS) have been reported to have anti-inflammatory actions that can be detected several hours after drug administration. However, the onset and duration of the effect have not been investigated. We therefore measured airway blood flow (Qaw) as an index of airway inflammation to determine the time course and dose dependence of an ICS's anti-inflammatory action in 20 patients with moderate asthma on regular ICS treatment. Methods: Qaw and spirometry were measured before and serially for 360 min after a single inhaled dose of 360 μg, 720 μg, and 1440 μg budesonide or placebo as well as after 4 repetitive 720 μg budesonide doses given 30 min apart. Results: Baseline mean Qaw was increased and FEV1 (L) was decreased without significant differences among the 5 treatment days. After budesonide inhalation, there was a transient, dose dependent decrease in mean Qaw from 12% to 21%, with significant differences from baseline at 60 and 90 minutes for the 720 μg and 1440 μg doses (p<0.05), Thirty minutes after 4 repetitive budesonide administrations mean Qaw was 28% below baseline (p<0.05) and remained 11% below baseline after 270 min. There was no change in mean FEV1 after any of the treatments. Conclusion: In subjects with moderate asthma, who use ICS regularly, inhaled budesonide caused a transient dose-dependent vasoconstriction in the airway thereby reversing one manifestation of airway inflammation. These results suggest that a pure controller medication can have immediate beneficial effects not paralleled by changes in airflow.

PMID: 24735128 [PubMed - as supplied by publisher]

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Noninvasive ventilation (NIV) has well-recognized benefits in acute exacerbation of chronic obstructive pulmonary disease and pulmonary edema. Its utilization in acute asthma, however, remains controversial. In this review, we describe the physiological basis to justify NIV use in acute asthma and contribute a critical appraisal of the available literature relating to this practice. A discussion of some of the more pertinent, clinically relevant practicalities is also provided. Original research articles were identified using the electronic PubMed database. Randomized controlled trials of NIV in the setting of acute asthma were selected. Retrospective observational studies were also included if they were considered to contribute to the literature review. The use of NIV in the acute asthma setting has been shown to be associated with improvements in important physiological variables including measures of airflow and respiratory rate, and lends support to further study in this field. Improvements in airflow may be a direct effect of applied positive airway pressure or an indirect effect secondary to better dispersal of aerosolized medication. Reductions observed in respiratory rate and dyspnea are likely influenced by the amount of pressure support provided. Evidence suggestive of any improvement in mortality, intubation rate, or hospital/intensive care unit length of stay, however, is lacking. Studies to date have been hampered by small numbers and a lack of demonstrable meaningful clinical outcomes. Data relating to mortality, endotracheal intubation rates, and hospital length of stay/admission should be sought in future large clinical trials.

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