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Macrolide Therapy Decreases Chronic Obstructive Pulmonary Disease Exacerbation: A Meta-Analysis.

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Macrolide antibiotics have anti-inflammatory effects, and long-term administration may reduce chronic obstructive pulmonary disease (COPD) exacerbations. Objective: To investigate the effects of long-term treatment of macrolide therapy for COPD.

Methods: We searched the PubMed and Embase databases to identify randomized controlled trials that evaluated the effect of macrolide therapy (of at least 2 weeks) for COPD. The primary outcome assessed was the frequency of acute exacerbations during follow-up.

Results: Six trials involving 1,485 COPD patients were included in the analysis. Analysis of the pooled data of all 6 trials showed that macrolide administration reduced the frequency of acute exacerbations of COPD [risk ratio (RR) = 0.62; 95% CI 0.43-0.89, p = 0.01].

Subgroup analysis showed that only erythromycin might be associated with decreased COPD exacerbations (erythromycin: p = 0.04, azithromycin: p = 0.22, clarithromycin: p = 0.18). Moreover, macrolide therapy for 3 months did not significantly reduce the number of exacerbations (p = 0.18), whereas a beneficial effect was conclusive in the 6-month (p = 0.009) and 12-month (p = 0.03) treatment subgroups. In addition, nonfatal adverse events were more frequent in the macrolide treatment groups than in the controls (RR = 1.32; 95% CI 1.06-1.64, p = 0.01). However, related clinical factors had no influence on the overall result (p = 0.19). There was no publication bias among the included trials.

Conclusions: Macrolide therapy was effective and safe in decreasing the frequency of exacerbations in patients with COPD. Treatment might provide a significant benefit but only when therapy lasts more than 6 months.

Effects of guideline-oriented pharmacotherapy in patients with newly diagnosed COPD: a prospective study.

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Whether guideline-oriented pharmacotherapy prevents the decline in pulmonary function or reduces systemic inflammation associated with chronic obstructive pulmonary disease (COPD) is uncertain.

OBJECTIVES: The aim of this study was to assess the outcome of COPD in clinical practice under real-world conditions in Taiwan as measured by pulmonary function and systemic inflammation parameters (C-reactive protein (CRP) or white blood cell (WBC)) after initiation of guideline-oriented pharmacotherapy.

METHODS: Newly diagnosed COPD patients were enrolled and prospectively observed in real-world outpatient practice following initiation of pharmacotherapy of COPD. Pulmonary function, WBC and neutrophil counts, and CRP level of COPD patients were assessed annually. This study enrolled 566 patients and 263 returned for follow-up visits.

RESULTS: Significantly higher postbronchodilator FVC, FEV1, and FEV1/FVC but lower DLCO were found at 1 year compared to baseline values. During 4-year follow-up period, FVC and FEV1 remained stable. DLCO progressively declined compared to baseline. No significant changes were seen in CRP and neutrophil count over a 3-year period. Values of CRP, WBC, and neutrophil count correlated inversely with FEV1, FVC, FEV1/FVC, and DLCO.

CONCLUSIONS: Guideline-oriented pharmacotherapy of COPD improves airflow limitation but does not prevent the alveolar destruction and systemic inflammation under real-world conditions in Taiwan.

Asthma medication delivery: Mists and myths.

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Asthma is usually treated with inhaled corticosteroids (ICS) and bronchodilators generated from pressurized metered dose inhalers (pMDI), dry powder inhalers (DPI), or nebulizers. The target areas for ICS and beta 2-agonists in the treatment of asthma are explained. Drug deposition not only depends on particle size, but also on inhalation manoeuvre. Myths regarding inhalation treatments lead to less than optimal use of these delivery systems.

We discuss the origin of many of these myths and provide the background and evidence for rejecting them.

Acute respiratory distress syndrome in children: physiology and management.

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The present review seeks to review the pathophysiologic processes that underlie the development of acute respiratory distress syndrome (ARDS) in children. The review intends to provide the physiologic foundation for the treatment strategies that are associated with the most optimal outcome.

RECENT FINDINGS: In infants and children, ARDS remains a significant cause of morbidity and mortality. Although any infant or child can develop ARDS, children who have experienced trauma, pneumonia, aspiration, or immune compromise are at increased risk. Data indicate that adoption of an open-lung ventilation strategy, characterized by sufficient positive end-expiratory pressure to avoid atelectasis, a tidal volume that is limited to less than 5-7  cc/kg per breath and a plateau pressure of 30  cm of water or less provides the greatest likelihood of survival and minimizes lung injury. The relative benefits of strategies such as high frequency oscillatory ventilation, surfactant replacement therapy and inhaled nitric oxide are considered.

SUMMARY: ARDS remains a cause of significant mortality and morbidity in children. By employing sound physiologic principles, clinical outcomes can be optimized.

Diagnostic accuracy of the bronchodilator response in children.

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The bronchodilator response (BDR) reflects the reversibility of airflow obstruction and is recommended as an adjunctive test to diagnose asthma. The validity of the commonly used definition of BDR, a 12% or greater change in FEV1 from baseline, has been questioned in childhood.

OBJECTIVES: We sought to examine the diagnostic accuracy of the BDR test by using 3 large pediatric cohorts.

METHODS: Cases include 1041 children with mild-to-moderate asthma from the Childhood Asthma Management Program. Control subjects (nonasthmatic and nonwheezing) were chosen from Project Viva and Home Allergens, 2 population-based pediatric cohorts. Receiver operating characteristic curves were constructed, and areas under the curve were calculated for different BDR cutoffs.

RESULTS: A total of 1041 cases (59.7% male; mean age, 8.9 ± 2.1 years) and 250 control subjects (46.8% male; mean age, 8.7 ± 1.7 years) were analyzed, with mean BDRs of 10.7% ± 10.2% and 2.7% ± 8.4%, respectively. The BDR test differentiated asthmatic patients from nonasthmatic patients with a moderate accuracy (area under the curve, 73.3%). Despite good specificity, a cutoff of 12% was associated with poor sensitivity (35.6%). A cutoff of less than 8% performed significantly better than a cutoff of 12% (P = .03, 8% vs 12%).

CONCLUSIONS: Our findings highlight the poor sensitivity associated with the commonly used 12% cutoff for BDR. Although our data show that a threshold of less than 8% performs better than 12%, given the variability of this test in children, we conclude that it might be not be appropriate to choose a specific BDR cutoff as a criterion for the diagnosis of asthma.

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