Non-invasive ventilation in severe asthma attacks.

Minerva Anestesiol. 2013 Mar 19;

Authors: Diehl JL, Guérot E

Abstract
Noninvasive ventilation (NIV) is a very effective technique for severe acute exacerbations of COPD/COLD and acute pulmonary edema, but its interest is still a matter of debate for severe asthma attacks. However, despite a slow decrease in asthma mortality, which actually mainly concerns older people, the prevalence of asthma is still raising and is associated to a high level of emergency visits and ICU hospitalizations for severe asthma attacks. Unfortunately, the level of knowledge on this topic is based only on observational studies and on 4 small RCTs, likely to be underpowered to demonstrate any benefit on the rate of tracheal intubation or on mortality. Nevertheless, some benefits have been shown with regard to functional improvement and length of hospital stay. From a technical point of view, one can expect in the future some improvements by combining NIV and nebulization and/or helium-oxygen therapy. Finally, there is a need for positive large randomized clinical trials before routine clinical use can be firmly recommended.

PMID: 23511354 [PubMed - as supplied by publisher]

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Ten years of tiotropium: clinical impact and patient perspectives.

Int J Chron Obstruct Pulmon Dis. 2013;8:117-25

Authors: Yohannes AM, Connolly MJ, Hanania NA

Abstract
Tiotropium bromide is an anticholinergic agent that has gained worldwide acceptance as a first-line, once daily maintenance therapy for patients with moderate-to-severe chronic obstructive pulmonary disease. The purpose of this review is to synthesize the evidence base in the past 10 years on the development of tiotropium and its efficacy compared to other able interventions such as long-acting beta agonists (LABAs), as well as to assess its safety profile and its effects on health-related outcomes in patients with COPD. Treatment with tiotropium bromide has generally improved patients' health-related quality of life, reduced the number of patients suffering from acute exacerbations, decreased the number of hospitalizations, improved dyspnea, and reduced adverse events compared to placebo. In the past decade, several studies have examined the safety and efficacy of tiotropium in comparison to placebo and to LABAs (salmeterol, formoterol, and indacaterol) over periods ranging from 3 months to 48 months of follow-up. Head-to-head comparisons of tiotropium 18 μg (once daily) with salmeterol 50 μg (twice daily) in well-controlled trials demonstrated that tiotropium was superior in reducing acute exacerbation events and in improving quality of life. In a few short-term studies, indacaterol was comparable to tiotropium in its efficacy in improving health-related outcomes. Although the safety record of tiotropium has been exemplary in comparison to placebo, anticholinergic events such as dry mouth can be encountered in some patients. While the long-term safety of tiotropium when delivered in the HandiHaler(®) has been well documented, its delivery using the Respimat(®) Soft Mist Inhaler™ was associated with an elevated risk of cardiovascular complications, including increased mortality when compared to placebo. The exact mechanism for this is not known but is being investigated in a large multinational study that will evaluate the long-term safety of different doses of tiotropium delivered by the Respimat(®) soft mist inhaler versus the HandiHaler(®). Further studies are required to investigate the efficacy and safety of tiotropium in comparison with novel LABAs such as indacaterol and vilanterol, and with other emerging novel anticholinergic agents such as aclidinium bromide and NVA237 (glycopyrronium bromide).

PMID: 23515335 [PubMed - in process]

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Shrinking the room for invasive ventilation in hypercapnic respiratory failure.

Int J Chron Obstruct Pulmon Dis. 2013;8:135-7

Authors: Scarpazza P, Incorvaia C, Melacini C, Cattaneo R, Bonacina C, Riario-Sforza GG, Casali W

Abstract
Noninvasive ventilation (NIV) was introduced as an alternative to invasive mechanical ventilation for acute respiratory failure caused from exacerbations of chronic obstructive pulmonary disease in the 1980s, and its use gradually rose worldwide. Seventy-eight patients (57 males, mean age 78.3 ± 9.2 years) undergoing NIV were evaluated. Of them, 48 (62.3%) had acute hypercapnic respiratory failure because of a chronic obstructive pulmonary disease exacerbation, and the remaining 30 had acute hypercapnic respiratory failure from other causes, mainly cardiac failure. All patients were treated by NIV using the bi-level positive airway pressure set up at high pressure/high backup rate. NIV was successful in 67 subjects (85.9%) and the patients were discharged, 57 of whom continued NIV at home and ten had spontaneous breathing. NIV was unsuccessful in eleven patients, ten of whom died and one was successfully treated by invasive mechanical ventilation. Significant differences were detected for a higher basal Glasgow Coma Scale score in successfully treated patients (P = 0.007), a higher basal Acute Physiology and Chronic Health Evaluation score in unsuccessfully treated patients (P = 0.004), and a lower pH after 1 hour in unsuccessfully treated patients (P = 0.015). These findings show a very high rate of success of NIV in patients with acute hypercapnic respiratory failure not only from chronic obstructive pulmonary disease but also from cardiac failure. This suggests that the use of invasive mechanical ventilation may be further reduced, with a decrease in its known complications as well.

PMID: 23516004 [PubMed - in process]

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Comparison of two systemic steroid regimens for the treatment of COPD exacerbations.

Pulm Pharmacol Ther. 2013 Mar 18;

Authors: Ceviker Y, Sayiner A

Abstract
RATIONALE: Systemic steroids shorten recovery time, improve lung function and hypoxemia in COPD exacerbations. Although several studies have shown that both parenteral and oral steroids are effective and GOLD guideline recommends use of oral steroids at a dose of 30-40 mg/day, very little data exists as to whether any route of admininstration (parenteral vs oral) or any dose is more effective and/or safer. METHODS: This was a randomized, parallel-group study aiming to compare the effectiveness and safety of orally administered lower dose of steroids with parenteral administration of higher doses. Thus, a total of 40 patients were included; one group (Group 1, n=20) received methylprednisolone (MP) as recommended by the GOLD guideline (PO 32 mg/day for seven days) and the other (Group 2, n=20) was given IV MP at 1 mg/kg/day for four days and 0.5 mg/kg/day for three days. RESULTS: The two groups were similar with regards to age (69.0±10.5 vs 67.1±8.4 years), duration of COPD (11.8±8.3 vs 9.7±7.7 years), FEV1 (41.3±17.3 vs 34.0±12.0%), PaO2 levels (55.5±9.9 vs 59.1±11.0 mmHg) and dyspnea scores (9.4±1.1 vs 10.0±1.0). Worsening hypercapnic respiratory failure developed in two patients from Group 1 on days 1 and 2, these were intubated and thus excluded from the study. At day 7, both groups showed significant improvements in FEV1 levels (49.1±19.8 and 40.0±18.3%, respectively), PaO2 levels (66.5±12.5 and 65.3±10.6 mmHg, respectively)(Fig. 1) and dyspnea scores (3,5±2,8 and 4.2±2.8)(Fig. 2). The length of hospital stay was similar for the two groups (11.0±3.9 vs 12.7±6.4). Regarding adverse events, four patients in Group 1 vs 11 patients in group 2 developed hyperglycemia. Besides, three patients in group 2 had worsening of previously controlled hypertension. All events were treated and controlled with administration of proper oral medications. All patients were followed up for three months. Eight patients in group 1 and 15 patients in group 2 had unplanned visits to their physicians or to the emergency rooms for recurring exacerbations. Four patients in group 1 and five patients in group 2 were readmitted to hospital for recurrence (p=NS). During the follow-up two patients from group 1 died. CONCLUSION: These data show that oral administration of MP at a dose 32 mg/day for seven days significantly improves lung function, symptom scores and oxygenation in patients admitted to the hospital for COPD exacerbation and is as effective as and possibly safer than parenteral admininistration of higher doses.

PMID: 23518215 [PubMed - as supplied by publisher]