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Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial.

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Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial.

Respir Care. 2012 Jul 10;

Authors: Galindo-Filho VC, Dornelas-de-Andrade A, Brandão DC, de Cássia S Ferreira R, Menezes MJ, Almeida-Filho P, Parreira VF, Silva TN, Rodrigues-Machado MD

Abstract
BACKGROUND: Despite the clinical improvements attributed to noninvasive ventilation (NIV) during asthma crises and the well-established effects of nebulization, there are few studies on the effects of these interventions together. We hypothesized that nebulization coupled to NIV should rise radioaerosol pulmonary deposition in asthmatics. The aims of this study were: 1) to assess the effects of coupling beta-agonist nebulization and NIV during asthma exacerbations on radioaerosol pulmonary deposition using scintigraphy and in the cardiopulmonary parameters; 2) to correlate pulmonary function with radioaerosol deposition index (RDI), radioaerosol penetration index (RPI) and pulmonary clearance (PC). METHODS: In this controlled trial 21 adults with moderate to severe asthma attack were randomized to a control group (NEB, n=11) or experimental group (NIV+NEB, n=10). All patients inhaled bronchodilators for nine minutes and after particles were counted with a gamma camera to analyze regions of interest and PC at 0, 15, 30, 45 and 60 minutes. RESULTS: Respiratory rate (RR) (p=<0.001) and minute ventilation (VE) (p=0.01) were reduced and tidal volume (VT) was increased (p=0.01) in NIV+NEB group compared with the NEB group. NIV+NEB group had improvement from baseline values compared to NEB group in the following parameters: forced expired volume in one second (FEV₁: 46.7±0.46% pred vs. 29.8±8.87% pred, p=<0.02), forced vital capacity (FVC; 41.2±1.51% pred vs. 23.2±7.12% pred, p=0.02), peak expiratory flow (PEF; 67.3±38.3% pred vs. 26.9±12.15% pred, p=0.01) and inspiratory capacity (IC; 54.92±28.8% pred vs. 31.2±9.06% pred, p=0.01). No differences were observed between groups regarding RDI or PC. Negative correlations were found between FEV₁, FEF25-75%, IC and RPI. CONCLUSION: Coupling nebulization and NIV during asthma exacerbation did not improve radioaerosol pulmonary deposition, but we observed clinical improvement of pulmonary function in these patients.

PMID: 22781558 [PubMed - as supplied by publisher]

An Asthma Action Plan Created by Physician, Educator and Patient Online Collaboration with Usability and Visual Design Optimization.

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An Asthma Action Plan Created by Physician, Educator and Patient Online Collaboration with Usability and Visual Design Optimization.

Respiration. 2012 Jul 10;

Authors: Gupta S, Wan FT, Hall SE, Straus SE

Abstract
Background: Asthma action plans (AAPs), which decrease hospitalizations and improve symptom control, are recommended in guidelines, but are seldom delivered to patients. Existing AAPs have been developed by experts, without the inclusion of all stakeholders (such as patients with asthma) and without specifically addressing usability and visual design. Objective: Our objective was to develop a more usable AAP by involving all stakeholders and considering design preferences. Methods: We created a Wiki-based system for multiuser AAP development. Pulmonologists, primary care physicians, asthma educators and patients used the system to collaboratively compile a single AAP by making multiple online selections over 1 week. We combined common elements from 3 AAPs developed in this way into 1, optimized visual design features and tested face validity in focus groups. Results: A total of 41 participants averaged 646 selections/week over a login-time of 28.8 h/week. Of 35 participants, 28 (80%) were satisfied with the final AAP and 32 (91%) perceived that they would be able to use it. The plans created by the 3 groups were very similar, with a unanimous or majority agreement in the handling of 100/110 (91%) AAP options. Conclusions: Inclusion of multiple stakeholders and focus on design preferences predict enhanced usability and uptake of medical tools. The validity of our AAP is further supported by the similarity between the AAPs created by each group, user engagement and satisfaction with the plan and agreement with existing validity criteria proposed by experts. This AAP can be implemented in care with a concurrent measurement of uptake and health impact.

PMID: 22797144 [PubMed - as supplied by publisher]

Does Bronchial Hyperresponsiveness in Childhood Predict Active Asthma in Adolescence?

Bronchial hyperresponsiveness (BHR) is an important, but not specific, asthma characteristic. We aimed to assess the predictive value of BHR tested by methacholine and exercise challenge at age 10 years for active asthma six years later.

METHODS: From a Norwegian birth cohort 530 children underwent methacholine challenge and exercise-induced bronchoconstriction (EIB) test (n= 478) at 10 years and structured interview and clinical examination at age 16 years. The methacholine dose causing 20% reduction in forced expiratory volume the first second (FEV1) (PD20) and the reduction in FEV1 (%) after a standardized treadmill test were used for BHR assessment. Active asthma was defined with at least two criteria positive: doctor's diagnosis of asthma, symptoms of asthma and/or treatment for asthma in the last year.

RESULTS: PD20 and EIB at 10 years of age increased the risk of asthma (β=0.94, (95% CI 0.92, 0.96) per μmol methacholine and β=1.10, (95% CI 1.06, 1.15) per per cent, respectively). Separately the tests explained 10 % and 7% respectively, and together 14% of the variation in active asthma six years later. The predicted probability for active asthma at the age of 16 years increased with decreasing PD20 and increasing EIB. The area under the curve (ROC curves) was larger for PD20 (0.69, 95% CI 0.62, 0.75) than for EIB (0.60, 95% CI 0.53, 0.67).

CONCLUSION: BHR at 10 years was a significant but modest predictor of active asthma six years later with methacholine challenge being superior to exercise test.

Relationship between Exhaled Nitric Oxide and Exposure to Low-Level Environmental Tobacco Smoke in Children with Asthma on Inhaled Corticosteroids.

The relationship between exhaled nitric oxide (FeNO) and asthma severity or control is inconsistent. Active smoking lowers FeNO, but the relationship between passive smoking and FeNO is less clear. Children may be exposed to low-level environmental tobacco smoke (ETS) or thirdhand smoke, even if parents avoid smoking in the presence of their children.

Our hypothesis was that FeNO is lower in children with asthma exposed to low-level ETS when compared with those who are not exposed.

Methods. Children with stable asthma, 8-18 years of age, on low- or medium-dose inhaled corticosteroids (ICS) were enrolled. Spirometry, Asthma Control Questionnaire (ACQ), FeNO, exhaled breath condensate pH (EBC pH), and EBC ammonia were compared between children with and without ETS exposure as determined by urinary cotinine.

Results. Thirty-three subjects were enrolled, of which 10 (30%) had urinary cotinine levels ≥1 ng/ml. There were no significant differences between the two groups in age, sex, BMI percentile, atopy status, FEV(1), EBC pH, or EBC ammonia. Median ACQ was 0.29 (IQR: 0.22-0.57) for those with cotinine levels <1 ng/ml and 0.64 (IQR: 0.57-1.1) for those with cotinine levels of ≥1 ng/ml, p = .02. Median FeNO (ppb) was 23.9 (IQR: 15.2-34.5) for unexposed subjects and 9.6 (IQR: 5.1-15.8) for exposed subjects, p = .008.

Conclusions: Children with asthma on low to medium doses of ICS and recent low-level ETS exposure have lower FeNO levels when compared with non-ETS-exposed subjects. Exposure to low-level ETS or thirdhand smoke may be an important variable to consider when interpreting FeNO as a biomarker for airway inflammation.

Secondhand smoke exposure and serum cytokine levels in healthy children.

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Exposure to secondhand smoke (SHS) is associated with morbidity in children. Alterations in immune responses may explain this relationship, but have not been well-studied in children.

Our objective was to determine the association between SHS exposure and serum cytokine levels in healthy children.

METHODS: We recruited 1-6year old patients undergoing routine procedures. A parent interview assessed medical history and SHS exposure. Children with asthma were excluded. Blood was collected under anesthesia. We used Luminex Multiplex Assays to test for a panel of cytokines; cotinine was determined using an enzyme-linked immunosorbent assay. Children were categorized as no, intermediate, or high exposure. A mixed-effects model was fit to determine differences in cytokines by exposure level.

RESULTS: Of the 40 children recruited, 65% (N=26) had SHS exposure; 16 intermediate, and 10 high. There were no differences by demographics. In bivariate analyses, children exposed to SHS had lower concentrations of IL-1β, IL-4, IL-5, and IFN-γ than those with no exposure. In the mixed-effects model, children with any SHS exposure had significantly lower concentrations of IL-1β (0.554pg/mL vs. 0.249pg/mL) and IFN-γ (4.193pg/mL vs. 0.816pg/mL), and children with high exposure had significantly lower mean concentrations of IL-4 (8.141pg/mL vs. 0.135pg/mL) than children with no exposure.

CONCLUSIONS: This study suggests that SHS exposure decreases expression of some pro-inflammatory cytokines in SHS exposed children, including IFN-γ. Further research to describe the acute and chronic effects of SHS on the immune systems of children is needed.

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