pulmicort and Emergencies

The use of systemic corticosteroids, together with bronchodilators and oxygen therapy, has become established for the management of acute asthma. These agents are undoubtedly effective, but are also associated with problems such as metabolic adverse effects. Inhaled corticosteroids (ICS) offer potential benefit in the acute setting because they are delivered directly to the airways. They are also likely to reduce systemic exposure, which would lead in turn to reductions in rates of unwanted systemic effects. In order to evaluate the role of budesonide in the management of acute asthma exacerbations we conducted a review of the literature and critically evaluated the rationale for the use of ICS in general in this setting. Trials in adults and children requiring treatment for acute exacerbation of asthma have shown clinical and/or spirometric benefit for budesonide when delivered via nebulizer, dry powder inhaler, or aerosol in the emergency department, hospital and follow-up settings. The efficacy seems to benefit from high doses given repeatedly during the initial phase of an acute exacerbation. These acute effects are likely to be linked to the drug's distinctive pharmacokinetic and pharmacodynamic profile. The current evidence base revealed encouraging results regarding the efficacy of the ICS budesonide in patients with wheeze and acute worsening of asthma. Future studies should focus on the efficacy of these agents in more severe asthma worsenings.

Topics: Acute Disease; Administration, Inhalation; Adolescent; Adult; Asthma; Bronchodilator Agents; Budesonide; Child; Drug Administration Schedule; Emergencies; Glucocorticoids; Hospitalization; Humans; Respiratory Sounds; Treatment Outcome

Oral corticosteroids (CS) are standard treatment for patients discharged from the emergency department (ED) after treatment for acute asthma. Several recent, relatively small trials have investigated the replacement of CS with inhaled corticosteroids (ICS), with varied results and conclusions. This systematic review examined the effect of using ICS in place of CS on outcomes in this setting.. Only randomized controlled trials were eligible for inclusion. Studies in which patients were treated for acute asthma in the ED or its equivalent, and on discharge compared ICS therapy to standard CS therapy, were eligible for inclusion. Trials were identified using the Cochrane Airways Review Group register, searching abstracts and bibliographies, and contacting primary authors and pharmaceutical companies. Data were extracted and methodologic quality assessed independently by two reviewers, and missing data were obtained from authors.. Seven trials, involving a total of 1,204 patients, compared high-dose ICS therapy vs CS therapy after ED discharge. There were no significant differences demonstrated between the treatments for relapse rates (odds ratio, 1.00; 95% confidence interval, 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to prove equivalence between the treatments, and severe asthmatics were excluded from these trials.. There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics on ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion.

Topics: Acute Disease; Administration, Inhalation; Administration, Oral; Adult; Androstadienes; Anti-Inflammatory Agents; Asthma; Budesonide; Child; Emergencies; Fluticasone; Humans; Patient Discharge; Randomized Controlled Trials as Topic

To determine whether long-term, continuous use of inhaled anti-inflammatory medications affects asthma outcomes in children with mild to moderate asthma after use is discontinued.. Of the 1041 participants in the Childhood Asthma Management Program randomized clinical trial, 941 (90%) were followed to determine whether 4.3 years of twice-daily budesonide or nedocromil administration (each compared with placebo) affected subsequent asthma outcomes during a 4.8-year posttrial period in which treatment was managed by the participants' physicians.. The groups treated continuously during the trial with either budesonide or nedocromil did not differ from the group given placebo in terms of lung function, control of asthma, or psychological status at the end of 4.8 years of posttrial follow-up. However, the decreased mean height in the budesonide group relative to the placebo group at the end of the trial (1.1 cm; P = .005) remained statistically significant (0.9 cm; P = .01) after an additional 4.8 years and was more pronounced in girls (1.7 cm; P = .001) than in boys (0.3 cm; P = .49). Participants in all groups used inhaled corticosteroids during 30% of the posttrial period.. Clinically meaningful improvements in the control of asthma and in airway responsiveness achieved during continuous treatment with inhaled corticosteroids do not persist after continuous treatment is discontinued.

Topics: Adolescent; Anti-Inflammatory Agents; Asthma; Body Height; Bronchodilator Agents; Budesonide; Drug Utilization; Emergencies; Female; Follow-Up Studies; Forced Expiratory Volume; Humans; Male; Nebulizers and Vaporizers; Nedocromil; Outcome Assessment, Health Care; Prednisone; Severity of Illness Index; Sex Factors; Vital Capacity

To compare the clinical effect of nebulized budesonide with placebo in acute pediatric asthma.. A randomized, controlled, double-blind trial with parallel design was used in the ED of a tertiary care children's hospital. Children aged 6 months to 18 years with a moderate to severe exacerbation of asthma [Pulmonary Index Score (PIS) > or = 5 or < or = 11 after a salbutamol nebulization of 0.15 mg/kg] were eligible. All patients received prednisone 1 mg/kg orally and nebulized salbutamol (0.15 mg/kg) every 30 minutes for 3 doses and then every hour for 4 hours. The intervention was 2 mg (4 mL) of nebulized budesonide or 4 mL of nebulized normal saline.. Baseline characteristics were comparable in the budesonide group (n = 24) and in the placebo group (n = 20). There were no significant differences in the primary outcome measure (PIS) between the 2 groups. However, the PIS at 1 hour had a tendency to be lower in the budesonide group (median = 5) as compared with the placebo group (median = 6; p = 0.07). Survival analysis of release/discharge from the ED/hospital showed a more rapid rate in the budesonide group as compared with the placebo group (p = 0.02). No adverse effects were seen.. Although these preliminary results suggest that nebulized budesonide may be an effective adjunct to oral prednisone in the management of moderate to severe asthma exacerbations, a larger trial will be required before the widespread use of inhaled budesonide in acute asthma can be advocated.

Topics: Acute Disease; Administration, Inhalation; Administration, Oral; Adolescent; Albuterol; Anti-Inflammatory Agents; Asthma; Bronchodilator Agents; Budesonide; Child; Child, Preschool; Double-Blind Method; Drug Therapy, Combination; Emergencies; Female; Hospitalization; Humans; Infant; Male; Nebulizers and Vaporizers; Prednisone; Respiratory Function Tests

Topics: Budesonide; Colectomy; Colitis; Colonic Diseases; Colonic Neoplasms; Diagnosis, Differential; Emergencies; Eosinophilia; Humans; Intestinal Obstruction; Male; Middle Aged; Sigmoid Diseases

International guidelines have been edited to standardize asthma management. These guidelines are often difficult to translate to clinical practice because of gaps in the knowledge of clinical practitioners but also because of compliance issues, particularly in children and adolescents. A new approach named SIT (for Single Inhaler Therapy) or SMART (for Symbicort Maintenance and Reliever Therapy) has demonstrated its safety and efficacy in numerous studies of adults with asthma summarized in two Cochrane reviews. We present here three clinical cases from our clinic where this approach was applied to children and adolescents with a clear clinical and functional response for two of them. We suggest that the SIT regimen can be used in some children and adolescents with asthma and has the potential to reduce compliance issues. Moreover asthma phenotypes have been described and it is possible that only some of these phenotypes respond to this regimen. However to confirm the efficacy and safety of the SIT regimen in children and adolescents more studies are needed.. La prise en charge de l’asthme se base sur des schémas résumés dans des recommandations internationales. En pratique, la mise en place de ces recommandations se heurte à de nombreux problèmes dont la méconnaissance du milieu médical, mais aussi l’observance, en particulier chez l’enfant et l’adolescent. Une nouvelle approche, appelée SIT (pour Single Inhaler Therapy) ou SMART (pour Symbicort Maintenance And Reliever Therapy) a démontré son efficacité chez l’adulte sur base de plusieurs études, résumées dans deux revues Cochrane. Nous présentons trois cas cliniques où ce traitement a été appliqué à des enfants et adolescents avec une efficacité certaine dans deux cas et une mauvaise réponse dans l’autre. Nous suggérons que ce schéma pourrait être efficace chez l’enfant et l’adolescent, notamment vu les problèmes de compliance dans cette tranche d’âge. En outre, il est possible que certains phénotypes d’asthme soient plus à même de répondre à ce schéma. Afin de confirmer l’efficacité et la sécurité de ce type de schéma dans cette tranche d’âge, des études complémentaires sont cependant indispensables.

Topics: Administration, Inhalation; Adolescent; Anti-Asthmatic Agents; Asthma; Budesonide; Child; Drug Therapy, Combination; Emergencies; Female; Formoterol Fumarate; Humans; Maintenance Chemotherapy; Male

Acute asthma is the third commonest cause of pediatric emergency visits at PGIMER. Typically, it presents with acute onset respiratory distress and wheeze in a patient with past or family history of similar episodes. The severity of the acute episode of asthma is judged clinically and categorized as mild, moderate and severe. The initial therapy consists of oxygen, inhaled beta-2 agonists (salbutamol or terbutaline), inhaled budesonide (three doses over 1 h, at 20 min interval) in all and ipratropium bromide and systemic steroids (hydrocortisone or methylprednisolone) in acute severe asthma. Other causes of acute onset wheeze and breathing difficulty such as pneumonia, foreign body, cardiac failure etc. should be ruled out with help of chest radiography and appropriate laboratory investigations in first time wheezers and those not responding to 1 h of inhaled therapy. In case of inadequate response or worsening, intravenous infusion of magnesium sulphate, terbutaline or aminophylline may be used. Magnesium sulphate is the safest and most effective alternative among these. Severe cases may need ICU care and rarely, ventilatory support.

Topics: Albuterol; Algorithms; Anti-Asthmatic Agents; Budesonide; Child; Child, Preschool; Diagnosis, Differential; Emergencies; Humans; Magnesium Sulfate; Respiratory Tract Diseases; Severity of Illness Index; Software Design; Status Asthmaticus; Terbutaline

Topics: Acute Disease; Aminophylline; Anti-Asthmatic Agents; Anti-Inflammatory Agents; Asthma; Bronchodilator Agents; Budesonide; Critical Care; Emergencies; Humans; Intensive Care Units; Oxygen Inhalation Therapy; Phosphodiesterase Inhibitors; Prednisolone; Pulmonary Disease, Chronic Obstructive; Respiration, Artificial; Respiratory Care Units; Respiratory Insufficiency; Respiratory Therapy; Status Asthmaticus; Time Factors