PURPOSE: Asthma control in older asthmatics is often less effective, which may be attributed to small airway dysfunction and poor inhalation technique. We compared the efficacy of 2 inhalers (fluticasone propionate/formoterol treatment using a pressurized metered-dose inhaler [p-MDI group] vs. fluticasone propionate/salmeterol treatment using a dry powder inhaler [DPI group]) in older asthmatics.METHODS: We conducted a 12-week, randomized, open-label, parallel-designed trial in older patients (over 55 years old) with moderate-to-severe asthma, and compared the efficacy and safety for asthma control between the 2 groups. Subgroup analyses on disease duration and air trapping were performed. Clinical parameters, including changes in lung function parameters, inhaler technique and adherence, were compared with monitoring adverse reactions between the 2 groups.RESULTS: A total of 68 patients underwent randomization, and 63 (30 in the p-MDI group and 33 in the DPI group) completed this study. The p-MDI group was non-inferior to the DPI group with regard to the rate of well-controlled asthma (53.3% vs. 45.5%, P < 0.001; a predefined non-inferiority limit of 17%). In subgroup analyses, the proportion of patients who did not reach well-controlled asthma in the p-MDI group was non-inferior to that in the DPI group; the difference was 12.7% among those with a longer disease duration (≥ 15 years) and 17.5% among those with higher air-trapping (RV/TLC ≥ 45%), respectively (a predefined non-inferiority limit of 17%, P < 0.001). No significant differences were observed in lung function parameters, inhalation techniques, adherence and adverse reactions between the 2 groups.CONCLUSION: These results suggest that the p-MDI group may be comparable to the DPI group in the management of older asthmatics in aspects of efficacy and safety.
Airway Management ; Asthma ; Dry Powder Inhalers ; Fluticasone ; Humans ; Inhalation ; Lung ; Medication Adherence ; Metered Dose Inhalers ; Nebulizers and Vaporizers ; Random Allocation

Adrenal Cortex Hormones ; Asthma ; Eosinophils ; Humans ; Inflammation ; Nebulizers and Vaporizers ; Nitric Oxide ; Odds Ratio ; Prescriptions ; Pulmonary Disease, Chronic Obstructive ; Respiratory Sounds

PURPOSE: Although mild to moderate asthma is much more common, the morbidity and mortality of severe asthma are much higher. This study was performed to identify and analyze the clinical characteristics of severe asthma in Korea. METHODS: We registered patients with severe refractory asthma into the Severe Asthma Registry supported by the Severe Asthma Work Group of the Korean Academy of Asthma, Allergy and Clinical Immunology. Patients were enrolled since 2010 from the 15 university hospitals nationwide in Korea. Severe asthma was defined according to modified European Respiratory Society/American Thoracic Society criteria. Information on demographics, medical history, pulmonary function tests and skin prick tests was collected; the clinical characteristics of severe asthmatics were analyzed from the collected data. RESULTS: A total of 489 patients were enrolled with a mean age of 62.3; 45% are male. Sixty percent of patients received Global Initiative for Asthma step 4 treatment, and 30% received step 5 treatment. The most common comorbidities were allergic rhinitis (58.7%). Aspirin hypersensitivity was observed in 14.0%. Approximately half (53.9%) are non-smokers. Atopy was proven in 38.5% of the patients. Regarding asthma medications, inhaled corticosteroids and long-acting β-agonist combination inhalers were most commonly prescribed (96.5%), followed by leukotriene antagonists (71.0%). A recombinant anti-immunoglobulin E monoclonal antibody (omalizumab) has been used in 1.8% of the patients. The mean forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and FEV1/FVC were 78.7%, 67.5% and 67.9% of predicted values, respectively. The mean Asthma Control Test and quality of life questionnaire scores were 16.5 out of 25 and 59.5 out of 85, respectively. CONCLUSIONS: The baseline characteristics of severe asthma patients in the Korea Severe Asthma Registry were analyzed and reported for the first time. With this cohort, further prospective studies should be performed to search for ways to improve management of severe refractory asthma.
Adrenal Cortex Hormones ; Adult* ; Allergy and Immunology ; Aspirin ; Asthma* ; Cohort Studies ; Comorbidity ; Demography ; Forced Expiratory Volume ; Hospitals, University ; Humans ; Hypersensitivity ; Korea* ; Leukotriene Antagonists ; Male ; Mortality ; Nebulizers and Vaporizers ; Prospective Studies ; Quality of Life ; Respiratory Function Tests ; Rhinitis, Allergic ; Skin ; Vital Capacity

BACKGROUND: Although vitamin D deficiency is prevalent in patients with chronic obstructive pulmonary disease (COPD), the influence of vitamin D deficiency on COPD has not been fully established. Moreover, the inflammation process is associated with vitamin D deficiency in the general population. Therefore, this study aimed to determine whether clinical phenotypes, comorbidities, and exacerbation rates are affected by the level of plasma fibrinogen, well studied by an inflammatory marker in COPD patients, and 25-hydroxy (25-OH) vitamin D. METHODS: This retrospective study analyzed patients with COPD whose inflammatory marker levels, especially plasma fibrinogen and 25-OH vitamin D levels, had been examined. A correlation analysis was conducted for inflammatory markers and 25-OH vitamin D. Clinical characteristics, comorbidities and exacerbation rates were compared among four groups based on plasma fibrinogen concentrations (threshold, 350 mg/dL) and 25-OH vitamin D levels (threshold, 20 ng/mL). RESULTS: Among 611 patients with COPD, 236 were included in the study. The levels of inflammatory markers had no statistical correlation with the serum 25-OH vitamin D levels. The four groups showed no statistically significant differences in age, sex, smoking history, inhaler use, and severity of comorbidities. Patients with high plasma fibrinogen concentrations and low 25-OH vitamin D levels had lower lung function, higher severity index, and higher annual rate of severe exacerbations 12 months before (0.23/year) and after (0.41/year) the measurement of 25-OH vitamin D levels than did the other patients. CONCLUSION: Our findings suggested an interaction between vitamin D deficiency and COPD. The measurement of plasma fibrinogen concentrations could help identify a severe phenotypic group among patients with vitamin D deficiency.
Comorbidity ; Fibrinogen ; Humans ; Inflammation ; Lung ; Nebulizers and Vaporizers ; Phenotype ; Plasma ; Pulmonary Disease, Chronic Obstructive ; Retrospective Studies ; Smoke ; Smoking ; Vitamin D Deficiency ; Vitamin D ; Vitamins

BACKGROUND: Although many risk factors are known to be associated with poor asthma outcomes in the elderly, the literature on the effect of risk factor control on asthma outcomes in the elderly is very sparse. OBJECTIVE: To evaluate the role of multifaceted interventions in reducing acute exacerbations in elderly asthmatics. METHODS: A total of 100 subjects were randomly selected from our prospective cohort of elderly asthmatics aged 65 years or older and were provided multifaceted intervention for 1 year. Our multifaceted interventions included repeated education on asthma and inhaler technique for patients and their caregivers, provision of an action plan to cope with acute exacerbations, short message service to prevent follow-up losses, and oral replacement of magnesium. The primary outcome was an acute asthma exacerbation rate compared to the previous year. RESULTS: Ninety-two subjects completed this study, although only 58 subjects continued to take magnesium. Compared to the previous year, the acute asthma exacerbation rate showed a significant reduction from 67% to 50% (p = 0001) and significant improvement was observed in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) (p = 0.04, p = 0.036 for each). Interestingly, a subgroup analysis revealed that predicted value of FEV1 increased significantly in subjects who continued to take magnesium from 79.6% to 87.1% (p = 0.008). CONCLUSION: To reduce acute exacerbations in elderly asthmatics, a multifaceted approach in increase medical awareness, proficiency and adherence to inhaler, assistance of caregivers and correction of micronutrients deficiency is likely to be effective. In addition, a continuous oral replacement of magnesium may increase FEV1 in elderly asthmatics.
Aged ; Asthma ; Caregivers ; Cohort Studies ; Education ; Follow-Up Studies ; Forced Expiratory Volume ; Humans ; Magnesium ; Micronutrients ; Nebulizers and Vaporizers ; Prospective Studies ; Risk Factors ; Text Messaging ; Vital Capacity

Bronchodilator therapy is central to the management of chronic obstructive pulmonary disease and are recommended as the preferred treatment by the Global Obstructive Lung Disease Initiative (GOLD). Long acting anti-muscarinics (LAMA) and long acting β₂ agonists (LABA) are both more effective than regular short-acting drugs but many patients remain symptomatic despite monotherapy with these drugs. Combination therapy with LAMA and LABA increases the therapeutic benefit while minimizing dose-dependent side effects of long-acting bronchodilator therapy. The TOviTO programme has investigated the benefits of treatment with a combination of tiotropium and olodaterol administered via a single inhaler. Tiotropium+olodaterol 5/5 µg significantly improved forced expiratory volume in 1 second (FEV₁) area under the curve from 0 to 3 hours, trough FEV₁ health status and breathlessness versus the mono-components and placebo. Tiotropium+olodaterol 5/5 µg also increased endurance time and reduced dynamic hyperinflation during constant work rate cycle ergometry. On the basis of these and other studies the 2017 GOLD report recommends escalating to dual bronchodilator therapy in patients in groups B and C if they remain symptomatic or continue to have exacerbations and as initial therapy for patients in group D.
Dyspnea ; Ergometry ; Forced Expiratory Volume ; Humans ; Lung Diseases ; Lung Diseases, Obstructive ; Nebulizers and Vaporizers ; Pulmonary Disease, Chronic Obstructive ; Tiotropium Bromide

Asthma, remains symptomatic despite ongoing treatment with high doses of inhaled corticosteroids (ICS) in conjunction with long-acting beta-agonists (LABA), is classified as “severe” asthma. In the course of caring for those patients diagnosed with severe asthma, stepping up from ICS/LABA to more aggressive therapeutic measures would be justified, though several aspects have to be checked in advance (including inhaler technique, adherence to therapy, and possible associated comorbidities). That accomplished, it would be advisable to step up care in accordance with the Global Initiative for Asthma (GINA) recommendations. Possible strategies include the addition of a leukotriene receptor antagonist or tiotropium (to the treatment regimen). The latter has been shown to be effective in the management of several subgroups of asthma. Oral corticosteroids have commonly been used for the treatment of patients with severe asthma in the past; however, the use of oral corticosteroids is commonly associated with corticosteroid-related adverse events and comorbidities. Therefore, according to GINA 2017 these patients should be referred to experts who specialize in the treatment of severe asthma to check further therapeutic options including biologics before starting treatment with oral corticosteroids.
Adrenal Cortex Hormones ; Asthma ; Biological Products ; Comorbidity ; Humans ; Immunoglobulin E ; Interleukin-5 ; Nebulizers and Vaporizers ; Receptors, Leukotriene ; Tiotropium Bromide

When it comes to the use in inhalers in the management of chronic obstructive pulmonary diseases, there are many options, considerations and challenges, which health care professionals need to address. Considerations for prescribing and dispensing, administering and following up, education, and adherence; all of these factors impact on treatment success and all are intrinsically linked to the device selected. This review brings together relevant evidence, real-life data and practice tools to assist health care professionals in making decisions about the use of inhalers in the management of chronic obstructive pulmonary diseases. It covers some of the key technical device issues to be considered, the evidence behind the role of inhalers in disease control, population studies which link behaviors and adherence to inhaler devices as well as practice advice on inhaler technique education and the advantages and disadvantages in selecting different inhaler devices. Finally, a list of key considerations to aid health care providers in successfully managing the use of inhaler devices are summarized.
Delivery of Health Care ; Education ; Health Personnel ; Humans ; Lung Diseases, Obstructive ; Nebulizers and Vaporizers* ; Population Control ; Pulmonary Disease, Chronic Obstructive

Severe asthma is associated with substantial morbidity, use of healthcare resources, and long-term sequelae including declining lung function and frequent exacerbations. The identification of severe asthma is challenging due to the heterogeneity of the disease, the complexity of diagnosis, and the impact of comorbidities. A structured approach to the assessment of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. The lack of a response to treatment or the requirement for high doses of medication to control symptoms are signs of disease mimickers, comorbidities, or the influence of environmental factors. Second, medication adherence and the inhaler technique should be checked in advance. Third, the phenotypic characteristics of patients confirmed to have severe asthma can indicate the therapies likely to be most effective. Further research that seeks to define the phenotypes of severe asthma based on endotype will enable the development of novel and effective therapeutic options for patients with severe asthma.
Asthma* ; Comorbidity ; Delivery of Health Care ; Diagnosis* ; Humans ; Lung ; Medication Adherence ; Nebulizers and Vaporizers ; Phenotype ; Population Characteristics

BACKGROUND: A rapid increase in desflurane concentration has been demonstrated to induce transient sympathetic hyperactivity and lead to increases in blood pressure and heart rate (HR). Additionally, the use of dexmedetomidine as an anesthetic adjunct has been reported to attenuate intraoperative sympathetic responses. We examined the hemodynamic effects of dexmedetomidine infusion before anesthetic induction on desflurane-induced cardiovascular changes. METHODS: Patients were randomly divided into three groups. They received either normal saline (NS) (group 1, only NS) or dexmedetomidine solution diluted in 50 ml NS (group 2, 0.5 µg/kg; group 3, 1.0 µg/kg) for 10 minutes with a syringe pump before anesthetic induction. Desflurane was administered at a vaporizer dial setting of 8% for 5 minutes by manual ventilation. RESULTS: In group 1, the HR significantly increased above the baseline during the entire 5 minutes after desflurane inhalation and the mean blood pressure (MBP) significantly increased above the baseline at 1, 2, and 3 minutes after desflurane inhalation. However, in groups 2 and 3, the increases in HR and MBP induced by desflurane inhalation were significantly suppressed. The HR and MBP in group 2 remained closer to the baseline than in group 3. CONCLUSIONS: A loading infusion of dexmedetomidine for 10 minutes before induction of general anesthesia effectively attenuates the transient cardiovascular stimulation induced by desflurane inhalation, without significant hemodynamic side effects. The HR and MBP remained closer to the baseline after administration of 0.5 µg/kg dexmedetomidine than after administration of a dose of 1.0 µg/kg.
Anesthesia, General ; Blood Pressure ; Dexmedetomidine* ; Heart Rate ; Hemodynamics ; Humans ; Inhalation* ; Nebulizers and Vaporizers ; Syringes ; Ventilation