Adding inhaled long-acting β2-agonists to a low dose of inhaled corticosteroids (ICS), results in better clinical asthma control than increasing the dose of ICS. However, this approach may mask underlying airway inflammation. In a double-blind parallel-group study, we evaluated the effect of adding formoterol to a low dose of budesonide, compared with a higher dose of budesonide, on the composition of induced sputum. After a 4-wk run-in period of treatment with budesonide (800 μ g, twice daily), 60 patients with moderate asthma were randomly assigned to a 1-yr treatment with 400 μ g of budesonide plus placebo, twice daily (BUD800), or 100 μ g of budesonide plus 12 μ g of formoterol, twice daily (BUD200 + F). All drugs were administered via Turbuhaler. Budesonide (800 μ g, twice daily) during run-in significantly reduced median sputum eosinophils from 4.5 to 0.68%. No significant changes in the proportion of eosinophils, EG2+ cells, other inflammatory cells, or ECP levels in sputum were observed over the ensuing 1-yr treatment with BUD200 + F or BUD800. Clinical asthma control was not significantly different between both groups. In conclusion, no significant differences in sputum markers of airway inflammation were observed during a 1-yr treatment with a low dose of inhaled budesonide plus formoterol compared with a higher dose of budesonide. Kips JC, O'Connor BJ, Inman MD, Svensson K, Pauwels RA, O'Byrne PM. A long-term study of the antiinflammatory effect of low-dose budesonide plus formoterol versus high-dose budesonide in asthma.
Summary Many of the airway responses to endogenous and exogenous stimuli are caused by indirect mechanisms such as the activation of neurons and/or inflammatory cells. In the present study we compare the bronchoamstrictor and the plasma protein extravasation response to adenosine and tachykinins in two highly inbred rat strains. F344 and BDE. BDE‐rats have a bronchoconstrictor response to adenosine at lower doses. Challenge with the A3‐adenosine receptor agonist APNEA demonstrates that the difference in airway responsiveness to adenosine between BDE‐ and F344‐rats is probably related to a higher number of A3‐receptors on the airway mast cells of BDE‐rats. In contrast. F344‐rats have a higher airway responsiveness to lachykinins than BDE‐rats. Taehykinins cause bronchoconstriction in F344‐rats mainly by an indirect mechanism, involving stimulation of NK 1 ‐receptors and mast cell activation. In BDE‐rats they cause bronchoconstriction by a direct effeet on airway smooth muscle via activation of NK 2 ‐receptors. Finally we also observed a difference between F344‐and BDE‐rats with regard to the mechanisms involved in the plasma protein extravasation in the airways caused by substance P or capsuicin. In K344‐rats but not in BDE‐rats mast cell activation and the release of 5‐hydroxytryptamine is partly responsible for this plasma protein extravasation.
Airway diseases account for a significant proportion of the respiratory physician's workload. Traditionally, conditions are classified according to clinical symptoms and abnormalities of function, although the major categories of airway disease (asthma, chronic cough and chronic obstructive pulmonary disease (COPD)) show considerable overlap in terms of both clinical picture and response to antiinflammatory treatment with corticosteroids. All of the above conditions are associated with airway inflammation, although to date there has been little interest in its routine measurement in clinical practice. The recent development of simple, safe and valid noninvasive techniques for the assessment of airway inflammation has increased interest in such an approach 1, 2. A number of techniques are available, ranging from measurement of exhaled nitric oxide levels to performing differential cell counts and assessment of mediator concentrations in induced sputum. Relatively little is known about the relationship between these different markers, although it is likely that they measure different aspects of the inflammatory response 3. A clearer understanding is desirable since some techniques are more suited to routine clinical use than others. Induced sputum cell and mediator measurements are particularly well validated 1, and normal ranges from a relatively large adult population have been published 4.
The present article summarises clinical studies pointing to the usefulness of induced sputum analysis in the following conditions: 1) asthma; 2) cough; 3) COPD; and 4) other respiratory conditions.
Asthma is commonly associated with sputum eosinophilia. Up to 80% of corticosteroidnaive subjects 1, 2 and >50% of corticosteroidtreated subjects 5 with currently symptomatic asthma have a sputum eosinophil count that is outside the normal range. Subjects with severe acute asthma usually exhibit marked sputum eosinophilia, although predominant neutrophilia has been noted in some studies in which subjects …
SummaryThe incidence of peri-operative pulmonary complications varies, depending on surgery and patient related determinants. Risk factors include upper abdominal or thoracic surgery, duration of anaesthesia, age, obesity, smoking history and underlying respiratory diseases such as COPD. The preoperative evaluation of patients undergoing general surgery is predominantly based on medical history and physical examination. A preoperative chest radiograph and pulmonary function tests are indicated in some high risk patient groups, and in all patients about to undergo lung resection surgery. If in this latter group, the preoperative lung function is severely compromised, a quantitative perfusion scan and exercise testing may be useful for the assessment of the operative risk. Prevention of postoperative pulmonary complications should begin with discontinuation of smoking at least 8 weeks prior to surgery. In high risk patients Preoperative chest physiotherapy, including incentive spirometry, is clearlv beneficial.
In this article, we explain why from our perspective as the largest academic medical center in the country, we consider it to be part of our mission to contribute to the elaboration of a value-based health care organization system. We describe our hospital quality management system and how we think that this can deliver added value by introducing lean principles in the care process. We also reflect on the importance of hospital accreditation and external benchmarking in the continuous quality improvement culture within the hospital.
We studied the bronchial effects of intravenously administered tachykinins in inbred rats. Substance P and related tachykinins caused a dose-dependent bronchoconstriction. The bronchial reactivity to substance P differed significantly between different inbred rat strains. Substance K, eledoisin and kassinin were more potent than substance P in causing bronchoconstriction. This suggests a predominance in the bronchi of SP-E receptors. The bronchial effects of substance P and eledoisin were largely inhibited by atropine and slightly enhanced by hexamethonium. In addition to a direct effect on airway smooth muscle, tachykinins interfere with the cholinergic airway innervation of the rat at the ganglionic and postganglionic level.
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