RESUMO
BACKGROUND: Randomized controlled trials (RCTs) indicate that long-acting bronchodilator combinations, such as ß2-agonist (LABA)/muscarinic antagonist (LAMA), have favorable efficacy compared with commonly used COPD treatments. The objective of this analysis was to compare the efficacy and safety of LABA/LAMA with LAMA or LABA/inhaled corticosteroid (ICS) in adults with stable moderate-to-very-severe COPD. METHODS: This systematic review and meta-analysis (PubMed/MEDLINE, Embase, Cochrane Library and clinical trial/manufacturer databases) included RCTs comparing ≥12 weeks' LABA/LAMA treatment with LAMA and/or LABA/ICS (approved doses only). Eligible studies were independently selected by two authors using predefined data fields; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS: Eighteen studies (23 trials) were eligible (N=20,185). LABA/LAMA significantly improved trough forced expiratory volume in 1 second (FEV1) from baseline to week 12 versus both LAMA and LABA/ICS (0.07 L and 0.08 L, P<0.0001), with patients more likely to achieve clinically important improvements in FEV1 of >100 mL (risk ratio [RR]: 1.33, 95% confidence interval [CI]: [1.20, 1.46] and RR: 1.44, 95% CI: [1.33, 1.56], respectively, the number needed to treat being eight and six, respectively). LABA/LAMA improved transitional dyspnea index and St George's Respiratory Questionnaire scores at week 12 versus LAMA (both P<0.0001), but not versus LABA/ICS, and reduced rescue medication use versus both (P<0.0001 and P=0.001, respectively). LABA/LAMA significantly reduced moderate/severe exacerbation rate compared with LABA/ICS (RR 0.82, 95% CI: [0.75, 0.91]). Adverse event (AE) incidence was no different for LABA/LAMA versus LAMA treatment, but it was lower versus LABA/ICS (RR 0.94, 95% CI: [0.89, 0.99]), including a lower pneumonia risk (RR 0.59, 95% CI: [0.43, 0.81]). LABA/LAMA presented a lower risk for withdrawals due to lack of efficacy versus LAMA (RR: 0.66, 95% CI: [0.51, 0.87]) and due to AEs versus LABA/ICS (RR: 0.83, 95% CI: [0.69, 0.99]). CONCLUSION: The greater efficacy and comparable safety profiles observed with LABA/LAMA combinations versus LAMA or LABA/ICS support their potential role as first-line treatment options in COPD. These findings are of direct relevance to clinical practice because we included all currently available LABA/LAMAs and comparators, only at doses approved for clinical use.
Assuntos
Corticosteroides/administração & dosagem , Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Broncodilatadores/administração & dosagem , Pulmão/efeitos dos fármacos , Antagonistas Muscarínicos/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Corticosteroides/efeitos adversos , Agonistas de Receptores Adrenérgicos beta 2/efeitos adversos , Broncodilatadores/efeitos adversos , Distribuição de Qui-Quadrado , Progressão da Doença , Combinação de Medicamentos , Volume Expiratório Forçado , Humanos , Pulmão/fisiopatologia , Antagonistas Muscarínicos/efeitos adversos , Razão de Chances , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVES: The aim of our study was to assess the new diagnostic criteria of acute kidney injury (AKI) proposed by the Acute Kidney Injury Network (AKIN) in a large cohort of mechanically ventilated patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This is a prospective observational cohort study enrolling 2783 adult intensive care unit patients under mechanical ventilation (MV) with data on serum creatinine concentration (SCr) in the first 48 hours. The absolute and the relative AKIN diagnostic criteria (changes in SCr ≥ 0.3 mg/dl or ≥ 50% over the first 48 hours of MV, respectively) were analyzed separately. In addition, patients were classified into three groups according to their change in SCr (ΔSCr) over the first day on MV (ΔSCr): group 1, ΔSCr ≤ -0.3 mg/dl; group 2, ΔSCr between -0.3 and +0.29 mg/dl; and group 3, ΔSCr ≥ +0.3 mg/dl). The primary end point was in-hospital mortality, and secondary end points were intensive care unit and hospital length of stay, and duration of MV. RESULTS: Of 2783 patients, 803 (28.8%) had AKI according to both criteria: 431 only absolute (AKI(A)), 362 both relative and absolute (AKI(R+A)), and 10 only relative. The relative criterion identified more patients when baseline SCr (SCr0) was <0.9 mg/dl and the absolute when SCr0 was >1.5 mg/dl. The diagnosis of AKI was associated with mortality. CONCLUSIONS: Our study confirms the validity of the AKIN criteria in a population of mechanically patients and the criteria's relationship with the baseline SCr.
Assuntos
Injúria Renal Aguda/diagnóstico , Creatinina/sangue , Indicadores Básicos de Saúde , Respiração Artificial , Injúria Renal Aguda/sangue , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Adulto , Idoso , Análise de Variância , Biomarcadores/sangue , Canadá , Distribuição de Qui-Quadrado , Europa (Continente) , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Arábia Saudita , Índice de Gravidade de Doença , América do Sul , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
PURPOSE: To compare characteristics and clinical outcomes of patients receiving airway pressure release ventilation (APRV) or biphasic positive airway pressure (BIPAP) to assist-control ventilation (A/C) as their primary mode of ventilatory support. The objective was to estimate if patients ventilated with APRV/BIPAP have a lower mortality. METHODS: Secondary analysis of an observational study in 349 intensive care units from 23 countries. A total of 234 patients were included who were ventilated only with APRV/BIPAP and 1,228 patients who were ventilated only with A/C. A case-matched analysis according to a propensity score was used to make comparisons between groups. RESULTS: In logistic regression analysis, the most important factor associated with the use of APRV/BIPAP was the country (196 of 234 patients were from German units). Patients with coma or congestive heart failure as the reason to start mechanical ventilation, pH <7.15 prior to mechanical ventilation, and patients who developed respiratory failure (SOFA score >2) after intubation with or without criteria of acute respiratory distress syndrome were less likely to be ventilated with APRV/BIPAP. In the case-matched analysis there were no differences in outcomes, including mortality in the intensive care unit, days of mechanical ventilation or weaning, rate of reintubation, length of stay in the intensive care unit or hospital, and mortality in the hospital. CONCLUSIONS: In this study, the APRV/BIPAP ventilation mode is being used widely across many causes of respiratory failure, but only in selected geographic areas. In our patient population we could not demonstrate any improvement in outcomes with APRV/BIPAP compared with assist-control ventilation.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Ventilação com Pressão Positiva Intermitente/métodos , Estudos de Coortes , Pressão Positiva Contínua nas Vias Aéreas/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva , Ventilação com Pressão Positiva Intermitente/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Few data are available regarding the benefits of one mode over another for ventilatory support. We set out to compare clinical outcomes of patients receiving synchronized intermittent mandatory ventilation with pressure support (SIMV-PS) compared with assist-control (A/C) ventilation as their primary mode of ventilatory support. METHODS: This was a secondary analysis of an observational study conducted in 349 ICUs from 23 countries. A propensity score stratified analysis was used to compare 350 patients ventilated with SIMV-PS with 1,228 patients ventilated with A/C ventilation. The primary outcome was in-hospital mortality. RESULTS: In a logistic regression model, patients were more likely to receive SIMV-PS if they were from North America, had lower severity of illness, or were ventilated postoperatively or for trauma. SIMV-PS was less likely to be selected if patients were ventilated because of asthma or coma, or if they developed complications such as sepsis or cardiovascular failure during mechanical ventilation. In the stratified analysis according to propensity score, we did not find significant differences in the in-hospital mortality. After adjustment for propensity score, overall effect of SIMV-PS on in-hospital mortality was not significant (odds ratio, 1.04; 95% CI, 0.77-1.42; P = .78). CONCLUSIONS: In our cohort of ventilated patients, ventilation with SIMV-PS compared with A/C did not offer any advantage in terms of clinical outcomes, despite treatment-allocation bias that would have favored SIMV-PS.
Assuntos
Ventilação com Pressão Positiva Intermitente/métodos , Insuficiência Respiratória/terapia , APACHE , Distribuição de Qui-Quadrado , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Ventilação com Pressão Positiva Intermitente/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , América do Norte , Curva ROC , Insuficiência Respiratória/mortalidade , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Resultado do Tratamento , Desmame do RespiradorRESUMO
Los pacientes que padecen de EPOC son claramente una población en riesgo, ya que la función pulmonar finalmente se reducirá con una tasa acelerada a medida que la enfermedad progrese. El manejo de la EPOC necesita centrarse en modificar el curso de la enfermedad, haciendo foco en cuatro áreas principales: 1) diagnóstico temprano de la enfermedad, 2) reducción del riego mediante el cese del consumo de tabaco, 3) tratamiento farmacológico y de rehabilitación pulmonar con el objeto de mejorar a corto y largo plazo, y 4) disminuir las complicaciones reduciendo las exacerbaciones. La intervención con el tratamiento farmacológico de mantenimiento en forma regular desde estadios leves de la EPOC, puede ser beneficioso para los pacientes tal como lo sugieren los ensayos en pacientes vírgenes de tratamiento (por ejemplo, tratados comoleves y utilizando beta2 agonistas a demanda). Hoy, solamente el cese del hábito tabáquico es la intervención que ha demostrado cambiar el curso clínico de la enfermedad preservando la función pulmonar. Está pendiente aún de demostrarse, si el tratamiento farmacológico puede cambiar el curso a largo plazo de la enfermedad. Los resultados de ensayos clínicos aún en curso, podrán proveer evidencia al respecto.
COPD patients are a risk group because their lung function will be reduced quickly as the disease progresses. Management of COPD needs to be focused on modifying the development of the diseases through: 1) making an earlier diagnose, 2) quitting thetobacco smoking habit, 3) making a pharmacologic and non pharmacologic plan focused on a rapid improvement, and 4) preventing exacerbations and improving the patient lung function. A sustained drug treatment intervention from the initial staging of the disease, may be beneficial, moreover in naive patients, but until now only the smoking cessation is the intervention that has proved to change the clinical course of the disease, preserving lung function. It is yet to be demonstrated whether drug treatment may change the long-term progress of the disease. The results of on going clinical trials will provide evidence on this question.
Assuntos
Humanos , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/reabilitação , Doença Pulmonar Obstrutiva Crônica/terapia , Broncodilatadores/uso terapêutico , Albuterol/uso terapêutico , Fatores de Risco , Tabagismo/efeitos adversosRESUMO
Community-acquired pneumonia (CAP) is the leading cause of death from infectious diseases in the US. It accounts each year for 500,000 hospitalizations and 45,000 deaths and represents one of the most common causes of intensive care unit (ICU) admission. The mortality rate due to severe CAP has shown little improvement in the past three decades, remaining between 21% and 58% in patients admitted to the intensive care unit. Antimicrobial agents are the cornerstone of therapy against CAP, but there are some novel antibiotic and nonantibiotic therapies that have been recently tested that may potentially impact outcomes of patients with severe CAP. We will review the most recent data regarding novel therapies in patients with the highest risk of death such as those with severe CAP.
Assuntos
Infecções Comunitárias Adquiridas/tratamento farmacológico , Sistemas de Liberação de Medicamentos , Pneumonia/tratamento farmacológico , Anti-Infecciosos/farmacologia , Anti-Infecciosos/uso terapêutico , Ensaios Clínicos como Assunto , Infecções Comunitárias Adquiridas/mortalidade , Infecções Comunitárias Adquiridas/fisiopatologia , Cuidados Críticos/métodos , Humanos , Pneumonia/epidemiologia , Pneumonia/fisiopatologia , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
La neumonía adquirida en la comunidad es una enfermedad que causa alta morbilidad, mortalidad y costos. Este artículo tiene como finalidad discutir los diferentes métodos de evaluación de severidad de la enfermedad, para determinar el mejor sitio para el tratamiento de los pacientes. Utilizamos un caso clínico ficticio a manera de ejercicio para aplicar las diferentes herramientas: PSI, CURB y CURB-65. Sugerimos el uso tanto del CURB como de CURB-65, por su fácil aplicación y buena efectividad en la práctica clínica. La presencia de dos o más de los criterios clínicos: (Confusión, BUN>19,6 mg/dL 7mmol/L), frecuencia respiratoria >=30/min, e hipotensión arterial (presión arterial sistólica o diastólica <90/60 mmHgl) sugieren que el paciente debe ser manejado en el hospital. Estos métodos no tienen la función de reemplazar sino de reforzar objetivamente el criterio clínico en la toma de decisión del lugar apropiado de tratamiento del paciente con neumonía adquirida en la comunidad...
Assuntos
Pneumonia , Hospitalização , Pneumonia/diagnósticoRESUMO
INTRODUCTION: Hispanics are the fastest growing ethnicity of the US population and the largest subset includes those of Mexican origin. Hispanics, including Mexican Americans (MAs), consistently report less tobacco exposure than European Americans (EAs), but limited data are available regarding differences in the clinical characteristics, severity of airflow obstruction, and functional status between MAs and EAs with chronic obstructive pulmonary disease (COPD). METHODS: Participants in a community-based study of aging and frailty among MAs and EAs, San Antonio Longitudinal Study of Aging, underwent spirometry. Participants with spirometry values consistent with COPD by Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria are described here. RESULTS: Thirty-four percent (248/721) of the participants who underwent spirometry had evidence of GOLD Stages 1-4 COPD. Significantly more MAs with COPD reported being never smokers compared to EAs with COPD. Among those with COPD who also smoked, MAs reported significantly less tobacco exposure than EAs (15.7 vs. 32.4 pack-years, respectively), but both groups had surprisingly similar severities of airflow obstruction. Additionally, MAs had worse functional status and perceived health than did EAs. CONCLUSIONS: Despite significantly less exposure to tobacco smoke, MAs with COPD had a similar degree of obstruction to airflow compared with EAs with COPD. Healthcare providers should have a high index of suspicion for COPD in MAs who are exposed to even small amounts of cigarette smoke.