Meta-analysis of real-life studies comparing inhaled corticosteroids with formoterol versus other reliever therapies for asthma control

( Martin Kristoffer E. Ogbac ),( Rodolfo V. Dizon,Jr. ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.-

Background: The Global Initiative for Asthma (GINA) 2019 guidelines recommend inhaled corticosteroids (ICS) with formoterol as the preferred reliever for asthma exacerbations. This results from several years of studies that identified the best reliever for asthma attacks. These included randomized controlled trials (RCTs), which followed strict protocols and parameters that may not be reflective of the actual practices by physicians and patients. Real-life studies are research trials that follow protocols but considers the techniques of physicians and adjustments by patients in an actual setting, thus being considered as having a more accurate outcome. We compared different real-life studies on the effects of ICS-formoterol and other reliever therapies for asthma exacerbations. Methods: Various published real-life studies comparing the effects of ICS-formoterol and other reliever therapies for asthma exacerbations were identified using PUBMED, MEDLINE, COCHRANE, and EMBASE. The studies were published from 208 to 2019. The primary outcome was the incidence of asthma exacerbations. Subset outcome analysis was performed comparing ICS-formoterol and short-acting beta agonists (SABA). Results: 3 real-life studies were included. Participants were 12 years and above. 2115 patients received ICS-formoterol. 1971 patients received other reliever therapies. ICS-formoterol group had severe exacerbation incidence of 7.57% and 10.35% for other relievers. Subset analysis revealed incidence of severe exacerbation of 7.62% for ICS-formoterol and 10.31% for SABA. There were less hospitalizations (5 vs 8) and emergency room (ER) consults (18 vs 22) with ICS-formoterol. Conclusions: Real-life studies are more reflective of the actual practices of physicians than RCTs. Its results are more accurate of the actual settings. In this meta-analysis of real-life studies, ICS-formoterol is statistically more favorable than other reliever therapies for asthma exacerbations. It is also more favorable than SABA as reliever therapy. There is no statistical difference between ICS-formoterol and other reliever therapies for steroid use after exacerbations.

Secondary spontaneous pneumothorax secondary to tuberculosis with klebsiella and pseudomonas co-infection: a case report

( Martin Kristoffer E. Ogbac ),( Pilar Madelyn P. Rozul ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.-

from a lung pathology. Tuberculosis is a common cause of SSP specially in endemic areas such as the Philippines. Organisms that causes pneumonia can also cause SSP. Among these, the most common are Staphylococcus, Klebsiella, Pseudomonas, and Pneumocystis. In patients with cystic fibrosis, the risk of SSP increases with Burkholderiacepaciaor Pseudomonas infection. We report a 37-year-old Filipino female, who had fever, cough, and lower back pain. Chest radiograph revealed left pneumothorax. Chest tube thoracostomy (CTT) was performed Antibiotics were started. Computed tomography revealed massive left pneumothorax and left lung relaxation atelectasis. Bronchoscopy reported moderate mucus. Bronchial aspirate revealed Klebsiella pneumoniae. Video-assisted thoracoscopic surgery (VATS) noted 300cc pleural fluid with septations and loculations; trapped left lower lobe by thick fibrin; 0.5 x 0.5cm pleural nodule; 4 x 2cm diaphragmatic mass. Pleural fluid revealed acid fast bacilli (AFB) and Pseudomonas aeruginosa. Diaphragmatic and pleural nodule histopathology reported chronic granulomatous inflammation with Langhan’s type giant cells consistent with tuberculosis. Anti-tuberculosis medications were started. CTT was subsequently removed. SSP due to tuberculosis results from diaphragmatic rupture due to pleural invasion by the organism with subsequent liquefactive necrosis. The same happens for pneumothorax due to other respiratory infections. Tuberculosis is diagnosed by identification of AFB in the sputum or pleural fluid. In endemic areas with inaccessible laboratory, diagnosis is made by high suspicion. There are limited cases of SSP secondary to tuberculosis with concomitant respiratory bacterial infection because pleural studies and bronchoscopy are not routinely done. Treatment consists of CTT and administration of both anti-tuberculosis and antibiotic medications. This case report of SSP secondary to tuberculosis with simultaneous respiratory bacterial infection of Pseudomonasand Klebsiellarecommends the inclusion of pleural fluid culture and AFB in the routine work-up of SSP. VATS and bronchoscopy are recommended to rule out other possible etiology.

Ventilator-associated pneumonia secondary to sphingomonas paucimobilis infection in a septic shock patient: a case report

( Martin Kristoffer E. Ogbac ),( Pilar Madelyn P. Rozul ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.-

Background: Sphingomonas paucimobilisis an aerobic, nonspore-forming, nonfermentative gram-negative bacillus and was known as Pseudomonaspaucimobilis. It is distributed in the natural environment and forms biofilm in water systems in hospitals and devices like nebulizers and ventilators. It is not a major pathogen with a low virulence, but several cases of severe infection have been reported with the organism being obtained from blood, sputum, urine, peritoneal fluid, and catheters. Case Summary: We report a 73-year-old Filipino male, who presented with difficulty of breathing. He was hypertensive, diabetic, and had chronic kidney disease (CKD) undergoing regular hemodialysis. He received treatment for pulmonary tuberculosis and underwent repeated thoracentesis for recurrent pleural effusions secondary to CKD. He was intubated for persistent dyspnea and was admitted at the intensive care unit. He was managed as severe sepsis secondary to pneumonia and was started on Piperacillin + Tazobactam and Azithromycin. Blood culture was negative for any bacteria. Tracheal aspirate culture revealed Enterobacter cloacae, which was sensitive to Piperacillin + Tazobactam. On the 13thhospital day, he developed persistent hypotension and desaturation. Noradrenaline drip was started and he was managed as septic shock secondary to ventilator-associated pneumonia. Antibiotics were shifted to Meropenem. Blood culture was negative. Tracheal aspirate revealed Extended Spectrum Beta-Lactamase positive Sphingomonas paucimobilis that was resistant to Meropenem. Antibiotics were changed to Ciprofloxacin however, persistent hypotension and desaturation recurred and despite additional inotropes, patient expired. Conclusion: The existence of Sphingomonas paaucimobilisin the natural environment does not pose any threat although recent literature shows that it can cause severe infection and shock among immunocompromised and critically-ill patients. In the Philippines, no published report has been made on its incidence. With the increasing episodes of antibiotic resistance and incidence of previous non-pathologic bacteria now causing severe infection, it is important that this organism be carefully studied and documented.

Adverse events of as-needed inhaled corticosteroid and formoterol versus short acting Beta2 agonists in asthma exacerbations: a meta-analysis

( Martin Kristoffer E. Ogbac ),( Rodolfo V. Dizon,Jr. ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.0

A major consideration influencing the treatment for asthma exacerbation are side effects of the medications. The latest Global Initiative for Asthma (GINA) guidelines in the management of acute exacerbations of asthma recommends the use of inhaled corticosteroid (ICS) with formoterol. This has replaced the short-acting beta2 agonists (SABA) as the preferred reliever therapy. Majority of the adverse events with ICS-formoterol combination are upper respiratory tract infection (URTI) and headache while tremors and nausea were reported with SABA. We reviewed the safety and adverse events observed in recent trials comparing ICS-formoterol and SABA as reliever in asthma exacerbations. Recently published randomized controlled trials (RCT) comparing the effects of ICS-formoterol and SABA as for asthma exacerbations were found using PUBMED, MEDLINE, COCHRANE, and EMBASE. Included studies were published from 2006. Primary outcome was the incidence of total adverse events. Secondary outcome was is the most common side event for each therapy. 12 RCTs were included. Patients aging from 12 years old and above were selected. 8,703 patients received ICS-formoterol while 14,009 patients received SABA. The ICS-formoterol group had an adverse event incidence of 33.23 % while the SABA group had 32.55%. Based on the reported adverse events during these trials, the most common for both ICS-formoterol and SABA group was the development of respiratory tract infection. This is followed by nasopharyngitis. This analysis reviewed the different adverse events observed during the trials comparing the efficacy of ICS-formoterol and SABA for asthma exacerbations. This report did not statistically favor any reliever therapy in terms of incidence of adverse events as both groups have similar incidence of adverse events. Respiratory tract infection was also observed in both relievers as the major adverse event followed by nasopharyngitis. Safety profile of medications must also be considered in treating asthma exacerbations specially that new guidelines have released.