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.

Reliever therapy using inhaled corticosteroid and formoterol versus short acting Beta2 agonist in chronic asthmatic patients: a meta-analysis

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

Background: Several approaches are applied in the managing asthma exacerbations. In the Global Initiative for Asthma (GINA) 2018, the preferred reliever was the used of as needed short-acting beta2 agonists (SABA). A year after GINA 2018, GINA 2019 was released. In GINA 2019, the preferred reliever therapy was as needed low dose of inhaled corticosteroid (ICS) with formoterol. For several years, the use of SABA as needed for asthma exacerbations was the recommended therapy and common practice. In this meta-analysis, we reviewed the different trials comparing the ICS-formoterol and SABA as reliever therapy for asthma exacerbations. Methodology: Several published randomized controlled trials (RCT) about the effect of ICS-formoterol and SABA as reliever therapy for asthma exacerbations were identified using PUBMED, MEDLINE, COCHRANE, and EMBASE. The studies included were published from 2005 to 2019. The primary outcome was the incidence of asthma exacerbations. Secondary outcome was the incidence of hospitalizations. Results: 16 RCTs were included in this analysis. These studies included diagnosed asthmatic patients aged 12 years old and above. A total of 12,956 patients received ICS-formoterol as reliever therapy while 16,906 patients received SABA. The ICS-formoterol group had an severe asthma exacerbation incidence of 14.36% while the SABA group had an incidence of 20.6%. The incidence of hospitalizations revealed 6% for the ICS-formoterol group and 9% for the SABA group. Discussion: Several studies have been made on the best treatment for asthma exacerbations. Appropriate management of asthma exacerbations leads to decreased frequency of exacerbations. This analysis of recent trials found out that the use of ICS-formoterol as reliever therapy in asthma exacerbations is more superior to SABA. In terms of having a lower incidence of severe exacerbations, the use of ICS-formoterol as reliever was favored over SABA. Lower hospitalizations were also associated with the use of ICS-formoterol as reliever therapy.

Effect of Hyperbaric Oxygen Therapy among COVID-19 Patients: A Metaanalysis

( Martin Kristoffer Ogbac ),( Jose Edzel Tamayo ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Background and Aims COVID-19 disease continues to be a major health concern despite numerous preventive measures and treatment availability. Hyperbaric oxygen therapy (HBOT) has been used in cases of severe anemia, air embolism, decompression sickness, and carbon monoxide poisoning. In COVID-19, the use of HBOT has been considered as it showed favorable Results in restoring normal oxyhemoglobin and tissue oxygenation in severe hypoxemia and tissue hypoxia. It has also exhibited antiinflammatory effects on inflammasomes, proinflammatory and inflammatory cytokines, and chemokines. With the given physiologic benefits of HBOT, this study aims to identify the effect of HBOT among severe COVID-19 patients. Methods Several trials using HBOT among COVID-19 patients were analyzed in this meta-analysis. The treatment group utilized HBOT while standard of care was used in the control group. The primary outcome is the incidence of in-patient mortality. The secondary outcome is the incidence of progression to invasive mechanical ventilation (IMV). Results and Conclusions 3 trials were included in this study. The incidence of mortality was 12% in the HBOT group and 26% in the standard of care group (P = 0.02). Progression to IMV was also lower in the HBOT with 13% compared to the control group with 46% (P = 0.003). HBOT for viral infections has been documented even before the COVID-19 pandemic. In this study, the use of HBOT among severe COVID-19 patients have shown favorable Results. HBOT is a promising alternative or additional treatment for COVID-19. Larger trials are needed to better demonstrate the benefit of HBOT.

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.

Comparison between Manual vs. Other Techniques of Pleural Fluid Evacuation during Thoracentesis: A Meta-analysis

( Martin Kristoffer Ogbac ),( Jose Edzel Tamayo ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Background and Aims Thoracentesis is an important procedure to determine the cause of pleural effusion and to relieve patients of symptoms such as cough and dyspnea. Common complications associated with thoracentesis include pneumothorax and re-expansion pulmonary edema. This meta-analysis compares the associated complications between different approaches in evacuating pleural effusion during thoracentesis. Methods 2 clinical trials were compared. Both trials assigned 60-mL syringes that were attached to a drainage bag to the manual aspiration group. These were compared with other techniques of evacuation of pleural fluid that consisted of vacuum container in one study and gravity via drainage catheter in the other study. The primary outcomes are the incidences of complications after thoracentesis and early termination of procedure due to symptoms. The secondary outcome is the incidence of pneumothorax after the procedure. Results and Conclusions A total of 240 patients were included in this analysis. The incidence of complications after thoracentesis and early termination due to symptoms were lower in the manual aspiration group but is not statistically significant (p=0.21, p=0.23). Pneumothorax was more observed in other techniques of evacuation compared to manual technique but is not statistically significant (p=0.5). Thoracentesis is an important procedure in managing pleural effusion with small risk of adverse events. It is a common procedure that is regularly performed by specialists with different techniques. This analysis showed that there are no differences among different Methods in evacuating pleural fluid. It is recommended that additional studies be conducted to identify the best approach to avoid complications.

Prevention of nosocomial infection using oral chlorhexidine among patients undergoing cardiac surgery: a meta-analysis

( Martin Kristoffer Ogbac ),( Jose Edzel Tamayo ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.-

Background: Infections namely pneumonia, urinary tract infection, and wound infection can complicate post-operative outcomes of cardiac surgeries such as percutaneous coronary intervention and coronary artery bypass grafts. These preventable complications have caused significant delay in the improvement and even death in certain patients undergoing these procedures. Oral chlorhexidine has been proven to prevent nosocomial infections particularly ventilator-associated pneumonia (VAP). Certain studies have also proved its effect on the prevention of infection among non-intubated patients. In this meta-analysis, we studied the different randomized controlled trials (RCT) comparing the effect of oral chlorhexidine in the prevention of nosocomial infections among patients undergoing cardiac surgeries. Methodology: Several published RCT about the effect of oral chlorhexidine and occurrence of nosocomial infection among patients undergoing cardiac surgeries were identified using PUBMED, MEDLINE, COCHRANE, and EMBASE. The studies included were published from 1996 to 2019. The primary outcome was the incidence of nosocomial infection. Subset analysis was also made comparing the different nosocomial infections. Results: Based on this meta-analysis, it was found that oral chlorhexidine has significantly reduced the number of nosocomial infections after cardiac surgeries. Among these infections, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), urinary tract infection, and wound infection have lower incidence in patients treated with oral chlorhexidine although only the HAP and VAP were statistically significant. The incidence of positive culture growth was also statistically in favor with oral chlorhexidine. Discussion: Nosocomial infections are deleterious complications of post cardiac procedures that can be easily prevented. With this study, it has shown that the use of oral chlorhexidine as part of the routine regimens during cardiac surgeries can significantly prevent if not lower incidence of infection.

Effect of Bromhexine among COVID-19 Patients - A Meta-anaylsis

( Martin Kristoffer Ogbac ),( Jose Edzel Tamayo ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Background and Aims Bromhexine is an affordable and easily available mucolytic that appears to be beneficial among patients with COVID-19. It acts as a potent inhibitor of transmembrane serine protease 2, which is essential for the viral entry and propagation of SARS-CoV-2. Several trials have been conducted to determine its efficacy, however, its usefulness remains controversial. Methods Trials that utilized bromhexine among COVID-19 patients were investigated. The treatment arm received bromhexine hydrochloride tablets for 14 days plus standard of care while the control arm received standard of care only. The primary outcomes were mortality within 28 days of hospitalization, rate of intubation, and clinical improvement. The secondary outcomes were rate of intensive care unit (ICU) admission, discharge from hospital, and requirement of oxygen support. Results and Conclusions 3 studies with a total of 196 patients were analyzed in this meta-analysis. The number of mortality, intubated patients, and patients who required oxygen support were lower in the bromhexine group however it was not statistically significant (p=0.14, p=0.08, p=062). Clinical improvement was also better with the bromhexine group but did not achieved statistical significance (p=0.14). The rate of ICU admission and discharge from hospital favored bromhexine and is also statistically significant (p=0.04, p=0.1). Despite numerous available treatment, COVID-19 continuous to be a major worldwide health concern. The use of bromhexine as an alternative treatment would be of great importance given its affordability and accessibility to patients however, additional studies are still needed to prove its benefits.

Community Acquired Pneumonia Secondary to Multidrug Resistant Pseudomonas Luteola: A Case Report

( Martin Kristoffer Ogbac ),( Euodia Guinmapang ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

We report a case of a 74 years old Filipino male, who was admitted due to increasing abdominal girth and generalized body weakness. He had chronic obstructive pulmonary disease and lung adenocarcinoma with liver and bone metastasis. He was a previous heavy smoker. On admission, initial blood exam revealed leukocytosis with neutrophil predominance (WBC 43.35; Neutrophils 68). Chest radiograph revealed bibasal haziness with consolidation on the right. He was previously on piperacillin + tazobactam as out-patient antibiotic therapy and was started on meropenem upon admission. He underwent jejunostomy and peritoneal drain insertion, right. Sputum culture revealed moderate growth of pseudomonas luteola with multidrug resistance. Bacterial cultures of blood and peritoneal fluid were negative. Vancomycin and fluconazole were added. Despite additional antibiotics, creatinine levels increased (177 from 105) and leukocytosis progressed (WBC 51.31). Meropenem and vancomycin were shifted to linezolid and cefepime with the addition of ciprofloxacin. On the 11th hospital day, he was noted to have persistent dyspnea and weakness and eventually expired on the 13th hospital day. Pseudomonas luteola is an aerobic, non-spore forming gram-negative rod bacteria and was first described and termed in 1974 as chryseomonas luetola. It is a rare pathogen with few reports of nosocomial pneumonia, endocarditis, septicemia, and foreign body-related infections. It has been recorded both in immunocompromised and immunocompetent patients with varying course outcomes. Community acquired pneumonia secondary to pseudomonas luteola has not been documented. Reporting emerging new infections is very important as it provides vital information for the treatment of such new pathogens.

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.

Correlation of Pleural Fluid Results and Diagnosis of Tuberculous Pleural Effusion among Adult Patients

( Martin Kristoffer Ogbac ),( Joven Jeremius Tanchuco ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Introduction The diagnosis of tuberculous pleural effusion (TPE) is difficult to establish because of the low yield, limited availability, and high costs of confirmatory studies. This concern has often led to delayed management or worse, untreated TPE. Other parameters have been used as alternative criteria to diagnose TPE however no local data is available. Methodology This was a retrospective cross-sectional study of 320 patients with pleural effusion. Patient demographics and Results of pleural fluid analysis (cell count and differential count; and exudative or transudative nature) were gathered from hospital records for data analysis. Results A total of 96 patients (30%) were treated as TPE. Clinic profile and pleural fluid Results of patients with TPE were compared with those with non-TPE. LNR was not associated with TPE. Patient’s age (p<0.001), unilateral lung involvement (p<0.001), history of TB treatment (p = 0.023), and exudative nature (p = 0.02) were all associated with TPE. Unilateral location was four times likely (aOR 4.304, 95% CI 2.10 to 8.83, p < 0.001) and having an exudative nature (aOR 3.155, 95% CI 1.19 to 8.34, p = 0.02) was three time likely to have TPE as cause of pleural effusion. Conclusion A timely diagnosis of TPE should be made specially in high TB-endemic areas. Age, unilateral presentation, history of TB treatment, and exudative nature should be considered in establishing TPE to avoid delay in management and untreated TPE.