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Pulmonary Journal Club

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May 2017 Phoenix Pulmonary/Critical Care Journal Club
October 2015 Phoenix Pulmonary Journal Club: Lung Volume Reduction
September 2015 Tucson Pulmonary Journal Club: Genomic Classifier
   for Lung Cancer
April 2015 Phoenix Pulmonary Journal Club: Endo-Bronchial Ultrasound in
   Diagnosing Tuberculosis
February 2015 Tucson Pulmonary Journal Club: Fibrinolysis for PE
January 2015 Tucson Pulmonary Journal Club: Withdrawal of Inhaled
    Glucocorticoids in COPD
January 2015 Phoenix Pulmonary Journal Club: Noninvasive Ventilation In 
   Acute Respiratory Failure
September 2014 Tucson Pulmonary Journal Club: PANTHEON Study
June 2014 Tucson Pulmonary Journal Club: Pirfenidone in Idiopathic
   Pulmonary Fibrosis
September 2014 Phoenix Pulmonary Journal Club: Inhaled Antibiotics
August 2014 Phoenix Pulmonary Journal Club: The Use of Macrolide
   Antibiotics in Chronic Respiratory Disease
June 2014 Phoenix Pulmonary Journal Club: New Therapies for IPF
   and EBUS in Sarcoidosis
March 2014 Phoenix Pulmonary Journal Club: Palliative Care
February 2014 Phoenix Pulmonary Journal Club: Smoking Cessation
January 2014 Pulmonary Journal Club: Interventional Guidelines
December 2013 Tucson Pulmonary Journal Club: Hypothermia
December 2013 Phoenix Pulmonary Journal Club: Lung Cancer
   Screening
November 2013 Tucson Pulmonary Journal Club: Macitentan
November 2013 Phoenix Pulmonary Journal Club: Pleural Catheter
   Infection
October 2013 Tucson Pulmonary Journal Club: Tiotropium Respimat 
October 2013 Pulmonary Journal Club: Pulmonary Artery
   Hypertension
September 2013 Pulmonary Journal Club: Riociguat; Pay the Doctor
August 2013 Pulmonary Journal Club: Pneumococcal Vaccine
   Déjà Vu
July 2013 Pulmonary Journal Club
June 2013 Pulmonary Journal Club
May 2013 Pulmonary Journal Club
March 2013 Pulmonary Journal Club
February 2013 Pulmonary Journal Club
January 2013 Pulmonary Journal Club
December 2012 Pulmonary Journal Club
November 2012 Pulmonary Journal Club
October 2012 Pulmonary Journal Club
September 2012 Pulmonary Journal Club
August 2012 Pulmonary Journal Club
June 2012 Pulmonary Journal Club
June 2012 Pulmonary Journal Club
May 2012 Pulmonary Journal Club
April 2012 Pulmonary Journal Club
March 2012 Pulmonary Journal Club
February 2012 Pulmonary Journal Club
January 2012 Pulmonary Journal Club
December 2011 Pulmonary/Sleep Journal Club
October, 2011 Pulmonary Journal Club
September, 2011 Pulmonary Journal Club
August, 2011 Pulmonary Journal Club
July 2011 Pulmonary Journal Club
May, 2011 Pulmonary Journal Club
April, 2011 Pulmonary Journal Club
February 2011 Pulmonary Journal Club 
January 2011 Pulmonary Journal Club 
December 2010 Pulmonary Journal Club

 

Both the Phoenix Good Samaritan/VA and the Tucson University of Arizona fellows previously had a periodic pulmonary journal club in which current or classic pulmonary articles were reviewed and discussed. A brief summary was written of each discussion describing thearticle and the strengths and weaknesses of each article.

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Wednesday
Feb042015

January 2015 Tucson Pulmonary Journal Club: Withdrawal of Inhaled Glucocorticoids in COPD

Magnussen H, Disse B, Rodriguez-Roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94. [CrossRef] [PubMed]

GOLD guidelines recommend various combinations of inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and long-acting muscarinic agonists (LAMA) to treat patients with chronic obstructive pulmonary disease (COPD) who are at high risk of exacerbation.  A substantial portion of patients are ultimately prescribed triple-therapy at some point. The WISDOM trial examined the risk of exacerbation among patients taking triple therapy who were subsequently weaned from their ICS treatment.

The present WISDOM trial was a randomized, double-blind, non-inferiority trial sponsored by Boehringer Ingelheim Pharma. Over 4 years, approximately 2500 participants in 23 non-US countries with severe or very severe COPD were randomized. Participants were eligible if they were >40 years of age, were current or former smokers with ≥10 pack-year history, and had at least one exacerbation within the year prior to screening. Numerous exclusion criteria included significant comorbidity, prior lung resection, asthma or bronchiectasis, chronic oxygen use, oral steroid requirement, recent exacerbation, respiratory tract infection, or pulmonary rehabilitation. The study had 90% power to evaluate a pre-specified non-inferiority margin of 1.20 for the upper limit of the 95% confidence interval for the hazard ratio.

All participants received an initial 6 week treatment with fluticasone 500 mcg BID, salmeterol 50 mcg BID, and tiotropium 18 mcg daily. Based on random assignment, participants either continued triple therapy or had their fluticasone withdrawn in a step-wise fashion. The primary outcome was the time to first moderate or severe COPD exacerbation during the 52 week study period. Eighty-three percent of participants were men, the overall mean age was 64 years, and the mean FEV1 was 0.93 liters (33% of predicted). Approximately 40% were receiving triple therapy prior to enrollment. Approximately 20% of participants did not complete the study.

The non-inferiority margin was confirmed with a hazard ratio of 1.06 (CI95% 0.94 - 1.19). The mean reduction in FEV1 for the ICS withdrawal group was 38 mL greater than the reduction for the control group at week 18, and this difference increased to 43 mL by the end of the study (p<0.001). The difference in the St. George’s Respiratory Questionnaire (SGRQ) score were statistically significant at week 52, an increase of 1.15 in the withdrawal group vs. decrease of 0.07 in the continuation group (p = 0.047). Adverse events did not differ among the two groups.

The results suggest that gradual withdrawal of ICS from a triple therapy regimen is not associated with a meaningfully increased risk of exacerbation among patients with moderate-to-severe COPD. However, there were statistically significant, but perhaps not clinically meaningful, deterioration in FEV1 and SGRQ scores. Strengths of this study included a large participant population, a year-long follow-up, and use of clinically relevant and patient-centered outcomes. While the study was conducted in many countries, most participants were white and male. The homogeneity of this group makes it difficult to generalize to other patient groups. Patients who had no exacerbations in the prior year (arguably the group most appropriate to step-down therapy) were not included. It also does not provide information on the safety of abrupt withdrawal of ICS. The long-term consequences of the small reductions in FEV1 and health status are uncertain. For patients intolerant to or reluctant to consider ICS treatment, dual LABA and LAMA treatment appears to yield clinically similar outcomes.

Candy Wong MD, Cristine Berry MD and Joe Gerald PhD

University of Arizona

Tucson, AZ

Reference as: Wong C, Berry C, Gerald J. January 2015 Tucson pulmonary journal club: withdrawal of inhaled glucocorticoids in COPD. Southwest J Pulm Crit Care. 2015;10(2):79-80. doi: http://dx.doi.org/10.13175/swjpcc019-15 PDF

Friday
Jan232015

January 2015 Phoenix Pulmonary Journal Club: Noninvasive Ventilation In Acute Respiratory Failure

Noninvasive positive pressure ventilation has expanded its role in the treatment of both chronic and acute respiratory failure. Its initial use in conditions such as obstructive sleep apnea, neuromuscular disease and tracheobronchomalacia, have been shown to improve quality of life and reduce mortality. Over the past 20 years studies have looked at using noninvasive ventilation in the management of acute respiratory failure from pulmonary edema, asthma and COPD exacerbations. During this month's journal club we reviewed 3 articles evaluating the efficacy of noninvasive ventilation in acute respiratory failure.

Gupta D, Nath A, Agarwal R, Behera D. A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. Respir Care. 2010;55(5):536-43. [PubMed]

This was a small unblinded randomized controlled trial (RCT) looking at the efficacy using noninvasive ventilation (NIV) in acute asthma. A total of 53 patients were included and divided into 2 groups of 28 patients (NIV) and 25 patients (standard). Both groups were treated with oxygen, intravenous corticosteroids and nebulizer treatments. Patients randomized to the NIV arm were then placed on Bilevel positive airway pressure (BiPAP) 8/4 cm H2O and pressure was titrated to maximum of 20/10 based on serial spirometry and arterial blood gases (ABG) taken at 1, 2, and 4 hrs. The primary outcome was an improvement in forced expiratory volume in 1 second (FEV1) by 50% and length of hospital stay. The results showed that there was no statistical difference in within the 2 groups with regards to improvement in FEV1. There was a small decrease in length of ICU stay by 14 hours and a reduction in hospital stay by 16 hours. A secondary outcome did show that there were lower doses of salbutamol and ipratropium required within the NIV group. The study showed that the role of NIV in asthma has little benefit over usual therapy alone. A Cochran review of 5 studies evaluating the role of NIV in asthma was done in 2013 (1). The aggregate size was 203 patients. The review showed no reduction in mortality or need for intubation when NIV is used in the treatment of asthma. The role of NIV in asthma remains unproven and should be considered as non-standard therapy.

Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J; 3CPO Trialists. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142-51. [CrossRef] [PubMed]

This was a large prospective RCT looking at the effect of NIV in the acute treatment of cardiogenic pulmonary edema. The primary endpoint was mortality and need for intubation within 7 days. 1069 patients were enrolled and divided among three arms: 1. Standard therapy with oxygen (367 patients); 2. CPAP (346 patients); and 3. NIV (356 patients). Inclusion criteria included radiographic pulmonary edema on chest x-ray, pH < 7.35 and respiratory rate > 20. The average continuous positive airway pressure (CPAP) was 10 cm H20 and average BIPAP pressure was 14:7 cm.

The results showed that there was no difference in mortality rates or need for intubation among the 3 groups. There was an improvement in dyspnea, acidosis, and hypercapnia in the groups receiving CPAP or BIPAP. The study was well done and presented a large sample size. The results did not show any short term benefit in mortality, however, a Cochrane review in 2013 further analyzed a total of 32 studies with > 2000 patients and did show that use of either CPAP or BIPAP resulted in lower rates of intubation and mortality (2). In addition, it reduced ICU length of stay by 1 day. The role of CPAP or BIPAP in the treatment of cardiogenic pulmonary edema may be of benefit and offers little downside. CPAP has been advocated to be more beneficial in the management of systolic heart failure.

Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817-22. [CrossRef] [PubMed]

This was a prospective RCT looking at the management of acute COPD exacerbations by standard treatment with antibiotics, steroids and oxygen verses standard therapy + NIV. A total of 85 patients were divided in 2 groups of 43 patients (standard treatment) and 42  patients (NIV). Inclusion criteria were shortness of breath, diagnosis of COPD by PFTS, pH< 7.35, respiratory rate > 30, and PaO2 < 45. Primary outcomes were need for intubation, mortality and length of hospital stay. Patients in the noninvasive NIV group received at least 6 hours per day of inspiratory pressure of 20 cm H2O. The results showed that the use of noninvasive ventilation reduced the need for intubation from 74% (3 patients in standard arm) to 26% (11 patients in NIV arm). The use of NIV also resulted in reduced mortality, 29% (12 patients in Standard Arm) vs 9% (4 patients in NIV arm). Other clinical parameters such as respiratory rate, encephalopathy, and blood gas results were also improved at a greater level with the use of NIV. The length of stay was reduced in the NIV group regardless of whether the patient required intubation or not. Although this was a smaller study the results were compelling for the benefits of using NIV in acute COPD exacerbation. Subsequent studies looking at the role of NIV both in acute COPD exacerbation as well as chronic stable COPD have also been positive. Although there are no optimal pressures outlined for NIV settings, this study showed that a higher pressure of 20 cm H2O of Inspiratory pressure was a good starting point. The use of NIV in acute COPD exacerbations has been shown to be beneficial and should be used with other standard pharmacological therapies.

Manoj Mathew, MD FCCP, MCCM

References

  1. Landry A, Foran M, Koyfman A. Does noninvasive positive-pressure ventilation improve outcomes in severe asthma exacerbations? Ann Emerg Med. 2013;62(6):594-6. [CrossRef] [PubMed]
  2. Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013 May 31;5:CD005351. [CrossRef] [PubMed] 

Reference as: Mathew M. January 2015 Phoenix pulmonary journal club: noninvasive ventilation in acute respiratory failure. Southwest J Pulm Crit Care. 2015;10(1):52-3. doi: http://dx.doi.org/10.13175/swjpcc011-15 PDF

Wednesday
Oct292014

September 2014 Tucson Pulmonary Journal Club: PANTHEON Study

Zheng JP, Wen FQ, Bai CX, Wan HY, Kang J, Chen P et al. for the PANTHEON study group. Twice daily N-acetylcysteine 600 mg for exacerbations of chronic obstructive pulmonary disease (PANTHEON): a randomized, double-blind placebo-controlled trial. Lancet Respir Med. 2014; 2(3):187-94. [CrossRef] [PubMed]

Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity, mortality, and healthcare utilization. Oxidative stress is thought to be important in COPD pathogenesis, and thus antioxidant therapy has been of great interest, including N-Acetylcysteine (NAC). However, prior studies of NAC in COPD patients have shown varied results. The PANTHEON study was designed to examine the effects of NAC on exacerbation rate in Chinese patients with COPD using a daily dose that is twice as high as that previously studied.

PANTHEON was a randomized double-blinded placebo-controlled trial that enrolled patients aged 40-80 years with GOLD class II, III and IV COPD from 34 academic pulmonary clinics in China. Patients with asthma, oxygen dependence, or poor compliance were excluded. The primary outcome was the COPD exacerbation rate following one year of observation. Exacerbations were defined using the Anthonisen instrument which relies on daily diary reporting. Important secondary outcomes included time to first exacerbation, time to subsequent exacerbations, number of patients requiring antibiotics or steroids, and number of patients requiring hospitalization. The enrollment goal was 1250 patients which would have provided have 95% power to detect a 20% reduction in the exacerbation; however, only 1006 patients were actually randomized. Nevertheless, the study was adequately powered for the primary outcome.

More than 80% of the patients were males; 46% had GOLD II severity, 53% had GOLD III severity, and 1% had GOLD IV severity. Mean FEV1 was 1.2 L. Twenty-five percent were non-smokers; 48% were using both ICS and a long-acting bronchodilator at enrollment; and 27% were taking theophylline.

As compared to placebo, twice daily treatment with 600mg of NAC led to a significant reduction in the annual COPD exacerbation rate (RR 0.78, 95% CI 0.67–0.90; p=0.001) and the rate of steroid or antibiotic-requiring exacerbations (RR 0.83 95% CI 0.69-0.99; p=0.04) but not the annual rate of hospitalizations. Interestingly, the time to first exacerbation did not differ between the groups but the time to second and third exacerbations was longer in the NAC group.

This study suggests that NAC, a relatively inexpensive compound that is available over-the-counter, may reduce exacerbation risk among patients with COPD. Given that NAC is safe and the costs would be borne entirely by the patient, it is reasonable to advise patients of this potential treatment option. Patients should be cautioned that the data supporting the benefits of NAC are not conclusive and the magnitude of benefit is likely to be modest. The major limitation includes reliance on a Chinese population of COPD patients in whom the benefits may not be generalizable to US patients. Of unknown importance is the fact that treatment benefits were limited to self-reported outcomes rather than objective observation of hospitalizations. To the extent that the self-reported data is free of bias, the failure to detect differences in hospitalizations may not matter to patients.

Bhupinder Natt MD1, Christine Berry MD1, Joe K. Gerald MD, PhD2

1Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona Medical Center; Tucson, AZ

2College of Public Health, University of Arizona Medical Center; Tucson, AZ

Reference as: Natt B, Berry C, Gerald JK. September 2014 Tucson pulmonary journal club: PANTHEON study. Southwest J Pulm Crit Care. 2014;9(4):249-50. doi: http://dx.doi.org/10.13175/swjpcc144-14 PDF

Wednesday
Oct292014

June 2014 Tucson Pulmonary Journal Club: Pirfenidone in Idiopathic Pulmonary Fibrosis

King TE, Bradford WZ, Castro-Bernardini S, et al. ASCEND Study Group. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. New Engl J Med. 2014;370(22), 2083-92. [CrossRef] [PubMed]

Idiopathic pulmonary fibrosis is a chronic, progressive, and fatal lung disease that is characterized by irreversible loss of lung function. The 5-year survival rate that is similar to the rates for several cancers (1).

In the 2011, the official ATS/ERS/JRS/ALAT statement regarding idiopathic pulmonary fibrosis underlined that the preponderance of evidence to date suggests that pharmacologic therapy for IPF is without definitive, proven benefit (2). The committee made recommendations of varying strength against most therapies.

Pirfenidone is a pyridone compound with anti-inflammatory, antifibrotic, and antioxidant properties, with antagonism of Transforming Growth Factor (TGF)-  B1 effects. Pirfenidone inhibits fibroblast proliferation and collagen synthesis and reduce cellular and histological markers of fibrosis in animal models of lung fibrosis.

Three previous phase 3 randomized, double-blind, placebo-controlled, that examined pirfenidone for idiopathic pulmonary fibrosis had varying results (3,4). That led to the approval of pirfenidone for idiopathic pulmonary fibrosis by many governing bodies worldwide but not by the US Food and Drug Administration. This prompted US regulatory authorities to request an additional trial to support the approval of pirfenidone.

The Assessment of Pirfenidone to Confirm Efficacy and Safety in Idiopathic Pulmonary Fibrosis (ASCEND) is the fourth in a series of randomized, double blind, placebo-controlled trials. Pirfenidone was compared with placebo in patients with idiopathic pulmonary fibrosis. The study was conducted at 127 sites in 9 countries. Eligible patients were between the ages of 40 and 80 years and had received a centrally confirmed diagnosis of idiopathic pulmonary fibrosis. Patients were recruited July 2011 through January 2013. A total of 555 patients were enrolled; 278 were assigned to receive pirfenidone, and 277 were assigned to receive placebo. Physical examination and clinical laboratory assessments were performed at baseline and at weeks 2, 4, 8, 13, 26, 39, and 52. Pulmonary function, exercise tolerance, and dyspnea were assessed at baseline and at weeks 13, 26, 39, and 52.

The major inclusion criteria were having clinical symptoms consistent with IPF of 12 months duration; diagnosis of IPF, defined as the first instance in which a patient was informed of having IPF, at least 6 months and no more than 48 months before randomization; age 40 through 80 years, inclusive, at randomization; diagnosis of UIP or IPF by High resolution CT or surgical lung biopsy.

Major exclusion criteria included end stage renal disease, obstructive lung disease, congestive heart failure, end stage liver disease, arrhythmias and recent IPF exacerbations.

The primary outcomes of the study were to confirm the treatment effect of pirfenidone 2403 mg/d compared with placebo on change in percent predicted forced vital capacity (%FVC) in patients with idiopathic pulmonary fibrosis (IPF) and confirm the safety of treatment with Pirfenidone 2403 mg/d compared with placebo in patients with IPF.

In this randomized, controlled trial, the use of pirfenidone in patients with idiopathic pulmonary fibrosis led to a slower rate of loss in forced vital capacity than the use of placebo. Pirfenidone, as compared with placebo, reduced disease progression, as reflected by lung function, exercise tolerance, and progression-free survival, in patients with idiopathic pulmonary fibrosis. Treatment was associated with an acceptable side-effect profile and fewer deaths.

The major strengths of the include the randomized double-blinded control study design, straightforward hypothesis, minimal drop out rates, similarity to previous studies, however with a larger sample size and more central confirmation of diagnosis.

The study offers “New Hope for Idiopathic Pulmonary Fibrosis” (5).  Major concerns would be extrapolating findings to treat patient populations that were not assessed in this study. That includes patients with more severe disease; other interstitial lung disease, and patients with comorbidities that were excluded in this study. The study also doesn't assess if the effects are durable beyond 1 year.

Mohammed Alzoubaidi MBBS and Kenneth S. Knox MD

University of Arizona

Tucson, Arizona

References

  1. Nicholson AG, Colby TV, Dubois RM, Hansell DM, Wells AU. The prognostic significance of the histologic pattern of interstitial pneumonia in patients presenting with the clinical entity of cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med. 2000;162(6):2213-7. [CrossRef] [PubMed]
  2. Raghu G, Collard HR, Egan JJ, et al. ATS/ERS/JRS/ALAT Committee on Idiopathic Pulmonary Fibrosis. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183(6):788-824. [CrossRef] [PubMed]
  3. Noble PW, Albera C, Bradford WZ, et al. CAPACITY Study Group. Pirfenidone in patients with idiopathic pulmonary fibrosis (CAPACITY): two randomised trials. Lancet. 2011;377(9779):1760-9. [CrossRef] [PubMed]
  4. Taniguchi H, Ebina M, Kondoh Y, et al. Pirfenidone Clinical Study Group in Japan. (2010). Pirfenidone in idiopathic pulmonary fibrosis. Eur Respir J. 2010;35(4):821-9. [CrossRef] [PubMed]
  5. Hunninghake GM. A new hope for idiopathic pulmonary fibrosis. New Engl J Med. 2014:,370(22), 214-3. [CrossRef] [PubMed]

Reference as: Alzoubaidi M, Knox KS. June 2014 Tucson pulmonary journal club: pirfenidone in idiopathic pulmonary fibrosis. Southwest J Pulm Crit Care. 2014;9(4):244-6. doi: http://dx.doi.org/10.13175/swjpcc142-14 PDF

Friday
Sep192014

September 2014 Phoenix Pulmonary Journal Club: Inhaled Antibiotics

The September 2014 pulmonary journal club focused on the utilization of inhaled antibiotics in non-cystic fibrosis (CF) bronchiectasis.

A total of four papers were reviewed, inhaled tobramycin (1), inhaled gentamicin (2),  inhaled colistin (3) and Inhaled aztreonam (4).  Each of the trials were randomized, placebo-controlled trials with small sample sizes. An aggregate sample size from all four trials totaled 255 patients in the treatment arms. The largest sample size was seen in the aztreonam trial with 134 patients in the treatment group vs. 132 in the placebo group while the smallest was in the inhaled tobramycin, with 16 patients in the treatment arm vs. 15 in placebo. The inhaled tobramycin and gentamicin studies looked at reduction in bacterial colony forming units and sputum density, whereas the inhaled colistin and aztreonam studies incorporated time to exacerbations and quality of life indicators. None of the studies incorporated an airway clearance modality. 

The results of the studies were not impressive. In the tobramycin and gentamicin trials the primary endpoints of a reduction of bacterial load and sputum density were reached but the effects were only sustained while on therapy.  The colistin trial was the most promising as it showed that a > 80% adherence to inhaled therapy resulted in reduction in Pseudomonas bacterial load, improved quality of life and a delay in time to the first exacerbation. The aztreonam study was the largest of the four trials and looked at quality of life as its primary endpoint but failed to achieve its goal. 

In the four trials the medications were well tolerated with main side effects being airway irritation and bronchospasm. There were no systemic side effects and the use of inhaled therapy did not change the bacterial resistance pattern.

The role of inhaled antibiotics in non-CF bronchiectasis remains unknown as the data is lacking. Translating what we know about CF bronchiectasis and applying it to non-CF bronchiectasis has not been successful.  Future trials need to incorporate an airway treatment protocol such as flutter valve or chest vest therapy, and continue to use varying doses durations of therapy. The mechanism of action on the meds vary from bactericidal  (colistin, aztreonam) to bacteriostatic (gentamicin, tobramycin), perhaps looking at a combination inhaled therapy for synergy is warranted? For now all we know from inhaled antibiotic therapy in non-CF bronchiectasis is that it’s fairly well tolerated with no significant systemic toxicity but its efficacy is unproven.

M Mathew, MD FCCP MCCM

Associate Editor

References

  1. Couch LA. Treatment With tobramycin solution for inhalation in bronchiectasis patients with Pseudomonas aeruginosa. Chest. 2001;120(3 Suppl):114S-117S. [CrossRef] [PubMed]
  2. Murray MP, Govan JR, Doherty CJ, Simpson AJ, Wilkinson TS, Chalmers JD, Greening AP, Haslett C, Hill AT. A randomized controlled trial of nebulized gentamicin in non-cystic fibrosis bronchiectasis. Am J Respir Crit Care Med. 2011;183(4):491-9. [CrossRef] [PubMed]
  3. Haworth CS, Foweraker JE, Wilkinson P, Kenyon RF, Bilton D. Inhaled colistin in patients with bronchiectasis and chronic Pseudomonas aeruginosa infection. Am J Respir Crit Care Med. 2014;189(8):975-82. [CrossRef] [PubMed]
  4. Barker AF, O'Donnell AE, Flume P, et al. Aztreonam for inhalation solution in patients with non-cystic fibrosis bronchiectasis (AIR-BX1 and AIR-BX2): two randomised double-blind, placebo-controlled phase 3 trials. Lancet Respir Med. 2014;2(9):738-49. [CrossRef] [PubMed]

Reference as: Mathew M. September 2014 Phoenix pulmonary journal club. inhaled antibiotics. Southwest J Pulm Crit Care. 2014;9(3):187-8. doi: http://dx.doi.org/10.13175/swjpcc125-14 PDF