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The Cochrane Database of Systematic... Feb 2018Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review.
OBJECTIVES
To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment.
SEARCH METHODS
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences.Date of last search: 28 September 2017.
SELECTION CRITERIA
All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment.
DATA COLLECTION AND ANALYSIS
Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE.
MAIN RESULTS
Six studies (reported in 50 publications) were included with a total of 784 participants.Duration of treatment in the included studies ranged from 12 days to six months, with open-label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non-respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population.Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole.While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies.Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate-quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non-users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non-respirable mannitol groups; however, we judged this evidence to be of low to very low quality.For the comparisons of mannitol and control, we found no consistent differences in health-related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health-related quality of life was not designed to assess mucolytics and pooling of the age-appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post-tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF.For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low-quality evidence from a 12-week cross-over study of 28 participants showed no statistically significant differences in the recorded domains of health-related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations.In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa).
AUTHORS' CONCLUSIONS
There is moderate-quality evidence to show that treatment with mannitol over a six-month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low-quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low-quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa.The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice.
Topics: Administration, Inhalation; Adult; Child; Cystic Fibrosis; Deoxyribonuclease I; Humans; Mannitol; Mucociliary Clearance; Powders; Randomized Controlled Trials as Topic; Recombinant Proteins; Respiratory Function Tests
PubMed: 29424930
DOI: 10.1002/14651858.CD008649.pub3 -
European Journal of Translational... Oct 2023Choking (or foreign body airway obstruction) is a widespread phenomenon with serious consequences of morbidity and mortality. Choking (often also called suffocation) can...
Choking (or foreign body airway obstruction) is a widespread phenomenon with serious consequences of morbidity and mortality. Choking (often also called suffocation) can be caused by food or inedible objects and leads to various degrees of asphyxiation or lack of oxygen in the blood stream. The incidence is very high in both young children and adults, especially seniors. However, since not all choking episodes end up in the emergency room or become fatalities, they often escape statistics. Although episodes of choking from non-edible bodies are infrequent, they affect mostly young children. Three of the most common risks for choking in general are neurological disorders, dysphagia and dental issues (few or no teeth, unstable or unsuitable prosthesis or orthodontic appliances). The purpose of this study was to evaluate the risk factors of choking and ways to reduce/avoid this event. We reported data on a series of 138 patients admitted to the emergency department following a choking event, at a hospital in Rome, Italy. The age group of the analyzed population ranged from 1 to 88 years, with the most represented age group of these between 40 and 59, with a similar distribution between males and females. The types of foods on which people choked reflected the seasonal, traditional and local foods: 67% of patients reported choking on fish bones followed by meat bones (9%) and artichokes (3%). Three relevant non-food choking elements reported were: orthodontic items, toothpicks and pins (one occurrence each). We also reported on two clinical cases of patients choking on meat and a chicken bone. In conclusion, choking awareness and prevention are essential for implementing potential life-saving precautions. Prevention is the first tool to reduce the occurrence of this event, therefore it is necessary to analyze the risk factors and educate the population to eliminate them. Proper chewing and oral manipulation are paramount functions in preventing choking, along with meal-time supervision if little children and elderly. Then, it behooves the healthcare professionals to disseminate knowledge.
PubMed: 37905785
DOI: 10.4081/ejtm.2023.11471 -
Respiratory Medicine May 2022Pulmonary hypertension (PH), as a consequence of lung disease or hypoxia, has been classified as Group 3 PH by the World Symposium on Pulmonary Hypertension. The most... (Review)
Review
Pulmonary hypertension (PH), as a consequence of lung disease or hypoxia, has been classified as Group 3 PH by the World Symposium on Pulmonary Hypertension. The most common lung diseases associated with Group 3 PH are chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). PH in ILD (PH-ILD) is associated with reduced exercise capacity, greater supplemental oxygen needs, decreased quality of life, and earlier death compared to ILD alone. Several agents have been evaluated in clinical trials for the treatment of Group 3 PH, but only one treatment has been recently approved by the FDA as conclusively demonstrating efficacy for the treatment of pulmonary hypertension in this group. In the INCREASE study, treprostinil inhalation solution (Tyvaso) demonstrated significant clinical benefit for patients with PH-ILD. The inhaled route of administration may be associated with cough, throat irritation, pharyngolaryngeal pain and risk of bronchospasm and are important considerations upon initiation of therapy. Here we provide a practical review of inhaled prostacyclin therapy and suggestions for healthcare professionals to optimize the management and outcomes for the treatment of WHO Group 3, PH-ILD patients. Recommendations include up-to-date practical considerations pertaining to the entire care team and encompass patient education and communication, monitoring, titration methods and mitigation of side effects.
Topics: Epoprostenol; Humans; Hypertension, Pulmonary; Lung Diseases, Interstitial; Prostaglandins I; Quality of Life; World Health Organization
PubMed: 35334313
DOI: 10.1016/j.rmed.2022.106806 -
The Cochrane Database of Systematic... May 2020Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Several agents are used to clear secretions from the airways of people with cystic fibrosis. Mannitol increases mucociliary clearance, but its exact mechanism of action is unknown. The dry powder formulation of mannitol may be more convenient and easier to use compared with established agents which require delivery via a nebuliser. Phase III trials of inhaled dry powder mannitol for the treatment of cystic fibrosis have been completed and it is now available in Australia and some countries in Europe. This is an update of a previous review.
OBJECTIVES
To assess whether inhaled dry powder mannitol is well tolerated, whether it improves the quality of life and respiratory function in people with cystic fibrosis and which adverse events are associated with the treatment.
SEARCH METHODS
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic databases, handsearching relevant journals and abstracts from conferences. Date of last search: 12 December 2019.
SELECTION CRITERIA
All randomised controlled studies comparing mannitol with placebo, active inhaled comparators (for example, hypertonic saline or dornase alfa) or with no treatment.
DATA COLLECTION AND ANALYSIS
Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias in included studies. The quality of the evidence was assessed using GRADE.
MAIN RESULTS
Six studies (reported in 36 unique publications) were included with a total of 784 participants. Duration of treatment in the included studies ranged from 12 days to six months, with open-label treatment for an additional six months in two of the studies. Five studies compared mannitol with control (a very low dose of mannitol or non-respirable mannitol) and the final study compared mannitol to dornase alfa alone and to mannitol plus dornase alfa. Two large studies had a similar parallel design and provided data for 600 participants, which could be pooled where data for a particular outcome and time point were available. The remaining studies had much smaller sample sizes (ranging from 22 to 95) and data could not be pooled due to differences in design, interventions and population. Pooled evidence from the two large parallel studies was judged to be of low to moderate quality and from the smaller studies was judged to be of low to very low quality. In all studies, there was an initial test to see if participants tolerated mannitol, with only those who could tolerate the drug being randomised; therefore, the study results are not applicable to the cystic fibrosis population as a whole. While the published papers did not provide all the data required for our analysis, additional unpublished data were provided by the drug's manufacturer and the author of one of the studies. Pooling the large parallel studies comparing mannitol to control, up to and including six months, lung function (forced expiratory volume at one second) measured in both mL and % predicted was significantly improved in the mannitol group compared to the control group (moderate-quality evidence). Beneficial results were observed in these studies in adults and in both concomitant dornase alfa users and non-users in these studies. In the smaller studies, statistically significant improvements in lung function were also observed in the mannitol groups compared to the non-respirable mannitol groups; however, we judged this evidence to be of low to very low quality. For the comparisons of mannitol and control, we found no consistent differences in health-related quality of life in any of the domains except for burden of treatment, which was less for mannitol up to four months in the two pooled studies of a similar design; this difference was not maintained at six months. It should be noted that the tool used to measure health-related quality of life was not designed to assess mucolytics and pooling of the age-appropriate tools (as done in some of the included studies) may not be valid so results were judged to be low to very low quality and should be interpreted with caution. Cough, haemoptysis, bronchospasm, pharyngolaryngeal pain and post-tussive vomiting were the most commonly reported side effects in both treatment groups. Where rates of adverse events could be compared, statistically no significant differences were found between mannitol and control groups; although some of these events may have clinical relevance for people with CF. For the comparisons of mannitol to dornase alfa alone and to mannitol plus dornase alfa, very low-quality evidence from a 12-week cross-over study of 28 participants showed no statistically significant differences in the recorded domains of health-related quality of life or measures of lung function. Cough was the most common side effect in the mannitol alone arm but there was no occurrence of cough in the dornase alfa alone arm and the most commonly reported reason of withdrawal from the mannitol plus dornase alfa arm was pulmonary exacerbations. In terms of secondary outcomes of the review (pulmonary exacerbations, hospitalisations, symptoms, sputum microbiology), evidence provided by the included studies was more limited. For all comparisons, no consistent statistically significant and clinically meaningful differences were observed between mannitol and control treatments (including dornase alfa).
AUTHORS' CONCLUSIONS
There is moderate-quality evidence to show that treatment with mannitol over a six-month period is associated with an improvement in some measures of lung function in people with cystic fibrosis compared to control. There is low to very low-quality evidence suggesting no difference in quality of life for participants taking mannitol compared to control. This review provides very low-quality evidence suggesting no difference in lung function or quality of life comparing mannitol to dornase alfa alone and to mannitol plus dornase alfa. The clinical implications from this review suggest that mannitol could be considered as a treatment in cystic fibrosis; but further research is required in order to establish who may benefit most and whether this benefit is sustained in the longer term. Furthermore, studies comparing its efficacy against other (established) mucolytic therapies need to be undertaken before it can be considered for mainstream practice.
Topics: Administration, Inhalation; Adult; Child; Cystic Fibrosis; Deoxyribonuclease I; Forced Expiratory Volume; Humans; Mannitol; Mucociliary Clearance; Powders; Randomized Controlled Trials as Topic; Recombinant Proteins; Respiratory Function Tests; Vital Capacity
PubMed: 32358807
DOI: 10.1002/14651858.CD008649.pub4 -
Journal of Acute Medicine Dec 2022Dentures dislodged into throat on bilevel positive airway pressure (BiPAP) ventilation can be overlooked and potentially compromise airway patency. An 81-year-old man...
Dentures dislodged into throat on bilevel positive airway pressure (BiPAP) ventilation can be overlooked and potentially compromise airway patency. An 81-year-old man with a history of chronic obstructive pulmonary disease (COPD) presented with increased shortness of breath and productive cough for 1 week. Inhaled bronchodilators, parenteral steroids, and BiPAP ventilation were administered for acute exacerbation of COPD complicated with acute hypercapnic respiratory failure. Fifty minutes after receiving BiPAP ventilation, his respiratory condition improved; however, he started to complain of neck pain. The patient remained intolerant to the device 3 hours later, despite receiving assurance that the discomfort might be caused by air pressure through mask ventilation. His throat did not exhibit any abnormality during visual examination. Neck radiographs were subsequently obtained and demonstrated a denture impacted in the hypopharynx. His neck pain resolved after the removal of the dislodged maxillary denture. Denture dislodgement can occur in mask ventilation and compromise airway patency if stuck in the hypopharynx or respiratory tract. Such adverse events may be overlooked on the coexistence of respiratory and pulmonary diseases. A precisely pharyngolaryngeal inspection and complete imaging studies must be performed to facilitate early identification and further retrieval intervention.
PubMed: 36761857
DOI: 10.6705/j.jacme.202212_12(4).0004 -
Indian Journal of Anaesthesia Aug 2009Supraglottic devices have changed the face of the airway management. These devices have contributed in a big way in airway management especially, in the difficult airway...
Supraglottic devices have changed the face of the airway management. These devices have contributed in a big way in airway management especially, in the difficult airway scenario significantly decreasing the pharyngolaryngeal morbidity. There is a plethora of these devices, which has been well matched by their wider acceptance in clinical practice. ProSeal laryngeal mask airway (PLMA) is one such frequently used device employed for spontaneous as well as controlled ventilation. However, the use of PLMA at times maybe associated with certain problems. Some of the problems related with its use are unique while others are akin to the classic laryngeal mask airway (cLMA). However, expertise is needed for its safe and judicious use, correct placement, recognition and management of its various malpositions and complications. The present article describes the tests employed for proper confirmation of placement to assess the ventilatory and the drain tube functions of the mask, diagnosis of various malpositions and the management of these aspects. All these areas have been highlighted under the heading of troubleshooting PLMA. Many problems can be solved by proper patient and procedure selection, maintaining adequate depth of anaesthesia, diagnosis and management of malpositions. Proper fixation of the device and monitoring cuff pressure intraoperatively may bring down the incidence of airway morbidity.
PubMed: 20640203
DOI: No ID Found -
Ear, Nose, & Throat Journal Mar 2017Pemphigus vulgaris is an autoimmune blistering disorder that involves the skin and mucous membranes. Few reports have described nasal and oropharyngolaryngeal lesions in...
Pemphigus vulgaris is an autoimmune blistering disorder that involves the skin and mucous membranes. Few reports have described nasal and oropharyngolaryngeal lesions in pemphigus vulgaris using an endoscopic ororhinolaryngologic examination. We retrospectively reviewed the clinical records of 11 patients with pemphigus vulgaris between 2001 and 2013 with respect to their symptoms, lesion sites, lesion features, and treatments received. All patients had undergone an endoscopic ororhinolaryngologic examination. Their mucosa-related symptoms were sore throat, oral pain, odynophagia, gingival bleeding, hoarseness, and epistaxis. The most frequent sites were the oral cavity (gingiva and buccal mucosa), larynx (epiglottis and vocal fold), oropharynx (soft palate), and nasal cavity (nasal septum). Lesions were typically characterized by erosion, erosion with a whitish exudate, and erythematous patches. Thus, our study findings reveal that pemphigus vulgaris involves both the nasal and oropharyngolaryngeal regions. Patients with pemphigus vulgaris should undergo an endoscopic ororhinolaryngologic examination to determine the range of their lesions.
Topics: Adult; Aged; Aged, 80 and over; Female; Gingiva; Humans; Laryngoscopy; Larynx; Male; Middle Aged; Mouth Mucosa; Nasal Cavity; Oropharynx; Otorhinolaryngologic Surgical Procedures; Pemphigus; Retrospective Studies
PubMed: 28346642
DOI: 10.1177/014556131709600311 -
Medical Science Monitor : International... Aug 2022BACKGROUND The Baska mask is a supraglottic airway device that has a continuous non-inflatable flexible cuff that mimics an airway, reducing the risk of overinflation... (Randomized Controlled Trial)
Randomized Controlled Trial
Safety and Efficacy of the Baska Mask Versus Endotracheal Intubation in 64 Women Undergoing Elective Laparoscopic Gynecological Surgery Under General Anesthesia: A Prospective Single-Center Study.
BACKGROUND The Baska mask is a supraglottic airway device that has a continuous non-inflatable flexible cuff that mimics an airway, reducing the risk of overinflation and aspiration of gastric contents. This prospective study from a single center aimed to compare the safety and efficacy of the Baska mask vs endotracheal intubation (ET) in 64 women undergoing elective laparoscopic gynecological surgery in Trendelenburg position under general anesthesia. MATERIAL AND METHODS This was a prospective randomized study conducted on 64 adult female patients, 32 in each group, undergoing gynecologic surgery under general anesthesia. The study population was divided into 2 groups: the Baska group and the ET group. The respiratory and haemodynamic variables, the degree of gastric distension, and postoperative pharyngolaryngeal symptoms were compared between groups. RESULTS After 2 patients dropped out of the study, data from 62 patients were analyzed. The Baska group showed significantly shorter device insertion time (28.4±10.7 vs 46.6±19.8, P=0.001), a significantly lower oropharyngeal leak pressure at all studied time points, and a higher leak fraction at 1 min after the completion of pneumoperitoneum (5.6% vs 2.1%, P=0.031) compared to the ET group. Respiratory and haemodynamic variables, the gastric antrum size, and postoperative pharyngolaryngeal symptoms showed no significant difference. CONCLUSIONS This study supports the findings from previous studies in patients undergoing general surgery. The Baska mask was as effective as ET in ventilation during general anesthesia in women undergoing elective laparoscopic gynecological surgery. Respiratory and hemodynamic responses were similar to ET, and no complications were associated with the Baska mask in this study.
Topics: Adult; Anesthesia, General; Female; Gynecologic Surgical Procedures; Humans; Intubation, Intratracheal; Laparoscopy; Laryngeal Masks; Prospective Studies
PubMed: 35927929
DOI: 10.12659/MSM.937630 -
British Journal of Anaesthesia Feb 2016Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic... (Review)
Review
Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use. We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries. The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.
Topics: Analgesia, Epidural; Humans; Pain, Postoperative
PubMed: 26787789
DOI: 10.1093/bja/aev453 -
Alimentary Pharmacology & Therapeutics Feb 2004Supra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD) are common and often under-appreciated, in part due to the absence of classic symptoms of... (Review)
Review
Supra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD) are common and often under-appreciated, in part due to the absence of classic symptoms of heartburn and regurgitation. Patients with supra-oesophageal manifestations of GERD may report symptoms involving the pulmonary, otolaryngologic or pharyngeal systems. Endoscopy is often negative and therefore of limited diagnostic value in these patients, and while laryngoscopy and 24 h dual-channel intra-oesophageal pH-metry may have greater yields they are costly, invasive and time-consuming. Therefore, a trial of proton pump inhibitor therapy is now widely considered a first-line diagnostic test in those with suspected GERD-induced supra-oesophageal symptoms. The dose as well as duration of the proton pump inhibitor trial is dependent upon a patient's presenting symptoms. For example, GERD-related non-cardiac chest pain may be relieved with a short-term (e.g. 1 week) treatment with standard doses of a proton pump inhibitor. The use of high-dose twice daily proton pump inhibitor therapy for an extended period (e.g. 2-3 months) may be required before any discernible improvement in pulmonary symptoms or pharyngo-laryngitis is noted. Patients who do not experience symptom improvement following a proton pump inhibitor trial may require further diagnostic evaluations including 24 h oesophageal pH studies, while on acid anti-secretory therapy, to establish the absence of persistent acid reflux. The role of anti-reflux surgical or endoscopic interventions in those with supra-oesophageal manifestations of GERD remains to be established.
Topics: Asthma; Chest Pain; Chronic Disease; Cough; Gastroesophageal Reflux; Humans; Laryngitis
PubMed: 14725578
DOI: 10.1111/j.0953-0673.2004.01836.x