Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation

Objectives: Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. Methods: A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. Results: Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT ( P < .0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation ( P = .042) in the multivariate analysis. Conclusions: Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.

Prevalence of adrenal insufficiency among patients with euvolemic hyponatremia

Background: The diagnosis of SIAD requires the exclusion of secondary adrenal insufficiency (AI) among patients with euvolemic hyponatremia (EuVHNa). Studies have suggested about 2.7% to 3.8% of unselected patients presenting to the emergency room with EuVHNa have undiagnosed AI and it is as high as 15% among patients admitted to specialized units for evaluation of hyponatremia. Objective: To study the prevalence of AI among inpatients with EuVHNa in a general medical ward setting Methods: This was a prospective, single centre observational study conducted among general medical inpatients with EuVHNa, defined as patients with a serum Na <135 mmol/L, clinical euvolemia and urine spot sodium >30mmol/L. Additionally patients with recent vomiting, current renal failure, diuretic use and those with uncontrolled hyperglycemia were excluded. Adrenal functions were assessed by a modified ACTH stimulation test called Acton Prolongatum™ stimulation test (APST). A cut off cortisol value of <18mg/dl after 60 minutes of ACTH injection was used to diagnose AI. Results: One hundred and forty-one (141) patients were included and underwent an APST. APST suggested 20/141 (14.2%) had undiagnosed AI. The most common cause of AI (9/20) was secondary AI because of the use of steroids including inhaled steroids and indigenous medicines contaminated with steroids. In 5 (3.5%) patients hypopituitarism was newly diagnosed. Despite primary adrenal insufficiency not commonly presenting as EuVHNa, 2/20 patients had primary adrenal insufficiency. Conclusions: AI is much commoner in our country among inpatients with EuVHNa primarily driven by exogenous steroid use and undiagnosed hypopituitarism.

The environmental impact of inhalers for asthma; a green challenge and a golden opportunity

The propellants used in metered-dose inhalers (MDIs) are powerful greenhouse gases, which account for approximately 13% of the NHS’s carbon footprint related to the delivery of care. Most MDI use is in salbutamol relievers in patients with poorly controlled disease. The UK lags behind in this regard with greater reliance on salbutamol MDI and correspondingly greater greenhouse gas emissions; roughly treble our European neighbours’. There has been a broad switch towards MDIs in the UK over the last 20 years to reduce financial costs such that two-thirds of asthma patients in the UK are on treatment dominated by salbutamol MDI. Strategies that replace overuse of reliever MDIs with regimes emphasising inhaled corticosteroids have the potential to improve asthma control alongside significant reductions in greenhouse gas emissions. Real-world evidence shows that once-daily long-acting combination dry-powder inhalers can improve compliance, asthma control and reduce the carbon footprint of care. Similarly, maintenance and reliever therapy (MART) which uses combination reliever and inhaled steroids in one device (usually a dry-powder inhaler) can simplify therapy, improve asthma control and reduce greenhouse gas emissions. Both treatment strategies are popular with patients, most of whom are willing to change treatment to reduce their carbon footprint. By focussing on patients who are currently using high amounts of salbutamol MDI, and prioritising inhaled steroids via dry-powder inhalers, there are golden opportunities to make asthma care more effective, safer and greener.

Inhaled therapy for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is characterised by progressive symptoms of productive cough, breathlessness, wheeze and exacerbations. Airway obstruction is detected by quality assured spirometry, and is defined as a Forced Expired Volume in one second / Forced Vital Capacity ratio <0.7. Inhaled therapy is the most effective treatment solution, with bronchodilators and inhaled steroids helping to improve symptoms, quality of life and lung function, while reducing risk of exacerbations. Bronchodilators are available as both monotherapy and as dual combination therapy. Inhaled steroids can be added to inhaled long-acting bronchodilators, but are not without significant complications, including pneumonia. Therefore, careful assessment of the phenotype of a patient with chronic obstructive pulmonary disease must be given before commencing any therapy that contains inhaled steroid and other treatments, such as flu vaccination, smoking cessation and pulmonary rehabilitation should be given due consideration.

A randomized controlled trial of inhaled ciclesonide for outpatient treatment of symptomatic COVID-19 infections

ImportanceSystemic corticosteroids are commonly used in the treatment of severe COVID-19. However, their role in the treatment of patients with mild to moderate disease is less clear. The inhaled corticosteroid ciclesonide has shown early promise as a potential treatment for COVID-19.ObjectiveTo determine whether the inhaled steroid ciclesonide is efficacious in patients with high risk for disease progression and can reduce the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.DesignThis was a phase III, multicenter, double-blind, randomized controlled trial to assess the safety and efficacy of ciclesonide metered-dose inhaler (MDI) for the treatment of non-hospitalized participants with symptomatic COVID-19 infection. Patients were screened from June 11, 2020 to November 3, 2020.SettingThe study was conducted at 10 centers throughout the U.S. public and private, academic and non-academic sites were represented among the centers.ParticipantsParticipants were randomly assigned to ciclesonide MDI 160 µg per actuation, two actuations twice a day (total daily dose 640 µg) or placebo for 30 days.Main Outcomes and MeasuresThe primary endpoint was time to alleviation of all COVID-19 related symptoms (cough, dyspnea, chills, feeling feverish, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell) by Day 30. Secondary endpoints included subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19.Results413 participants were screened and 400 (96.9%) were enrolled and randomized (197 in the ciclesonide arm and 203 in the placebo arm). The median time to alleviation of all COVID-19-related symptoms was 19.0 days (95% CI: 14.0, 21.0) in the ciclesonide arm and 19.0 days (95% CI: 16.0, 23.0) in the placebo arm. There was no difference in resolution of all symptoms by Day 30 (odds ratio [OR] 1.28, 95% CI: 0.84, 1.97). Participants treated with ciclesonide had fewer subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19 (OR 0.18, 95% CI: 0.04 - 0.85). No subjects died during the study.Conclusions and RelevanceCiclesonide did not achieve the primary efficacy endpoint of time to alleviation of all COVID-19-related symptoms. Future studies of inhaled steroids are needed to explore their efficacy in patients with high risk for disease progression and in reducing the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.Trial RegistrationClinicalTrials.govNCT04377711https://clinicaltrials.gov/ct2/show/NCT04377711Key PointsQuestionCan the inhaled steroid ciclesonide be efficacious in patients with high risk for disease progression and reduce the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2?FindingsIn this randomized clinical trial of 413 patients, ciclesonide did not reduce the time to alleviation of all COVID-19-related symptoms. However, patients treated with ciclesonide had fewer subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19.MeaningFuture studies of inhaled steroids are needed to explore their efficacy in patients with high risk for disease progression and in reducing the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.

Radiation-Induced Lung Injury—Current Perspectives and Management

Radiotherapy plays an important role in the treatment of localized primary malignancies involving the chest wall or intrathoracic malignancies. Secondary effects of radiotherapy on the lung result in radiation-induced lung disease. The phases of lung injury from radiation range from acute pneumonitis to chronic pulmonary fibrosis. Radiation pneumonitis is a clinical diagnosis based on the history of radiation, imaging findings, and the presence of classic symptoms after exclusion of infection, pulmonary embolism, heart failure, drug-induced pneumonitis, and progression of the primary tumor. Computed tomography (CT) is the preferred imaging modality as it provides a better picture of parenchymal changes. Lung biopsy is rarely required for the diagnosis. Treatment is necessary only for symptomatic patients. Mild symptoms can be treated with inhaled steroids while subacute to moderate symptoms with impaired lung function require oral corticosteroids. Patients who do not tolerate or are refractory to steroids can be considered for treatment with immunosuppressive agents such as azathioprine and cyclosporine. Improvements in radiation technique, as well as early diagnosis and appropriate treatment with high-dose steroids, will lead to lower rates of pneumonitis and an overall good prognosis.

Comparison of montelukast versus montelukast plus inhaled corticosteroid (Budesonide) in children with mild persistent asthma.

Objective: To compare therapeutic response between Montelukast versus Montelukast plus inhaled corticosteroid (Budesonide) in children having mild persistent asthma. Study Design: Randomized Controlled Trial. Setting: Department of Pediatrics Medicine, National Institute of Child Health, Karachi. Period: 1st April 2016 to 30th September 2016. Material & Methods: Children aged 2 years to 14 years having mild persistent asthma for more than 6 months were included. After treatment Good response was considered when, forced expiratory volume in first second (FEV1) became >7.5% from baseline. Group A was given montelukast as monotherapy once daily and Group B was given Montelukast along with inhaled corticosteroid (Budesonide. At 6 weeks followup change in FEV1 was recorded. Result: Mean age of the patients in montelukast alone (Group A) was 6.77+/-2.16 years while in montelukast with Inhaled Corticosteroid (Group B) was 6.97+/-2.17 years. Duration of disease in Group A was 18.32+/-6.12 months while in montelukast with ICS group was 18.50 +/-6.08 months. Baseline FEV1 in Group A was 81.83+/-0.85% while in Group B was 82.05 +/-0.63%. Males were higher with 131 (61.8%). Family history was positive in 82 (38.70%) patients. After 6 weeks mean FEV1 was 89.49 +/-0.87% in Group A while in Group B was 89.53+/-0.86%. Overall good responses were found in 21 (9.09%) patients. In Group A, good response was found in 5 (4.7%) patients while in Group B was in 16 (15.1%) with significant p-value. Conclusion: In our study montelukast along with inhaled steroids had better response than montelukast alone in mild persistent asthma.