Gustavo Rodrigo - Academia.edu (original) (raw)

Papers by Gustavo Rodrigo

2 Background: Current guidelines recommend the use of a combination of inhaled beta2-agonists and... more 2 Background: Current guidelines recommend the use of a combination of inhaled beta2-agonists and anticholinergics, particularly for patients with acute severe or life threatening asthma in the emergency setting. However, this statement is based on a relatively small number of randomised controlled trials and related systematic reviews. This review was undertaken to incorporate the more recent evidence available about the effectiveness of treatment with beta2-agonists and anticholinergics compared with beta2-agonists in acute asthma treatment. Methods: A search was conducted of all randomised controlled trials published prior to

Archivos de Bronconeumología ((English Edition)), 2004

Los altos niveles de prevalencia del asma a nivel mundial y en Latinoamérica, así como el increme... more Los altos niveles de prevalencia del asma a nivel mundial y en Latinoamérica, así como el incremento de su morbimortalidad en las últimas décadas, constituyen un importante problema de salud pública. La evaluación y el tratamiento del paciente asmático en crisis en el área de emergencia es un eslabón fundamental dentro de la estrategia global de manejo de la enfermedad. Este artículo intenta analizar el tema realizando una revisión no sistemática con una búsqueda bibliográfica exhaustiva a la que se incorporan trabajos de los autores en diversos tópicos. Ello significa diez años de investigación clínica en un servicio de emergencia sobre unos 500 pacientes asmáticos con exacerbación aguda. Se identifican los elementos clínicos y de función pulmonar que tienen valor pronóstico. Se recomienda el uso de medidas objetivas de la obstrucción de vía aérea para establecer criterios de predicción. Se dan parámetros concretos y se crea un índice de severidad que ayude en la operativa diaria. Palabras clave: Estado asmático-epidemiología Estado asmático-mortalidad Estado asmático-terapia Servicios médicos de urgencia

BMJ clinical evidence, Jan 4, 2011

About 10% of adults have suffered an attack of asthma, and up to 5% of these have severe disease ... more About 10% of adults have suffered an attack of asthma, and up to 5% of these have severe disease that responds poorly to treatment. Patients with severe disease have an increased risk of death, but patients with mild to moderate disease are also at risk of exacerbations. Most guidelines about the management of asthma follow stepwise protocols. This review does not endorse or follow any particular protocol, but presents the evidence about specific interventions. We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute asthma? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency ...

Evidence-based Respiratory Medicine

Current Clinical Practice

Medicina Intensiva, 2004

INHALED THERAPY FOR ACUTE ASTHMA Inhaled drugs and gases are the method of choice for the treatme... more INHALED THERAPY FOR ACUTE ASTHMA Inhaled drugs and gases are the method of choice for the treatment of acute asthma. In most patients, the use of oxygen supply is indicated. The success of treatment with aerosols depends on an adequate quantity of the drug reaching specific sites in the lung (receptors) with minimal adverse effects. The effectiveness of treatment depends on multiple factors. β 2-Antagonists together with anticholinergic agents constitute the first line treatment of patients with severe exacerbations who can breathe spontaneously or who require mechanical ventilation. Recent studies have shown that in non-ventilated patients, the bronchodilation achieved with pressurized metered dose inhalers with a spacer device was at least equivalent to that produced by nebulizers and had fewer adverse effects and shorter treatment time. The same is true for ventilated patients. Finally, there is insufficient evidence to support the routine use of inhaled corticosteroids, heliox or magnesium sulphate in these patients.

Thorax, 2011

Concerns about the safety of long-acting b2-agonist (LABA) therapy, has led to the appearance of ... more Concerns about the safety of long-acting b2-agonist (LABA) therapy, has led to the appearance of multiple publications and recommendations. This review critically examines the available clinical evidence and safety requirements for LABA use. On the basis of nearly 20 systematic reviews and databases, the authors conclude that LABA monotherapy significantly increases the risk of asthma-related adverse effects. We also conclude that the use of LABAs concomitantly with inhaled corticosteroids (ICS) significantly reduces asthma hospitalisations and is not associated with lifethreatening events and asthma-related deaths, especially when concurrent use of LABAs and ICS can be reasonably assured (use of a single inhaler device). An appropriate clinical study would require an extremely large sample, making it impractical. Finally, some of the new US Food and Drug Administration (FDA) recommendations have caused confusion and do not appear to be fully evidence based. Although limited by low statistical power, the evidence supports the use of LABAs plus ICS in a single inhaler device (to increase adherence and reduce the potential use of LABA monotherapy) for all patients (not only children) with moderate to severe asthma.

Respiratory Medicine, 2013

Background: Intermittent ICS treatment with SABA in response to symptoms, is an emerging strategy... more Background: Intermittent ICS treatment with SABA in response to symptoms, is an emerging strategy for control of mild-to-moderate asthma, and recurrent wheezing. This systematic revue compares the efficacy of daily vs. intermittent ICS among preschoolers, children and adults with persistent wheezing and mild to moderate stable persistent asthma. Methods: Systematic review of randomized, placebo-controlled trials with a minimum of 8 weeks of daily (daily ICS with rescue SABA during exacerbations) vs. intermittent ICS (ICS plus SABA at the onset of symptoms), were retrieved through different databases. Primary outcome was asthma exacerbations; secondary outcomes were pulmonary function tests, symptoms, days without symptoms, SABA use, corticosteroids use, days without rescue medication use, expired nitric oxide and serious adverse events. Results: Seven trials (1367 participants) met inclusion criteria there was no statistically significant difference in the rate of asthma exacerbations between those with daily vs. intermittent ICS (0.96; 95% CI: 0.86, 1.06, I 2 Z 0%). In the subgroup analysis, no differences were seen in duration of studies, step-up strategy or age. However, compared to intermittent ICS, the daily ICS group had a significant increase in asthma-free days and non-significant decreases in rescue SABA use and exhaled nitric oxide measurement.

Pediatrics, 2009

OBJECTIVE. To compare the efficacy of inhaled corticosteroids in infants and preschoolers with re... more OBJECTIVE. To compare the efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing or asthma. METHODS. Randomized, prospective, controlled trials published January 1996 to March 2008 with a minimum of 4 weeks of inhaled corticosteroids versus placebo were retrieved through Medline, Embase, and Central databases. The primary outcome was wheezing/asthma exacerbations; secondary outcomes were withdrawal caused by wheezing/asthma exacerbations, changes in symptoms score, pulmonary function (peak expiratory flow and forced expiratory volume in 1 second), or albuterol use. RESULTS. Of eighty-nine studies identified, 29 (N = 3592 subjects) met the criteria for inclusion. Patients who received inhaled corticosteroids had significantly less wheezing/asthma exacerbations than those on placebo (18.0% vs 32.1%); posthoc subgroup analysis suggests that this effect was higher in those with a diagnosis of asthma than wheeze but was independent of age (infants versus ...

The Journal of Pediatrics, 2004

Objective To compare the efficacy of b-agonists given by metered-dose inhaler with a valved holdi... more Objective To compare the efficacy of b-agonists given by metered-dose inhaler with a valved holding chamber (MDI+VHC) or nebulizer in children under 5 years of age with acute exacerbations of wheezing or asthma in the emergency department setting. Study design Published (1966 to 2003) randomized, prospective, controlled trials were retrieved through several different databases. The primary outcome measure was hospital admission. Results Six trials (n = 491) met criteria for inclusion. Patients who received b-agonists by MDI+VHC showed a significant decrease in the admission rate compared with those by nebulizer (OR, 0.42; 95% CI, 0.24-0.72; P = .002); this decrease was even more significant among children with moderate to severe exacerbations (OR, 0.27; 95% CI, 0.13-0.54; P = .0003). Finally, measure of severity (eg, clinical score) significantly improved in the group who received b-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, ÿ0.44; 95% CI, ÿ0.68 to ÿ0.20; P = .0003). Conclusions The use of an MDI+VHC was more effective in terms of decreasing hospitalization and improving clinical score than the use of a nebulizer in the delivery of b-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma. (J Pediatr 2004;145:172-7) W heezing-associated illnesses are a major cause of morbidity in infants and preschool children, with acute exacerbation of wheezing or asthma being a common reason for emergency department (ED) visits and hospital admissions. In general, nebulized short-acting b-agonists are the standard management for acute exacerbations. 1-3 However, nebulizers are more expensive (both in equipment cost and personnel time and equipotent drug cost), require a power source, need regular maintenance, represent a potential cause of cross-infection, and can be highly variable with respect to the rate of aerosol production and the nature of the aerosol. 4 A valved holding chamber (VHC) and metered-dose inhaler (MDI) combination is an alternative system for administration of b-agonists and is generally used for mild exacerbations of asthma or wheezing among young children. 5,6 The MDI+VHC combination has been evaluated in all ranges of severity in acute asthma among adults and is at least as effective as the nebulizer in outpatient, inpatient, ED and intensive care units. 5,7-9 Moreover, compared with the nebulizer, the MDI+VHC combination provides a quicker and more cost-effective way to deliver aerosolized b-agonists, with fewer side effects in older children with acute wheezing or asthma, 10-18 as demonstrated by a recent meta-analysis. 5 However, there are only a few studies comparing inhaled b-agonist therapy administered by MDI+VHC versus nebulizer in infants or children under 5 years of age with acute exacerbation of wheezing or asthma, and their conclusions have in some cases not been very well defined or were limited by small sample size (type II error). As a consequence, a systematic review with meta-analysis in this particular population will be useful and important. Thus, the objective of this systematic review was to compare the use See editorial, p 151.

The Journal of Emergency Medicine, 2006

Background: Current guidelines recommend the use of a combination of inhaled beta2agonists and an... more Background: Current guidelines recommend the use of a combination of inhaled beta2agonists and anticholinergics, particularly for patients with acute severe or life threatening asthma in the emergency setting. However, this statement is based on a relatively small number of randomised controlled trials and related systematic reviews. This review was undertaken to incorporate the more recent evidence available about the effectiveness of treatment with beta2-agonists and anticholinergics compared with beta2agonists in acute asthma treatment. Methods: A search was conducted of all randomised controlled trials published prior to April 2005. Results: Data from 32 randomised controlled trials (n = 3611 subjects) showed significant reductions in hospital admissions in both children (RR = 0.73; 95% CI: 0.63 to 0.85, p = 0.0001) and adults (RR = 0.68; 95% CI: 0.53 to 0.86, p = 0.002) that received inhaled anticholinergics. Combined treatment also produced a significant increase on spirometric tests at 60-120 min after the last treatment in children (SMD =-0.54; 95%

Emergency Medicine Journal, 2005

Diabetes Research and Clinical Practice, 2010

Background-Chronic airway inflammation in asthma or chronic obstructive pulmonary disease (COPD) ... more Background-Chronic airway inflammation in asthma or chronic obstructive pulmonary disease (COPD) may be involved in the pathogenesis of type 2 diabetes; however, prospective data have been limited. Methods-A prospective cohort of 38,570 women who were aged ≥ 45 years, free of cardiovascular disease and cancer at baseline, and free of diabetes at baseline and in the first 12 month were analyzed. We classified all women into three groups according to the presence and absence of self-reported asthma or COPD (including emphysema, chronic bronchitis, and bronchiectasis). Results-During a median follow-up of 12.2 years, 2,472 incident type 2 diabetes events were documented. Women who had ever reported asthma or COPD were associated with an increased diabetes risk; the multivariate RRs were 1.37 (95% CI, 1.20-1.57) for women who had asthma alone and 1.38 (95% CI, 1.14-1.67) for COPD without asthmatic symptoms. Furthermore, these associations were not significantly modified by age, smoking status, physical activity, BMI, alcohol intake, hormone replacement therapy, menopausal status or randomized treatment.

Chest, 2004

All patients with asthma are at risk of having exacerbations. Hospitalizations and emergency depa... more All patients with asthma are at risk of having exacerbations. Hospitalizations and emergency department (ED) visits account for a large proportion of the health-care cost burden of asthma, and avoidance or proper management of acute asthma (AA) episodes represent an area with the potential for large reductions in health-care costs. The severity of exacerbations may range from mild to life threatening, and mortality is most often associated with failure to appreciate the severity of the exacerbation, resulting in inadequate emergency treatment and delay in referring to hospital. This review describes the epidemiology, costs, pathophysiology, mortality, and management of adult AA in the ED and in the ICU.

Chest, 2000

Study objectives: (1) To determine the frequency of rapid-onset asthma attacks (ROAAs) and slow-o... more Study objectives: (1) To determine the frequency of rapid-onset asthma attacks (ROAAs) and slow-onset asthma attacks (SOAAs) in adult patients with acute, severe disease (18 to 50 years old), who presented to an emergency department (ED); and (2) to establish whether ROAA patients differ from SOAA patients in terms of clinical and spirometric characteristics; and (3) in terms of the response of treatment. Subjects and methods: Four hundred three patients (with peak expiratory flow [PEF] or FEV 1 of < 50% of predicted value) with acute exacerbations of asthma were enrolled in the trial using a prospective cohort study. Asthma attacks were classified as an ROAA (< 6 h of symptoms) or an SOAA (> 6 h). All patients were treated with albuterol, four puffs at 10-min intervals (100 g per actuation), delivered by metered-dose inhaler with a spacer device during 3 h. Results: On the basis of previously determined criteria, 11.3% of patients were classified as having a ROAA. Male patients comprised 53.6% of the ROAA group (p ‫؍‬ 0.03). In ROAA patients, the exacerbation was less likely to be attributed to respiratory tract infection (p ‫؍‬ 0.001) and more likely to have no identifiable cause (p ‫؍‬ 0.0001). Also, ROAA patients had lower pulmonary function (FEV 1) at presentation (mean difference, ؊ 0.13; 95% confidence interval [CI], ؊ 0.22 to ؊ 0.04 L; p ‫؍‬ 0.04) than SOAA patients. At the end of treatment, ROAA patients had an overall 48.0 L/min (95% CI, 14.1 to 81.8 L/min) greater improvement in PEF and a 0.31 L (95% CI, 0.08 to 0.54 L) greater improvement in FEV 1 than SOAA patients. Also, ROAA patients presented with less accessory muscle use (p < 0.05) and higher oxygen saturation (p ‫؍‬ 0.005). Finally, SOAA patients showed an increased incidence of hospital admission (relative risk, 3.89; 95% CI, 1.01 to 15.0). Conclusions: Data from this study support the notion that ROAAs constitute a distinct but uncommon acute asthma ED presentation, with a predominance of male patients. Upper respiratory tract infection was not believed to be a significant trigger factor in these patients, and ROAA patients had rapid deterioration of their conditions followed by a more rapid response to treatment and a lower hospital admission rate than SOAA patients. Thus, we have identified a subgroup of patients who appear to have common characteristics with patients with sudden-onset near-fatal/fatal asthma.

Chest, 2002

Controlled Trials Register were searched. The search terms were stated. The bibliographies of all... more Controlled Trials Register were searched. The search terms were stated. The bibliographies of all identified trials and reviews were screened. Articles published in any language were considered. Study selection Study designs of evaluations included in the review Randomised controlled trials (RCTs) were eligible for inclusion. Specific interventions included in the review Studies that compared the early use of continuous with intermittent nebuliser delivery of beta-agonists were eligible for inclusion. Continuous delivery could include frequent refilling of the nebuliser, use of a nebuliser or infusion pump, or use of a large volume nebuliser with high output extended respiratory therapy (HEART). The included studies used nebulised albuterol with a dose in the first hour ranging from 2.5 to 16 mg. Systemic steroids were used in all of the included studies. Participants included in the review Studies of adults (aged 18 years or more) who were treated for acute asthma in the emergency room were eligible for inclusion. The patients in the primary studies included adults with severe acute asthma (pulmonary function tests less than 50% of predicted). Outcomes assessed in the review Studies that reported changes in pulmonary function tests as the primary outcome were eligible for inclusion. The studies could assess the absolute or per cent predicted of either the peak expiratory flow rate (PEF) or the forced expiratory volume in one second (FEV1). The secondary outcomes assessed in the review were side-effects and admission to hospital. The review assessed outcomes up to 3 hours of treatment. How were decisions on the relevance of primary studies made? Two authors independently screened the titles and abstracts, and selected potentially relevant studies. They then reviewed the full publication of each identified study with respect to the eligibility criteria. Any disagreements were resolved by consensus. The two authors were masked to the authors' names, journal and date of publication. Interauthor agreement was assessed using the Kappa (K) statistic. Assessment of study quality Study quality was assessed using the 5-point scale described by Jadad et al. (see Other Publications of Related Interest). This scale assesses the adequacy of randomisation, blinding, and the handling of withdrawals and drop-outs. The authors do not state how the papers were assessed for quality, or how many of the reviewers performed the quality assessment.

Chest, 1999

The authors performed a search of the electronic MEDLINE database (1966 to October 1998) using th... more The authors performed a search of the electronic MEDLINE database (1966 to October 1998) using the MeSh terms: 'Asthma or Wheez*', and 'glucocorticoids or steroids', and 'Acute* or Emerg'. The authors also searched Current Contents, a previous meta-analysis, review articles, and the reference sections of located studies. The authors also handsearched 15 journals in respiratory care and emergency medicine. The search was limited to English language publications. Study selection Study designs of evaluations included in the review Randomised controlled trials (RCTs) conducted in an emergency care setting. Specific interventions included in the review Corticosteroids (CCSs) (hydrocortisone (HYD), methylprednisolone, or flunisolide with HYD equivalents ranging from 8.3 to 300.0 mg/kg/24 hours) administered either orally, intramuscularly, intravenously, or by inhalation) with a cointervention of aminophylline for the intervention groups, and placebo for the control groups. Participants included in the review Adult patients over 18 years of age with asthma, presenting in acute-care settings, whose acute exacerbations were the primary reason for assessment. The mean age of participants was 32.3 years. Outcomes assessed in the review Pulmonary function tests and hospital admission rates. How were decisions on the relevance of primary studies made? Two authors independently reviewed the articles for inclusion using specific criteria. Disagreements were resolved by consensus. Agreement was measured using k-statistics. Assessment of study quality All trials were assessed using the following criteria: randomisation method; demographic characteristics of the sample; inclusion/exclusion criteria; asthma definition; sample size calculations; and withdrawals. The mean score of the two evaluations was divided by the possible score of 12 and was expressed as a value between 0.08 and 1.0. Trials with a score of > 0.7 were considered to be good quality. Validity criteria were applied by two of the authors. Inter-rater reliability was measured by using the k-statistic.

Chest, 2002

The role for anticholinergic medications in acute asthma is not well-defined. Thus, the use of th... more The role for anticholinergic medications in acute asthma is not well-defined. Thus, the use of therapy with anticholinergics and ␤ 2-agonists, either simultaneously or in sequence, has produced positive as well as negative results in trials. Therefore, the current recommendations for the use of these drugs in the emergency department (ED) and hospital management of asthma exacerbations are not precise. This review answers the following question: what level of evidence is available in the literature to support the use of anticholinergic medications in combination with ␤ 2-agonists in acute asthma patients? We limited the search on our therapy question to systematic reviews of randomized trials and/or randomized controlled trials not included in the reviews. After an extensive review of the most relevant evidence, the following conclusions may be emphasized. (1) The use of multiple doses of ipratropium bromide are indicated in the ED treatment of children and adults with severe acute asthma. The studies reported a substantial reduction in hospital admissions (30 to 60%; number needed to treat, 5 to 11) and significant differences in lung function favoring the combined treatment. No apparent increase in the occurrence of side effects was observed. (2) The use of single-dose protocols of ipratropium bromide with ␤ 2-agonist treatment produced, particularly in children with more severe acute asthma, a modest improvement in pulmonary function without reduction in hospital admissions; in adults, the data showed a similar increase in pulmonary function with an approximately 35% reduction in the hospital admission rate. In patients with mild-to-moderate acute asthma, there is no apparent benefit from adding a single dose of an anticholinergic medication.

Chest, 2007

Background: In acute asthma (AA), overweight/obesity (body mass index [BMI] > 25 kg/m 2) have bee... more Background: In acute asthma (AA), overweight/obesity (body mass index [BMI] > 25 kg/m 2) have been related to poorer outcomes and higher risk of complications. Methods: We designed a prospective cohort study to determine if overweight/obese adults with severe episodes of AA require longer duration of emergency department (ED) treatment and have higher hospitalization rates compared with underweight/normal asthmatics (BMI < 25 kg/m 2). All patients received inhaled albuterol (maximum 6 h). Patients were discharged or admitted according to standard accepted criteria. The weight and height of each patient were measured during the ED stay. Results: Four hundred twenty-six patients (mean, 33.4 ؎ 11.5 years [؎ SD]; 63% women) with severe exacerbations (FEV 1 , 28.2 ؎ 11.9% of predicted) were enrolled. One hundred sixty-three patients (38.3%) were classified as overweight/obese. Patients with BMI > 25 kg/m 2 showed significant increases in length of ED stay (2.3 h vs 1.9 h, p ‫؍‬ 0.01) and rate of hospitalization (13.7% vs 6.8%, p ‫؍‬ 0.02), despite adjustments for other confounding variables. They also presented a higher rate of use of inhaled steroids and theophylline within the past 7 days. At the end of treatment, overweight/obese patients displayed more wheezing. Multivariate analysis demonstrated that BMI > 25 kg/m 2 resulted unrelated to final change in peak expiratory flow from baseline. By contrast, BMI > 25 kg/m 2 was related with duration of ED treatment (p ‫؍‬ 0.002). Conclusions: Overweight/obese patients were admitted to the hospital more frequently than underweight/normal patients. This may reflect a difference in the perception of dyspnea, or it may reflect an underlying difference in asthma severity between the two groups.

Archivos de Bronconeumología ((English Edition)), 2004

BMJ clinical evidence, Jan 4, 2011

Evidence-based Respiratory Medicine

Current Clinical Practice

Medicina Intensiva, 2004

Thorax, 2011

Respiratory Medicine, 2013

Pediatrics, 2009

The Journal of Pediatrics, 2004

The Journal of Emergency Medicine, 2006

Emergency Medicine Journal, 2005

Diabetes Research and Clinical Practice, 2010

Chest, 2004

Chest, 2000

Chest, 2002

Chest, 1999

Chest, 2002

Chest, 2007