HYPERTONIC SALINE MAKES A BIG DIFFERENCE

A randomized, double-blind, controlled study has shown that in infants with viral bronchiolitis, 3 mg of nebulized hypertonic saline plus 5 mg of terbutaline significantly lowers clinical severity scores after the first day of treatment.

The study, performed by Sarrell et al, randomized 65 infants younger than 24 months to receive either 5 mg terbutaline plus 0.9% nebulized saline or 5 mg terbutaline plus 3% hypertonic nebulized saline; both regimens were administered three times per day. Anteroposterior and lateral chest films were taken on days 1 and 3. Clinical severity scores were measured at baseline and daily thereafter.

Roughly 80% of the infants in both groups were infected with the respiratory syncytial virus. Baseline clinical severity scores for the treatment and control groups were 6.6 and 6.4, respectively. After day 1, clinical severity scores taken before and after inhalation therapy were significantly lower in the 3% saline group than in the 0.9% saline group. There was no between-group difference in radiographic assessment at any time.

Studies have suggested that hypertonic saline decreases mucosal edema and inflammation, aids mucus clearance, and improves mucociliary function. The simple substitution of 3% hypertonic saline for 0.9% normal saline had a significant positive impact on symptoms.

Sarrell EM, Tal G, Witzling M, et al. Nebulized 3% hypertonic saline solution treatment in ambulatory children with viral bronchiolitis decreases symptoms. Chest. 2002;122:2015-2020.

OMALIZUMAB DECREASES INHALED STEROID USE IN ASTHMA

Subcutaneous omalizumab, a recombinant anti-immunoglobulin E antibody, improves asthma-related quality of life (QOL) in patients with severe allergic asthma. It also allows them to significantly reduce their use of inhaled corticosteroids.

A randomized, double-blind, placebo-controlled trial conducted by Finn et al assessed the safety, efficacy, and tolerability of omalizumab. The study included 440 patients who had symptoms of severe allergic asthma despite the use of moderate to high doses of inhaled corticosteroids. All patients were switched to beclomethasone dipropionate (BDP) therapy during a four- to six-week run-in period. Afterward, patients randomly received either placebo or omalizumab every two or four weeks for 28 weeks. During the final 12 weeks of this phase, the BDP dose was reduced by 25% every two weeks until the lowest possible dose was achieved. Patients then continued their respective treatments for 24 weeks. Asthma-related QOL was evaluated at baseline and at 16, 28, and 52 weeks.

A significant improvement in asthma-related QOL occurred in the treatment group compared with the placebo group. In the treatment group, improvement in QOL paralleled improvement in asthma control. Clinically relevant improvement in asthma-related QOL was concurrent with a significant reduction reliance on inhaled corticosteroids.

Subcutaneous omalizumab may be of particular use in patients using moderate to high doses of inhaled corticosteroids who have severely asthma-impaired QOL.

Finn A, Gross G, van Bavel J, et al. Omalizumab improves asthma-related quality of life in patients with severe allergic asthma. J Allergy Clin Immunol. 2003;111:278-284.

POST-HOSPITAL MORTALITY HIGH IN ELDERLY WITH CAP

Nearly half of all elderly patients hospitalized for community-acquired pneumonia (CAP) die in the year following hospital discharge. Using data from the 1997 Medicare hospital discharge database, Kaplan et al performed a case-control analysis of patients 65 and older who were hospitalized with a diagnosis of CAP. For each patient, five age-, sex-, and race-matched controls were chosen. Hospital and one-year mortality rates were then compared.

The database identified 158,960 elderly patients who had been hospitalized for CAP, along with 794,333 controls hospitalized for other reasons. In the control group, hospital mortality was half that in the CAP group (5.5% vs 11%). One year after hospitalization, mortality among CAP patients was more than 40%. In the control group, however, one-year mortality was less than 30%. In both groups, mortality increased with age and number of comorbidities.

The authors noted that in patients with CAP, long-term survival must be considered. Hospital mortality is not an appropriate outcome measure for studies of elderly patients with CAP because most deaths occur after discharge. Prophylactic interventions, such as the pneumococcal and influenza vaccines, and lifestyle changes, including regular physical activity and increased social support, may help improve outcomes in this population.

Kaplan V, Clermont G, Griffin MF, et al. Pneumonia: still the old man’s friend? Arch Intern Med. 2003;163:317-323.

ERYTHROCYTE MAGNESIUM LEVELS FALL DURING ASTHMA EXACERBATIONS

Patients experiencing acute asthma attacks have low levels of magnesium in erythrocytes but normal levels in plasma. A study by Zervas et al found that after symptom control is achieved, erythrocyte magnesium concentrations return to normal.

The study involved 30 patients with acute asthma and two control groups of 20 patients each: one group with stable asthma and the other without asthma. All patients with acute asthma received treatment with nebulized ß2-agonists and systemic corticosteroids. The magnesium levels in plasma and erythrocytes were measured in all patients at admission, two and five days later, and at discharge (six to 10 days after admission).

At baseline, erythrocyte magnesium levels were significantly lower in the acute asthma group than in the other two groups. After treatment of the asthma exacerbations, erythrocyte magnesium levels increased significantly, and levels from the last sample taken were similar in all groups. Plasma magnesium levels did not differ among the groups at any time.

The authors speculated that during exacerbation-induced bronchoconstriction, the body uses magnesium to relax airway smooth muscle.

Zervas E, Papatheodorou G, Psathakis K, et al. Reduced intracellular Mg concentrations in patients with acute asthma. Chest. 2003;123:113-118.

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