Changing practices in Respiratory Care!

Changes in evaluation and treatment of Retinopathy of Prematurity
Important changes include recommendations for treatment of high-risk prethreshold ROP as well as for threshold ROP and more frequent evaluation of infants with suspected aggressive posterior ROP and infants with immature vascularization without ROP.¹

Respiratory Distress Syndrome and CPAP
A follow-up report of the SUPPORT trial provided further evidence that the initial use of continuous positive airway pressure (CPAP) is a good alternative to early intubation and surfactant administration for extremely premature infants (gestational age between 24 and 27 weeks), who are at-risk for respiratory distress syndrome.²

At 18 to 22 months corrected age, there was no difference in death or neurodevelopmental outcome between the initial CPAP and intubation with surfactant administration groups (27.9 versus 29.9 percent). Impaired neurodevelopmental outcome was defined as a predefined poor score on cognitive testing, moderate or severe cerebral palsy, hearing impairment, or bilateral visual impairment.

Narcolepsy following adjuvanted 2009 pandemic H1N1 influenza vaccination
Individuals in several countries in Europe have developed narcolepsy after receiving Pandemrix, an AS03 (oil-in-water emulsion)-adjuvanted 2009 pandemic H1N1 influenza vaccine. Pandemrix was used in certain countries during the 2009-2010 H1N1 influenza pandemic, but it was not used in the United States. This association was first reported among children and adolescents in Finland and Sweden in 2010.³ These findings have been confirmed in a subsequent large retrospective database review that included six countries in Europe over a 10-year period; increased narcolepsy rates were observed in Sweden, Finland, and Denmark after the initiation of Pandemrix vaccination campaigns, primarily in children and adolescents.³ An increased risk of narcolepsy was also observed in children and adolescents who received Pandemrix in the United Kingdom.⁴

2012-2013 seasonal influenza vaccine effectiveness

In a case-control study conducted early in the 2012-2013 influenza season, the United States Centers for Disease Control and Prevention estimated that the effectiveness of 2012-2013 seasonal influenza vaccine in preventing laboratory-confirmed influenza is approximately 60 percent overall (55 percent for influenza A viruses and 70 percent for influenza B viruses).⁵ Given the moderate effectiveness of the vaccine, influenza infection will occur among some individuals who received the influenza vaccine. This highlights the importance of early antiviral therapy (regardless of vaccination status), particularly for those at risk for severe or complicated influenza infection.

High-frequency oscillatory ventilation in adults with ARDS

High-frequency oscillatory ventilation (HFOV), with respiratory rates up to 900 breaths per minute, improves oxygenation in patients with severe hypoxemia due to adult respiratory distress syndrome (ARDS), although two new studies have shown it does not improve survival for most patients. In one large multicenter trial (OSCILLATE), adult patients with new-onset, moderate-to-severe ARDS were randomly assigned to HFOV or to an ARDSNet (low tidal volume) ventilation strategy.⁶

The study was terminated for harm after enrollment of 548 of a planned 1200 patients, due to an in-hospital mortality of 47 percent in the HFOV arm compared with 35 percent in the ARDSNet arm. The OSCAR trial, which enrolled nearly 800 patients in the United Kingdom, also failed to demonstrate a mortality benefit with HFOV at 30 days, although the detrimental effect of HFOV on mortality observed in the OSCILLATE trial was not seen.⁷ Thus, HFOV is not recommended as an initial treatment strategy for adult patients with ARDS.

Long-term azithromycin for bronchiectasis

The role of long-term azithromycin in preventing exacerbations of bronchiectasis has been examined in patients with non-cystic fibrosis bronchiectasis. In the Effectiveness of Macrolides in patients with Bronchiectasis using Azithromycin to Control Exacerbations (EMBRACE) trial, 141 patients with at least one exacerbation of bronchiectasis in the prior year were randomly assigned to take azithromycin 500 mg or placebo, three times a week for six months.⁸

Azithromycin was associated with a significant decrease in exacerbations compared with placebo. Although no significant difference was noted in lung function or quality of life, long-term azithromycin may be useful in some patients with bronchiectasis.

Citations

1. Fierson WM. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2013;131(1):189-95.
2. Vaucher YE, Peralta-carcelen M, Finer NN, et al. Neurodevelopmental outcomes in the early CPAP and pulse oximetry trial. N Engl J Med. 2012;367(26):2495-504.
3. Wijnans L, Lecomte C, De vries C, et al. The incidence of narcolepsy in Europe: before, during, and after the influenza A(H1N1)pdm09 pandemic and vaccination campaigns. Vaccine. 2013;31(8):1246-54.
4. Miller E, Andrews N, Stellitano L, et al. Risk of narcolepsy in children and young people receiving AS03 adjuvanted pandemic A/H1N1 2009 influenza vaccine: retrospective analysis. BMJ. 2013;346:f794.
5. Early estimates of seasonal influenza vaccine effectiveness—United States, January 2013; MMWR Morb Mortal Wkly Rep. 2013;62 (Early release):1.
6. Ferguson ND, Cook DJ, Guyatt GH, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med. 2013;368(9):795-805.
7. Young D, Lamb SE, Shah S, et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med. 2013;368(9):806-13.
8. Wong C, Jayaram L, Karalus N, et al. Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (EMBRACE): a randomised, double-blind, placebo-controlled trial. Lancet. 2012;380(9842):660-7.