Aim: To determine whether the addition of nebulised ipratropium to the therapy of acute asthma leads to a cost-effective reduction in the mean duration of admission and time to maximum peak expiratory flow rate (PEFR). Method: Patients with an admission diagnosis of acute asthma were studied in a double-blind, placebo-controlled trial in which they received a standard therapeutic regimen of continuous intravenous aminophylline, 4-hourly fenoterol nebulisation, intravenous methylprednisolone 125mg 12-hourly, and, every four hours, either nebulised saline placebo or ipratropium bromide 500mcg in 3ml saline. Data on age, gender, initial and maximum PEFR, time to maximum PEFR, and duration of hospital stay was collected from the hospital record after discharge. Statistical techniques: 2-way contingency tables for categorical variables, 1-way ANOVA for treatment effects, and life-table analysis of the time till discharge. Results: Records of 279 of the 400 patients entered in the study were suitable for analysis after excluding re-admissions, non-asthmatics and incomplete records. Baseline comparisons of age and severity on presentation showed no significant differences. The trial group did not differ significantly from the control group with respect to either time to PEFR (respectively 21.11 hours (SD 14.3) versus 22.89 (SD 15.82)) or duration of admission (5.02 (SD 3.65) versus 5.38 (SD 3.13) 6-hour units). In a sub-group of patients (n=155) demonstrating more than 100% improvement in PEFR, the time to maximum PEFR was significantly shorter in the ipratropium group (20.35 hours SD 12.4) versus 25.20 hours (SD 17.0); p= 0.045). Conclusion: The addition of ipratropium bromide to a standard treatment regimen for acute asthma reduced the time to achieve maximum PEFR in a sub-group of patients with markedly reversible airflow limitation. Overall, however, the addition did not prove cost-effective.

Aerosolized bronchodilator drugs are commonly used for treatment of horses with chronic obstructive pulmonary disease. Relative efficacy of sympathomimetic and parasympatholytic bronchodilators for relief of acute airway obstruction and improvement of pulmonary gas exchange was compared in 6 horses with COPD. Physical examination, arterial and venous blood gas analysis and measurement of end-tidal CO₂ tension were performed at time zero, 30 minutes, 1, 2, 3 and 4 hours after administration of aerosol ipratropium (0.35 μg/kg), albuterol (1 μg/kg) or placebo via an equine Aeromask and metered dose inhaler. Physiologic shunt fraction (QS/QT), alveolar dead space fraction (VD/VT) and alveolar to arterial oxygen tension difference (p(A-a)O₂) were calculated using standard formulas. At time zero, horses demonstrated severe respiratory compromise and marked alterations in pulmonary gas exchange, indicative of alveolar hypoventilation, VA/Q mismatching and diffusion impairment. Ipratropium treatment significantly (p< 0.05) reduced arterial CO₂ tension and end-tidal CO₂ tension toward normal, but significantly increased p(A-a)O₂ from baseline. The change in paCO₂ after ipratropium treatment was significantly different from albuterol and placebo treatment groups. There were no significant changes in response variables after albuterol and there were no treatment by time interactions. These results indicate that, under the conditions of this study, ipratropium (0.35 μg/kg) improved alveolar ventilation and had superior bronchodilator efficacy than albuterol (1 μg/kg) in horses with severe COPD. Marked impairment of pulmonary gas exchange persisted after bronchodilators, emphasizing that anti-inflammatory therapy and environmental control are also necessary for effective treatment of severe equine COPD. / Master of Science

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Visando estudar os efeitos da retirada abrupta apÃs o tratamento crÃnico com brometo de ipratrÃpio (BI) ratos machos pesando 200-250 g no inÃcio dos experimentos, foram introduzidos em uma caixa de acrÃlico e submetidos durante 7 minutos à inalaÃÃo de brometo de ipratrÃpio (600ÂM). Este procedimento se repetiu a cada quatro horas durante um perÃodo de 14 dias. Foram utilizadas duas cÃmaras de inalaÃÃo, uma para o grupo experimental (tratado com BI) e outra para o grupo controle (CONT, salina). Outro grupo de animais foi sensibilizado (SENS) e submetido ao mesmo protocolo de inalaÃÃo com BIque inalaram o brometo de ipratrÃpio e outra para os animais controle. Os animais SENS foram desafiados 24 horas antes do sacrifÃcio com inalaÃÃes do antÃgeno (OVA: 1mg/ml; 5mg/ml; 15/15 minutos; grupo DESF). Ao fim de uma Ãnica inalaÃÃo ou ao tÃrmino do perÃodo de tratamento crÃnico com BI os animais foram sacrificados 0, 4, 8, 12 horas apÃs a Ãltima inalaÃÃo e as traquÃias rapidamente removidas. ApÃs a dissecaÃÃo a traquÃia foi montada sob a forma de anÃis, em banho para ÃrgÃo isolado contendo 8 ml de soluÃÃo de Krebs-Henseleit (37ÂC, 95% O2, 5% CO2). Foram entÃo, confeccionadas curvas concentraÃÃo-efeito (CCE), ao carbacol (Cch), serotonina (5-HT), potÃssio (KCl), cÃlcio(CaCl2) e estÃmulo elÃtrico. As CCE ao Cch obtidas com traquÃias isoladas de ratos apÃs uma Ãnica inalaÃÃo de brometo de ipratrÃpio demonstrou desvio para a direita com significativo aumento da CE50[CE50x10-7M: CONT=1,78(1,32 â 2,32); BI 14,6(2,05 â 58,1), p<0,05). Imediatamente apÃs o fim do tratamento crÃnico as CCE ao Cch tambÃm apresentaram aumento significativo da CE50 [CE50x10-7M: CONT=2,33(1,25 â 4,32); BI=42,5(21,1 â 85,8), p<0,01). Nos experimentos realizados com traquÃias isoladas de ratos 4, 8 e 12 horas apÃs o fim do tratamento crÃnico ocorreu um progressivo aumento da contratilidade, com a resposta mÃxima(RM) atingindo um valor mÃximo 12 horas apÃs a supressÃo do tratamento crÃnico com BI (RM 12h: CONT= 1,69Â0,04, BI 2,64Â0,23 gF, p<0,01). Esta supersensibilidade caracterizada por aumento vertical, tambÃm se manifestou para outros agonistas e estÃmulos contrÃteis. Assim, ocorreu supersensibilidade para a serotonina (RM-12h: CONT=0,59Â0,04; BI=1,06Â0,10gF, p<0,01) potÃssio (RM: CONT= 0,70Â0,05; BI=1,27Â0,17 gF; p<0,01) e ao estÃmulo elÃtrico (RM: CONT=1,25Â0,07; BI=1,64Â0,06 gF; p<0,01). As CCE obtidas 12 horas apÃs o fim do tratamento crÃnico com BI, pela adiÃÃo de cÃlcio ao lÃquido de incubaÃÃo, apÃs ter sido obtida resposta contrÃtil ao KCl ou ao Cch, as quais avaliaram, respectiva e indiretamente, a entrada de cÃlcio via canais VOC e ROC demonstraram que a entrada de cÃlcio està facilitada em ambos os tipos de canal de cÃlcio estudados (RM-12h CaCl2/KCl: CONT=1,00Â0,09; BI=1,54Â0,19 gF; p<0,01) (RM-12h CaCl2/Cch: CONT=1,27Â0,10; BI=1,66Â0,05 gF; p<0,01). Nos experimentos realizados com animais desafiados, a supressÃo do tratamento crÃnico imediatamente apÃs Ãltima inalaÃÃo diminuiu a sensibilidade desviando para a direita a CCE ao Cch [CE50x10-7M: CONT=2,10(1,28 â 3,44); BI=17,12(4,37 â 67,05), p<0,01)]. Enquanto que, traquÃias isoladas de animais desafiados 12 horas apÃs o fim do tratamento ocorreu aumento significativo da contratilidade e da resposta mÃxima obtida para o carbacol (RM-12h: CONT=2,48Â0,19; BI=3,48Â0,13 gF; p<0,01). Estes resultados sugerem que a supressÃo do processo de inalaÃÃo crÃnica com BI induz um aumento de resposta contrÃtil ao Cch atingindo um valor mÃximo 12 horas apÃs a interrupÃÃo do tratamento crÃnico. Esta supersensibilidade 12 horas apÃs a supressÃo do tratamento crÃnico com BI, tambÃm foi manifestada para vÃrios outros agonistas, bem como para o estÃmulo elÃtrico. A supersensibilidade foi tambÃm detectada na resposta contrÃtil ao Cch, seguindo o mesmo protocolo experimental de interrupÃÃo do tratamento em traquÃias isoladas de ratos desafiados a OVA. Este aumento de resposta contrÃtil observado na musculatura traqueal de ratos, 12 horas tambÃm que a supersensibilidade està presente, apÃs o desafio antigÃnico, com incremento ainda maior na resposta contrÃtil quando comparada traquÃias isoladas de animais nÃo desafiados submetidos à retirada abrupta apÃs tratamento crÃnico com BI / In order to evaluate ipratropium bromide (IB) abrupt withdrawal effects after chronic treatment in isolated rat tracheas, male rats weighing 200-250g were placed in plastic chambers and submitted to inhalation of IB (600ÂM) during seven minutes. This protocol was repeated each four hours during 14 days. Two inhalation chambers were used, one with experimental group (IB inhalation) and the other with control group (CONT, saline). Another group was ovalbumin (OVA) actively sensitized (SZ) and submitted to the same protocol of inhalation. These animals were challenged 24hours before the beginning of the experiments by antigen inhalation (OVA: 1mg/ml; 5mg/ml; 15/15 minutes) (group DESF). At the end of IB treatment period the animals were killed and 0, 4, 8, 12 hours after the last inhalation the tracheas were quickly removed. After dissection the tracheal rings were transferred to a 8 ml organ bath containing Krebs-Henseleit solution mMol/l: NaCl 113.0; KCl 4.7; CaCl2.2H2O 1.2; KH2PO4 1.2; MgSO4.7H2O 1.2; NaHCO3 25.0; Glucose 11.0; 37 C; 95%O2/5%CO2). Concentration-effect curves (CEC) were constructed to carbachol (Cch), serotonin (5-HT), potassium (KCl), calcium (CaCl2) and electric stimulus. CEC to Cch obtained with tracheas isolated from rats submitted to only one IB inhalation showed shift to the right with an increase in the EC50 values [EC50x10-7M: CONT=1.78(1.32-2.32); IB=14.6(2.05-58.1) p<0.05]. Immediately after chronic treatment CEC to Cch also showed significant increase at EC50 level [EC50x10-7M: CONT=2.33(1.25-4.32); IB=42.5(21.1-85.8); p<0,01]. Experiments realized with isolated rats tracheas 4, 8, 12 hours after ended the IB chronic treatment showed a Cch maximum response (MR) progressive increase, reaching the greater value 12 hours after IB chronic treatment interruption [MR-12h: CONT=1.69Â0.04; IB=2.64Â0.23 gF, p<0.01). This kind of supersensitivity characterized by a vertical increase, was also obtained to other agonists and contractile stimulus. In this way the results showed supersensitivity to serotonin (MR-12h: CONT=0.59Â0.04; IB=1.06Â0.10; gF; p<0.01), potassium (MR-12h: CONT=0.70Â0.05; IB=1.27Â0.17; gF; p<0.01) and electric stimulus (MR-12h: CONT=1.25Â0.07; IB=1.64Â0.06; gF; p<0.01). Calcium CCE were obtained 12hours after the end of IB chronic treatment, after the addition of KCl or Cch in calcium free buffer. This kind of experiment measured, respsctively and indirectly the influx of calcium by voltage operated channelsVOC) and by receptor operated channels(ROC). The results demonstrated that influx of calcium was facilitated in both calcium channels studied in this work (MR-12h: CaCl2/KCl: CONT=1.00Â0.09; IB=1.54Â0.19; gF; p<0.01) (MR-12h: CaCl2/Cch; CONT= 1.27Â0.10; IB=1.66Â0.05; gF; p<0.01). The experiments with OVA challenged animals, realized immediately after the end of chronic treatment, showed a decreased in the sensibility. The CEC to Cch were shift to the right [EC50X10-7M: CONT=2.10(1.28-3.44); IB=17.13(4.37-67.05), P<0,01]. However, trachea isolated from rat challenged 12 hours after the end of the treatment, showed an increase in the contractility and in the MR obtained to carbachol (MR-12h: CONT=2.48Â0.19; IB=3.48Â0.13; gF; p<0,01). These data suggest that IB chronic inhalation process follow suppression induced an evident Cch contractile response increase in isolated rat trachea, reaching a maximum value 12 hours after interrupted IB chronic treatment abrupt suppression, was here demonstrated to several agonists and electric stimulus. Supersensitivity was also detected to carbachol contractile response through the same withdrawal experimental protocol in isolated tracheas from rats challenged with OVA. This increased contractile response obtained in rats tracheal smooth muscle, 12 hours after the end of ipratropium bromide chronic treatment, could be related with a component linked with the facilitation influx of calcium by voltage operated channels (VOC) and/or receptor operated channels (ROC)

Streptococcus pneumoniae ist der häufigste Erreger bakterieller Meningitiden. Eine Pneumokokken-Meningitis führt trotz Ausschöpfung aller heute verfügbaren Behandlungsmöglichkeiten in 25 % der Fälle zum Tod. Steigende Antibiotikaresistenzen und die Limitation verfügbarer Vakzine auf einige Serotypen von S. pneumoniae erfordern neue Ansätze in der antimikrobiellen Therapie. Cholin-bindende Proteine (CBPs) sind gemeinsames Merkmal aller Pneumokokkenstämme und für die Virulenz dieses Bakteriums essenziell. Durch Zugabe potenter Anticholinergika können die CBPs von der Bakterienoberfläche abgelöst und damit inhibiert werden. In dieser Arbeit wurde untersucht, ob durch Inhibition von CBPs während des Wachstums der Pneumokokken deren Phagozytose durch Mikrogliazellen in vitro gesteigert werden kann. Während ihres Wachstums wurden die Bakterien dazu mit potenten Anticholinergika inkubiert und am Ende ihrer exponentiellen Wachstumsphase auf murine Mikrogliazellen gegeben. Nicht alle eingesetzten Anticholinergika konnten die Inhibition der CBPs – angezeigt durch die Bildung langer Kokkenketten – bewirken, obwohl für sie alle eine hohe Affinität zu den CBPs in früheren Arbeiten nachgewiesen worden war. Ipratropium, das in höheren Konzentrationen das Pneumokokkenwachstum inhibiert, induzierte in den von uns eingesetzten niedrigen Konzentrationen weder die Bildung von Ketten noch führte es zu einer erhöhten Phagozytoseleistung. Mit DMAE funktionalisiert zeigten PAMAM-Dendrimere der 1. Generation ebenfalls keine Inhibition der CBPs: Es bildeten sich weder Kokkenketten noch zeigte sich eine erhöhte Bakterienaufnahme der Mikroglia. Im Gegensatz dazu stellte sich unter Einfluss von PPI-g2-DMAE neben ausbleibender Kettenbildung ein dosisabhängiger phagozytosehemmender Effekt dar. Einzig durch Co-Inkubation mit dem mit Cholin funktionalisierten PPI-Dendrimer der 2. Generation gelang die Inhibition der CBPs mit resultierender Bildung langer Ketten. Die Phagozytoseleistung zeigte eine dosisabhängige Steigerung sowohl für eine CoInkubation während der gesamten exponentiellen Wachstumsphase als auch nach Co-Inkubation während ihrer letzen 2 Stunden. Dennoch konnte im Sepsismodell der Maus durch intraperitoneale Injektion dieses Dendrimers 15 min vor Infektion mit S. pneumoniae kein protektiver Effekt erzielt werden: Zwischen den mit Dendrimeren behandelten Tieren und denen der Kontrollgruppe zeigten sich keine Unterschiede in Überlebenszeit und Sterblichkeit, dem krankheitsbedingten Gewichtsverlust, dem klinischen Score und der durch Ausplattieren von Milzhomogenaten ermittelten Keimkonzentration im Blut infektionsbedingt verstorbener Tiere. Die von uns eingesetzten Konzentrationen von Ipratropium scheinen für eine Inhibition der CBPs nicht ausgereicht zu haben. Der bislang nicht genau geklärte wachstumsinhibitorische Effekt, der sich in unseren Versuchen bereits ab 5 mM bemerkbar machte, könnte jedoch durch Inhalation von Ipratropium gezielt zur Prophylaxe von Pneumokokken-Pneumonien genutzt werden. Bei an Dendrimere gekoppelten, eigentlich potenten Liganden der CBPs konnte beobachtet werden, dass sie als Teil des Dendrimers ihre Affinität gegenüber den CBPs nicht nur deutlich verändern, sondern auch unerwartete Effekte (Verminderung der Phagozytose) hervorrufen können. Wegen der raschen Elimination scheint die einmalige Gabe eines potenten Dendrimers zur Inhibition der CBPs in vivo nicht auszureichen und erklärt das Versagen im Sepsismodell. Neuere Untersuchungen zur Distribution im Hirnparenchym nach intraventrikulärer oder subarachnoidaler Injektion lassen hoffen, dass durch Gabe subtoxischer Dosen die von uns beobachtete Phagozytosesteigerung in vivo reproduzierbar ist. Durch Inhibition der CBPs ist es möglich, die Virulenz aller Serotypen des Pneumokokkus stark zu reduzieren. Potente Inhibitoren könnten sowohl als Therapeutikum als auch zur Infektionsprophylaxe eingesetzt werden, ohne dass es dabei zur Ausbildung von Resistenzen kommt, da zeitgleich mehrere Virulenzfaktoren inhibiert werden. Es ist daher von großem medizinischen Interesse, Inhibitoren der CBPs zu entwickeln, die in subtoxischen Dosen eine hohe Affinität zu den CBPs aufweisen und diese inhibieren.