Methacholine bronchial provocation measured by spirometry versus wheeze detection in preschool children

BACKGROUND

Determination of PC20-FEV1 during Methacholine bronchial provocation test (MCT) is considered to be impossible in preschool children, as it requires repetitive spirometry sets. The aim of this study was to assess the feasibility of determining PC20-FEV1 in preschool age children and compares the results to the wheeze detection (PCW) method.

METHODS

55 preschool children (ages 2.8-6.4 years) with recurrent respiratory symptoms were recruited. Baseline spirometry and MCT were performed according to ATS/ERS guidelines and the following parameters were determined at baseline and after each inhalation: spirometry-indices, lung auscultation at tidal breathing, oxygen saturation, respiratory and heart rate. Comparison between PCW and PC20-FEV1 and clinical parameters at these end-points was done by paired Student's t-tests.

RESULTS AND DISCUSSION

Thirty-six of 55 children (65.4%) successfully performed spirometry-sets up to the point of PCW. PC20-FEV1 occurred at a mean concentration of 1.70+/-2.01 mg/ml while PCW occurred at a mean concentration of 4.37+/-3.40 mg/ml (p < 0.05). At PCW, all spirometry-parameters were markedly reduced: FVC by 41.3+/-16.4% (mean +/-SD); FEV1 by 44.7+/-14.5%; PEFR by 40.5+/-14.5 and FEF25-75 by 54.7+/-14.4% (P < 0.01 for all parameters). This reduction was accompanied by de-saturation, hyperpnoea, tachycardia and a response to bronchodilators.

CONCLUSION

Determination of PC20-FEV1 by spirometry is feasible in many preschool children. PC20-FEV1 often appears at lower provocation dose than PCW. The lower dose may shorten the test and encourage participation. Significant decrease in spirometry indices at PCW suggests that PC20-FEV1 determination may be safer.

Aerosol delivery to young children by pMDI-spacer: is facemask design important?

This study aimed at identifying in a daily-life setting the influence of facemask design on drug delivery via a spacer to young children. In a 4-week randomized crossover study, 24 children (7-23-months old) with recurrent wheeze tested the AstraZeneca, Galemed, and Hans Rudolph facemask combined with the NebuChamber at home. Each mask was tested twice daily for seven consecutive days. Filters positioned between the NebuChamber and facemask trapped the budesonide aerosol (200 microg, Pulmicort). Parents were asked to score the child's degree of cooperation during administration on diary cards. The administration procedure was evaluated through video recordings. Mean filter dose (standard deviation (s.d.)), expressed as % of nominal dose, was 39% (14), 47% (12), and 42% (11) for the AstraZeneca, the Galemed and the Hans Rudolph mask, respectively. Irrespective of the degree of cooperation, the Galemed mask gave significantly higher mean filter doses than the other masks (level of significance) (p < 0.045). Median (range) within-subject dose variability, expressed, as coefficient of variation (CV), was 37% (19-255), 32% (9-114), and 30% (9-115) for the AstraZeneca mask, the Galemed mask and the Hans Rudolph mask, respectively, not significant. Dose variability increased with decreasing cooperation for all three masks (p = 0.007). Drug delivery to young children with recurrent wheeze by means of the NebuChamber can be enhanced using the Galemed facemask. Dose variability seems to be independent of facemask design but mainly depends on cooperation.

Vocal cord dysfunction: an uncommon cause of stridor

We present a case of vocal cord dysfunction syndrome (VCDS) presenting as acute angioedema of the upper airway. The presentation of this syndrome and its differentiation from other upper airway conditions that require far different and more urgent treatment is discussed.

A comparative study of bronchodilator reversibility with albuterol, between asthma symptomatic and asymptomatic children according to ISAAC questionnaire in Mexico City

BACKGROUND

Asthma is an important childhood disease. Recent surveys of the International Study of Asthma and Allergies in Childhood (ISAAC) suggest that the prevalence of asthma is increasing but these surveys do not include any pulmonary tests to confirm the possible diagnosis of asthma.

OBJECTIVE

To compare bronchodilator reversibility with the albuterol test in symptomatic and asymptomatic 6-7-year-old children with asthma participating in the ISAAC survey and living in Mexico City.

PATIENTS AND METHODS

We performed an observational, descriptive, comparative, cross sectional study in children participating in phase 3b of the ISAAC study. According to the ISAAC questionnaire children were classified as asthma symptomatic or asymptomatic. Both groups had bronchodilator reversibility with the albuterol test, using the guidelines of the American Thoracic Society to confirm or rule out the diagnosis of asthma.

RESULTS

The asymptomatic group had a baseline FEV1 of 1.70 +/- 0.34 l/sec (mean +/- SD) and an endpoint FEV1 of 1.76 +/- 0.42 l/sec; in the symptomatic group the respective values were 1.51 +/- 0.41 l/sec and 1.57 +/- 0.44 l/sec (p < 0.05). A positive reversibility test was found in 13/136 (9.6 %) children in the asymptomatic group and in 22/112 (19.6 %) children in the symptomatic group (p < 0.05).

CONCLUSION

Because of its low sensitivity, bronchodilator reversibility cannot be considered a diagnostic tool to confirm diagnosis of asthma.

Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing

The jet nebulizer is a common device used for administering aerosol medication in young children. However, compared to a metered dose inhaler-spacer (MDI-spacer), it takes more time and personnel. This study aimed to compare the efficacy of salbutamol aerosol therapy given via these two devices in young wheezing children. A prospective randomized, double-blind, placebo-controlled trial was performed in children up to 5 years old who had acute wheezing and were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital. Patients were randomly divided into two groups. The first group received 2 puffs of placebo via MDI-spacer, followed by 0.15 mg/kg salbutamol respiratory solution via jet nebulizer. The second group received 2 puffs (100 microg/puff) of salbutamol via MDI-spacer, followed by placebo via jet nebulizer. Clinical scores and tidal breathing pulmonary function test were evaluated before and after treatment. Pulmonary function parameters included those derived from flow volume loops (volume to peak tidal expiratory flow over total expiratory volume, V(PTEF)/V(E); time to peak tidal expiratory flow over total expiratory time, T(PTEF)/T(E); and ratio of tidal expiratory flow at 25% remaining expiration to peak expiratory flow, 25/PF), compliance (Crs), and resistance (Rrs) of the respiratory system. The efficacy of both methods was compared by using analysis of covariance. Forty-seven wheezing children were studied (24 received salbutamol via MDI-spacer, and 23 received it via jet nebulizer). There was no statistical difference between the two groups regarding clinical scores and all pulmonary function parameters. However, heart rate was significantly increased after treatment in the jet nebulizer group when compared to those in the MDI-spacer group (P = 0.004). In conclusion, the efficacy of salbutamol aerosol therapy via MDI-spacer compared to jet nebulizer in young wheezing children was not different in terms of clinical score and postbronchodilator pulmonary function parameters. However, salbutamol aerosol therapy via jet nebulizer significantly increased the heart rate when compared to the MDI-spacer.

Levocetirizine in 1 – 2 year old children: pharmacokinetic and pharmacodynamic profile

BACKGROUND

Levocetirizine is an antihistamine with high affinity and selectivity for H1-receptors, which exhibits an excellent benefit/risk ratio in the treatment of allergic rhinitis and urticaria. This is the first study performed with this drug in very young children.

OBJECTIVE

The aim of this study was to confirm the intended regimen of levocetirizine (0.125 mg/kg twice a day) for further studies in children aged 12-24 months.

MATERIAL AND METHODS

The pharmacokinetic/pharmacodynamic profile of levocetirizine was studied in 15 toddlers suffering from recurrent cough and other allergy-related symptoms, aged 20.7 +/- 3.7 months, and treated twice a day with 0.125 mg/kg for 90 days. A histamine-induced wheal and flare test (W&F) was performed prior to treatment. Blood was sampled at 1, 2, 4, 6, 9 and 12 hours after the first dose. Twelve hours after the evening dose on Days 3-6, and on day 90, a histamine-induced wheal and flare test was repeated and a blood sample was taken for trough value assessment.

RESULTS

A peak plasma level of 286 +/- 68 ng/ml was observed after one hour. The elimination half-life was 4.1 +/- 0.7 hours, the apparent body clearance 1.05 +/- 0.10 ml/min/kg, and the apparent volume of distribution 0.37 +/- 0.06 l/kg. Morning trough values at Days 3-6, and at Day 90 were respectively 78 +/- 30 ng/ml and 110 +/- 86 ng/ml. The median inhibition of the wheal was 100% at Days 3-6, and Day 90. That of the flare was 99.6% at Days 3-6, and 98.9% at Day 90. The overall safety profile of this three-month open study was good.

CONCLUSION

This first study with levocetirizine in children aged 12-24 months shows the adequate pharmacokinetic/pharmacodynamic profile and the good safety profile of 0.125 mg/kg levocetirizine given twice a day, which can be proposed for further studies in this age group.

Safety of budesonide inhalation suspension in infants aged six to twelve months with mild to moderate persistent asthma or recurrent wheeze

OBJECTIVE

To compare the safety of budesonide inhalation suspension (BIS) with placebo in infants 6 to 12 months of age with mild to moderate persistent asthma or recurrent wheeze.

STUDY DESIGN

In this multicenter, randomized, double-blinded, parallel-group, placebo-controlled study, 141 patients received 0.5 mg BIS (n = 48), 1.0 mg BIS (n = 44), or placebo (n = 49) once daily for 12 weeks. The primary variable was adrenal function, based on cosyntropin-stimulated plasma cortisol levels. Spontaneous adverse events and clinical laboratory findings also were monitored.

RESULTS

Overall, the types and frequencies of adverse events reported during the study were comparable across treatment groups. The response to cosyntropin stimulation was similar across treatment groups, with no significant difference between BIS treatment and placebo.

CONCLUSIONS

The safety profile of BIS was similar to that of placebo, with no suppressive effect on adrenal function in patients 6 to 12 months of age with mild to moderate persistent asthma or recurrent wheeze.

Infantile wheezing and bronchodilator treatment

Wheezing is a symptom, not a diagnosis. Wheezing disorders are not equal to childhood asthma. Wheezing in the youngest children is often episodic, associated with upper respiratory infection. Early wheezing disorders, particularly in the first 2-3 years of life, should be considered as largely independent of later childhood asthma. It is difficult to distinguish an initial episode of asthma triggered by a viral respiratory infection from acute viral bronchiolitis. Most of the infants with wheezing have transient conditions associated with diminished airway function at birth and do not have increased risks of asthma or allergies later in life. There is no evidence for an overall beneficial clinical effect of nebulized a2-agonists in acute severe wheezing episodes or acute bronchiolitis in infants, although some may seem to respond.

Efficacy of fluticasone propionate on lung function and symptoms in wheezy infants

The role of inhaled corticosteroids in the treatment of recurrent or persistent wheeze in infancy remains unclear. We evaluated the effect of 3 months of treatment with inhaled fluticasone propionate, 200 microg daily (FP200), on lung function and symptom scores in wheezy infants. Moreover, we evaluated whether infants with atopy and/or eczema respond better to FP200 as compared with non-atopic infants. Forced expiratory flow (Vmax(FRC)) was measured at baseline and after treatment. Sixty-five infants were randomized to receive FP200 or placebo, and 62 infants (mean age, 11.3 months) completed the study. Mean Vmax(FRC), expressed as a Z score, was significantly below normal at baseline and after treatment in both groups. The change from baseline of Vmax(FRC) was not different between the two treatment arms. After 6 weeks of treatment, and not after 13 weeks, the FP200 group had a significantly higher percentage of symptom-free days and a significant reduction in mean daily cough score compared with placebo. Separate analysis of treatment effect in infants with atopy or eczema showed no effect modification. We conclude that in wheezy infants, after 3 months of treatment with fluticasone, there was no improvement in lung function and no reduction in respiratory symptoms compared with placebo.

Comparison of clinical outcome with oral and inhaled bronchodilators in the management of wheezy children aged 1-59 months in the community: a randomised trial in Pakistan

BACKGROUND

Wheeze is a significant problem in children. There is a gradual trend of switching from oral to inhaled bronchodilator therapy. No randomised trials have been carried out in the community to compare the clinical outcome of two modes of therapy. If outcome with oral and inhaled bronchodilators is the same in young wheezers in developing countries, it will be easier to manage them.

METHODS

In a randomised multicentre trial, wheezy children aged 1-59 months with fast breathing and/or lower chest indrawing received oral or inhaled salbutamol at home after responding to up to three cycles of inhaled bronchodilators. They were re-assessed on days 3 and 5 for clinical outcome.

RESULTS

From May 2001 to August 2002, 780 children were enrolled; 390 each were randomised to oral and inhaled salbutamol. On day 5, 324 (83.1%) children in the oral and 328 (84.1%) in the inhaled group were completely well. There were no differences in clinical outcome of both modes of therapy.

CONCLUSIONS

The clinical outcome of children aged 1-59 months with wheeze is similar when treated with oral or inhaled salbutamol. Acute respiratory infection control programmes in developing countries should continue to use oral bronchodilators for the management of wheeze to save both time and money.

The response to β-agonists in wheezy infants: three methods compared

BACKGROUND

Studies into the effects of salbutamol in the treatment of wheeze in infancy have been conflicting, possibly due to differences in outcome variables. We aimed to assess the response to salbutamol using indices derived from passive and forced expiration.

METHODS

We recruited 39 infants who had a history of wheezing (mean age 43 weeks) and measured maximum flow at functional residual capacity (V'(max FRC)) by rapid thoracoabdominal compression (RTC), and forced expired volume at 0.4s (FEV0.4) using the raised-volume RTC technique (RV-RTC). We calculated passive compliance (C(rs)), resistance (R(rs)) and time constant (tau) from relaxed expirations that followed the augmented inspirations delivered during RV-RTC. Measurements were repeated after aerosol salbutamol (800 mcg).

RESULTS

Data were obtained in 32 infants for V'(max FRC), 22 for FEV0.4 and 19 for passive mechanics. There were no mean changes in any index of forced expiration after salbutamol. Some individuals showed significant changes (improvement or worsening) in one or other index. Overall, there was a small increase in C(rs) after salbutamol but no change in R(rs) or tau.

CONCLUSIONS

We found no consistent pattern of response in either index of forced expiration. Validated clinical scores or alternative physiological techniques may be preferable to respiratory mechanics in assessing bronchodilator response.

Inhaled fluticasone dipropionate decreases levels of nitric oxide in recurrenty wheezy infants

We examined the effect of inhaled fluticasone diproprionate (FDP) on symptoms, lung function (FEV(0.5)), and exhaled nitric oxide (Fe(NO)) in infants with recurrent wheeze and raised Fe(NO). Thirty-one infants aged 6-19 months (mean, 12.7 months; 12 girls) completed the study. All infants had a history of recurrent wheeze and a parental history of atopy. All children had raised Fe(NO), as determined by an offline tidal breathing technique prior to randomization. Lung function and Fe(NO) were assessed before and after 4 weeks of treatment with FDP or placebo. The parents recorded daily symptoms during the treatment period. Sixteen infants received FDP and 15 the placebo for 4 weeks. At completion of the study, infants treated with FDP had a significant reduction in Fe(NO) (35.0 ppb to 16.5 ppb) compared to those that received placebo (35.2 ppb to 30.2 ppb) (P = 0.05). Small increases in FEV(0.5) were observed in both groups, but these changes were not different between groups (P = 0.8). Symptom scores were not significantly different in either group following the intervention. We showed that a moderate dose of inhaled FDP reduces levels of Fe(NO), a potential marker of airway inflammation, even in the absence of significant changes in lung function and symptoms.

beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis

OBJECTIVE

To compare the efficacy of beta-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 beta-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 beta-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, -0.44; 95% CI, -0.68 to -0.20; 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 beta-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma.

Paradoxical vocal cord motion: an often misdiagnosed cause of postoperative stridor

This conference reports a case of acute functional airway obstruction occurring in the postoperative anesthesia care unit, which was diagnosed by fiberoptic laryngoscopy and successfully treated with intravenous midazolam after other more common causes of stridor were ruled out. The presentation, etiology, diagnosis, and treatment of paradoxical vocal cord motion as it relates to the care of the postoperative patient are discussed.

Prevalence of asthma and exhaled nitric oxide are increased in bleachery workers exposed to ozone

The aims of the present study were to determine whether exposure to high peaks of ozone resulted in an increased prevalence of asthma or respiratory symptoms among bleachery workers and whether nitric oxide (NO) was elevated in the exhaled air of these workers. Bleachery workers (n=228) from three Swedish pulp mills who had been exposed to ozone, together with 63 unexposed control subjects, were investigated by means of spirometry, Phadiatop, exhaled and nasal NO and answers to a questionnaire concerning respiratory symptoms and exposure. Exposure to an ozone peak that gave rise to respiratory symptoms was defined as a "gassing". Bleachery workers reporting four or more gassings involving ozone had an increased prevalence of adult-onset asthma, wheeze, and current asthma symptoms. They also had a higher median concentration of exhaled NO in comparison with those who reported no such gassings (19.2 versus 15.7 parts per billion). No such associations were found in respect of nasal NO. The results from this study show that bleachery workers who have been repeatedly exposed to ozone gassings have an increased prevalence of adult-onset asthma. The results also indicate exhaled nitric oxide may be a marker of airway inflammation in bleachery workers who have been exposed to high peaks of ozone.

Pseudoseizures and hysterical stridor

Differentiation of pseudoseizures from epileptic seizures and hysterical stridor from asthma is key to the treatment of patients. Both pseudoseizures and hysterical stridor are associated commonly with sexual abuse, eating disorders, depression, substance abuse, anxiety disorders, and personality disorders. Failure to reach an appropriate diagnosis results in inappropriate medical care including recurrent intubations, antiepileptic drugs, and excessive hospitalizations. This case represents the first instance of reported pseudoseizures in a patient with hysterical stridor secondary to childhood sexual abuse.

How long does stridor at rest persist in croup after the administration of oral prednisolone?

OBJECTIVES

To determine the duration of stridor at rest (SAR) after the administration of oral prednisolone (1 mg/kg) to children admitted to hospital with croup from the ED. The secondary objective was to determine whether children with mild croup had a more rapid resolution of SAR.

METHODS

This was a retrospective explicit chart review of all children admitted to the paediatric ward of a community, paediatric teaching hospital with a diagnosis of croup over one year. Data collected included patient demographics, Westley and Geelhoed croup scores on presentation to the ED and the duration of SAR after administration of steroids.

RESULTS

For the 188 cases analyzed, median duration of SAR was 6.5 h (95% CI 6-7 h, range 0.5-82 h). Children with a Westley score of < or = 2 or a Geelhoed score of < or = 3 had a shorter duration of SAR than those with higher scores (6 h vs. 7 h, P < 0.05), which although statistically significant is unlikely to be of clinical significance.

CONCLUSIONS

Stridor at rest resolves promptly after the administration of oral steroids in the vast majority of cases. This suggests that a subset of patients previously admitted to hospital with croup may be able to be treated and discharged from the ED.

Slow release of bone morphogenetic protein 2 from a gelatin sponge to promote regeneration of tracheal cartilage in a canine model

OBJECTIVES

We investigated whether bone morphogenetic protein 2, released slowly from a gelatin sponge, could induce cartilage regeneration in a canine model of tracheomalacia and evaluated the long-term results.

METHODS

A 1 x 5-cm gap was made in the anterior cervical trachea by removing 5-cm long strips of 10 sequential cartilagines. In the control group (n = 5), the gaps were left untreated. In the gelatin sponge group (n = 5), a gelatin sponge soaked in a buffer solution was implanted in each defect. In the bone morphogenetic protein group (n = 5), a gelatin sponge soaked in a buffer solution containing 12 microg bone morphogenetic protein 2 was implanted in each defect.

RESULTS

Tracheomalacia was observed in the control and gelatin sponge groups but not in the bone morphogenetic protein group. No regenerated cartilage was detected in the control or gelatin sponge groups, even 6 months after surgery. In contrast, regenerated cartilage, which had developed from the host perichondrium, was observed around the stumps of the resected cartilagines in the bone morphogenetic protein group. This regenerated cartilage maintained the integrity of the internal lumen for longer than 6 months. A compressive fracture test revealed that the tracheal cartilage in the bone morphogenetic protein group was significantly more stable than that in the gelatin sponge and control groups (P =.0015 and P =.0001, respectively).

CONCLUSIONS

In this canine model of tracheomalacia, cartilage regeneration was induced around the stumps of tracheal cartilagines by bone morphogenetic protein 2 released slowly from a gelatin sponge. This regenerated cartilage was not reabsorbed for longer than 6 months and was strong enough to maintain the integrity of the internal lumen of the trachea.

Twelve-month safety and efficacy of inhaled fluticasone propionate in children aged 1 to 3 years with recurrent wheezing

OBJECTIVE

Our aim was to compare the 12-month safety and efficacy of fluticasone propionate (FP) and sodium cromoglycate (SCG) in children aged 1 to 3 years with mild to moderate recurrent wheeze.

METHODS

The study was a randomized, parallel-group, open-label multicenter study of 625 children, aged 1 to 3 years, with recurrent wheeze randomized in a 3:1 ratio to treatment for 52 weeks with FP (100 microg twice daily) via metered-dose inhaler and Babyhaler spacer device or SCG (5 mg 4 times daily) via metered-dose inhaler and Nebuhaler spacer device, respectively.

RESULTS

There was no significant difference in mean adjusted growth rates between the 2 groups: 84.0 mm/year in the FP group versus 86.4 mm/year in the SCG group (difference FP-SCG: -2.4 mm/year; 95% confidence interval: -6.6 to 1.8). Growth comparisons were independent of age, gender, previous use of steroid, or whether measured as length and/or height. Serum and urinary cortisol concentrations showed a statistically significant suppression of 10% and 14%, respectively, but the number of patients with serum cortisol levels below the lower normal limit was reduced during the trial. Both treatments were well tolerated. The most common drug-related adverse events were cough (2% FP vs 1% SCG) and hoarseness (1% FP vs 0% SCG). One incident of cataract was observed at baseline and 1 after FP treatment; the latter had resolved after 12 months. The efficacy of FP was superior to SCG with fewer cases of symptom worsening, exacerbations, and requirements for oral steroid treatment and more symptom-free days and days without use of rescue treatment.

CONCLUSIONS

Twelve months of treatment with inhaled FP (100 microg twice daily) in preschool children aged 1 to 3 years with recurrent wheeze has no effect on growth and no other clinically important side effects but is more efficacious than SCG.

A randomised crossover trial of facemask efficacy

The efficacy of different facemasks that can be used in the delivery of aerosol medication to children with recurrent wheeze or asthma was investigated. The results showed a statistically significant difference between some of the masks used, which has important implications for current clinical practice

Ketotifen alone or as additional medication for long-term control of asthma and wheeze in children

BACKGROUND

Ketotifen is an antihistamine which may be used to treat asthma. Since administering inhaled therapy to younger children can be difficult, an oral agent such as ketotifen offers potential advantages.

OBJECTIVES

The objective of this review is to determine, whether ketotifen alone or in combination with other co-interventions results in better control of asthma in children with asthma and/or wheezing and examine its safety profile.

SEARCH STRATEGY

We searched the Cochrane Airways Group register of trials (based on MEDLINE, EMBASE, CINAHL and handsearched respiratory journals) and reference lists of articles. The latest search was carried out in October 2002.

SELECTION CRITERIA

Clinical studies had to be randomised-controlled and double-blinded, comparing oral ketotifen with placebo in children with asthma and/or wheeze for at least eight weeks at a dose not less than one mg daily.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed selection of trials, quality assessment and data extraction; a third reviewer was included in the consensus process if necessary.

MAIN RESULTS

A total of 26 relevant studies involving 1826 participants were included in this review. Children's age ranged from 4 months to 18 years and ketotifen was given between 10 and 32 weeks. The proportion of children able to reduce or stop their bronchodilator use within 12 to 16 weeks of treatment was significantly higher in the ketotifen group (relative risk 2.39, 95% CI 1.64 to 3.48) based on four trials; this result was statistically significant in a subgroup of two trials with well described and adequate method of blinding. Statistically significant beneficial effects of ketotifen were also observed in the following secondary outcomes: efficacy evaluated by physician (10 trials) and parents/patients (7 trials), asthma symptom score (4 trials), asthma exacerbations (2 trials), and reduction in use of oral steroids (4 trials). However, sub-group analyses of trials with well described and adequate method of blinding was only significant for the outcome asthma symptom score and non-significant for the remaining secondary outcomes. Reported side effects were more frequent in the ketotifen group (sedation: 21%, weight gain: 27%) than in the placebo group (sedation: 12%, weight gain: 17%).

REVIEWER'S CONCLUSIONS

Evidence from randomised controlled trials indicates that ketotifen alone or in combination with other co-interventions improves control of asthma and wheezing in children with mild and moderate asthma. However due to the high proportion of children with atopy in some trials the results cannot necessarily be generalised to all asthmatic children. The benefit is obtained at the cost of minor side effects, namely sedation and weight gain. The validity of this conclusion is limited by the low reported, methodological quality of included trials.

[Beta 2 agonists in infants and young children with a wheeze: often ineffective]

Wheezing is a common symptom in infants and young children, for which the treatment of choice is beta 2-agonists. However, the efficacy of beta 2-agonists in children aged 2 years and younger is not evidence based. Approximately 60% of wheezy infants do not have asthma, but a transient condition related to airway obstruction that is associated with coughing, wheezing and/or stuffiness: so-called infant asthma. In infants, beta 2-agonists may make the airways more compliant, resulting in more severe airway obstruction. In addition to this, beta 2-agonists increase the metabolism and cause ventilation-perfusion mismatch in the lung which may lead to a decrease in the oxygen saturation. Since it is unclear which infants will benefit from beta 2-agonists, a trial treatment is justified and this should be critically evaluated. Beneficial clinical effects of beta 2-agonists are a reduction in breathing frequency, reduction in or disappearance of retractions or the use of accessory respiratory muscles during breathing and possibly an increase in oxygen saturation. beta 2-agonists are effective and safe for the treatment of asthma. However, there is no basis for continuing the treatment in the case of infants and young children with an airway obstruction unless there is a clinically favourable effect.

Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial

BACKGROUND

Episodic wheeze triggered by viral colds is common in children aged between 1 and 5 years (preschool viral wheeze). Most affected children are asymptomatic by age 6 years. Persistence of wheeze is associated with above-average systemic eosinophil priming. Use of parental-initiated oral prednisolone is recommended at the first sign of preschool viral wheeze. However, evidence for this treatment strategy is conflicting. We therefore aimed to assess the efficacy of a short course of oral prednisolone for preschool viral wheeze, with stratification for systemic eosinophil priming.

METHODS

Children aged 1-5 years admitted to hospital with viral wheeze were allocated to either a high-primed or low-primed stratum according to amounts of serum eosinophil cationic protein and eosinophil protein X, and randomised to parent-initiated prednisolone (20 mg one daily for 5 days) or placebo for the next episode. The primary outcomes were the 7-day mean daytime and night-time respiratory symptom scores, which were analysed by mean differences between treatment groups.

FINDINGS

108 children were randomised to placebo and 109 to prednisolone. Outcome data were available for 120 (78%) of 153 children who had a further episode of viral wheeze, of whom 51 received prednisolone and 69 placebo. Mean daytime (difference in means -0.01 [-0.22 to 0.20]) and night-time (0.10 [-0.12 to 0.32]) respiratory symptom scores and need for hospital admission did not differ between treatment groups. Within the high-primed (n=59) and low-primed (n=61) strata there was no difference in primary outcome between treatment groups.

INTERPRETATION

There is no clear benefit of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years even in those with above-average eosinophil priming.

[Metered-dose inhalers with home-made spacers versus nebulizers to treat moderate wheezing attacks in children]

OBJECTIVE

To compare the effectiveness of salbutamol administration by metered-dose inhaler with a home-made spacer versus jet nebulizer in children with moderate wheezing attacks.

MATERIAL AND METHODS

A randomized, single-blinded trial was performed with a convenience sample of children presenting wheezing. The children were enrolled in an emergency room and randomly assigned to one of two treatment groups: home-made spacer group or nebulizer group. Clinical scores and oxygen saturation were recorded at baseline and 15 minutes after salbutamol administration. Treatment with salbutamol (100 microg/3 kg in the spacer group, and 250 microg/3 kg in the nebulizer group) was repeated at 20-minute intervals, until the child was considered to have improved significantly, with no need of any further dose, or until three doses were delivered. Treatment cost, time spent to prepare and deliver the drug, and level of parental satisfaction with the treatment were recorded.

RESULTS

Fifty-four children with age between 22 days and 11.7 years were enrolled--27 in each group. Baseline and demographic characteristics were similar for both groups. The spacer was as effective as the nebulizer in terms of clinical score and oxygen saturation. The different doses (100 microg/3 kg with the spacer, and 250 microg/3 kg with the nebulizer) were shown to be clinically equivalent. Treatment cost was significantly lower in the spacer group, as was the time to prepare and deliver the drug. Parental satisfaction was similar for both inhaler devices.

CONCLUSION

The home-made spacer with a metered-dose inhaler is a cost-effective alternative to a jet nebulizer in the delivery of salbutamol to children with moderate wheezing attacks.

[Clinical and transcutaneous oxygen saturation characteristics in hospitalized infants with acute viral bronchiolitis]

OBJECTIVE

To describe the clinical characteristics of infants with acute viral bronchiolitis (AVB) and to assess the influence of oxygen desaturation time (DT) as a prognostic test to estimate the evolution of such patients.

METHODS

We performed a cohort study with 111 hospitalized patients diagnosed with AVB receiving oxygen therapy through nasal prong. The outcomes were: length of admission, length of oxygen therapy and time elapsed to read 95% saturation in room air. A severity score was obtained twice a day based on clinical signs during the time when the patient required oxygen supplementation. After the supply of oxygen was interrupted, the time required for transcutaneous oxygen saturation decreased to 90% and 85%. The Chi2 test or Fisher's exact test were used to compare categorical variables. The t test or Mann-Whitney's test were used for numerical variables. Spearman's correlation was used to evaluate associations in continuous variables with asymmetric distribution.

RESULTS

Most patients (61.3%) were younger than 4 months. Patients with wheezing history (45%) were analyzed separately and had similar results to those of the group with AVB (p< or =0.05). Twenty-six patients (23%) had moderate or severe malnutrition. All patients were using bronchodilators; 20% were using systemic corticosteroids; and 47%, antibiotics. The median time of oxygen therapy required for a reading of 95% oxygen saturation in room air was 83 hours (IQI 55-128). The median of length of admission was 7 days (IQI 5-10.5). Little clinical variability was observed in the period studied. No significant correlations were found between the clinical scores, DT and the outcomes.

CONCLUSION

DT was not useful as an aid to assess AVB patients on oxygen therapy in this study. It is possible that this tool could have been more useful in patients with more clinical variability.

Soluble E-selectin and soluble ICAM-1 levels as markers of the activity of atopic dermatitis in children

The expression of adhesion molecules is up-regulated in the skin of atopic dermatitis (AD) patients, and the levels of the soluble adhesion molecules sE-selectin and sICAM-1 have been reported to reflect the endothelial activation in the skin of AD patients. The objective of the study was to investigate the relationship between symptom score and levels of sE-selectin, sICAM-1 and sVCAM-1 before and after 2 weeks of treatment. Eighteen children with an exacerbation of AD were admitted and treated with corticosteroid dilutions under occlusive wet dressings (wet-wrap treatment). Symptom score (objective SCORAD) and levels of sE-selectin, sICAM-1, and sVCAM-1 were assessed before and after 2 weeks of treatment. A significant correlation between the objective SCORAD before treatment and the level of sE-selectin (p < 0.05), but not the level of sICAM-1 (p = 0.7) or sVCAM-1 (p = 0.5) was observed. The treatment resulted in a high degree of remission, which was reflected by a significant decrease in the level of sICAM-1 (p < 0.01), whereas there was only a trend in the level of sE-selectin to decrease (p = 0.08). The level of sE-selectin after 2 weeks of treatment still correlated significantly with the objective SCORAD before treatment (p < 0.005). Soluble E-selectin is a relative objective marker for the severity of AD. SCORAD is a treatment-sensitive symptom of AD, whereas E-selectin may be a more stable underlying systemic representation of AD.

[The effectiveness of montelukast in recurrent post-bronchiolitis wheezing]

Some studies showed increased levels of leukotrienes in the nasopharyngeal secretions in children with wheezing secondary to viral infections, leading to therapeutical attempts with leukotriene receptor inhibitors in infants and small children with recurrent wheezing. This is a double blind randomized study for evaluating the efficacy of montelukast in infants and small children. In the study group (20 children) treated with montelukast, 5 mg/day for 3 months, the frequency of bronchial obstruction episodes in the 6 months following the start of therapy was significantly lower (p = 0.001) than the 6 months before treatment (1.25 +/- 1.41 versus 3.79 +/- 2.41). In the control group (18 children) treated with placebo, the frequency of the bronchial obstruction episodes decreased (from 3.04 +/- 1 to 2.41 +/- 1.5) in the two analyzed periods, but the differences were not statistically significant (p = 0.067). The differences between the two groups are present also after excluding the children with atopy. The results suggest the beneficial role of leukotriene receptor antagonists in improving the symptoms of patients with recurrent post-bronchiolitis wheezing.

Anticholinergic agents for the treatment of "death rattle" in patients with myasthenia gravis

Difficulty clearing upper airway secretions (death rattle) is a frequent problem at the end of life. Treatment often includes the use of anticholinergic drugs. Myasthenia gravis is a disease characterized by muscle weakness and fatigue caused by an immune-mediated deficiency of acetylcholine receptors at the neuromuscular junction, and it is treated with anticholinesterase agents. We report the case of a patient dying of myasthenia gravis who had problems with the "death rattle" and who presented a dilemma as to whether the use of anticholinergics would be helpful or would cause deterioration of her myasthenia. This is accompanied by a review of the relevant literature.

Airway difficulty after a brachial plexus subclavian perivascular block

IMPLICATIONS

We report a case of upper airway obstruction after subclavian perivascular block in a patient with a preexisting unrecognized paralyzed vocal cord on the opposite side. We discuss the incidence of vocal cord paralysis after subclavian perivascular block and the risk of airway compromise if contralateral vocal cord paralysis is known or suspected.

Anti-inflammatory treatment for recurrent wheezing in the first five years of life

Medications identified for the treatment of recurrent wheezing in preschool children by the Expert Panel Report of the NHLBI Guidelines for the Diagnosis and Management of Asthma include inhaled corticosteroids, chromones, theophylline, and leukotriene pathway modifiers. However, these various agents differ in their mechanism, extent of action on the airway inflammatory process, and degree of clinical efficacy. Inhaled corticosteroids can control symptoms in many young children with even severe persistent wheezing, but data on their long-term safety when administered in preschool-age children are scarce. There is some information on the uninterrupted use of inhaled corticosteroids in school-age children and the absence of an adverse effect on ultimate adult height. Despite laboratory evidence of adrenal suppression in some studies, few pediatric cases of clinical adrenal insufficiency have been reported. Low-dose inhaled corticosteroid (<400 mcg/day for beclomethasone), which is adequate for controlling mild persistent symptoms, is generally safe. Chromones have a remarkable safety profile, but they are most effective for symptoms of mild severity. Promising data have been published on the efficacy and safety of leukotriene pathway modifiers when used in young children with persistent symptoms. It is uncertain whether early introduction and long-term administration of inhaled corticosteroids prevent development of irreversible airway obstruction. Nevertheless, they may be especially useful for patients with moderate to severe disease in whom other agents (chromones or leukotriene pathway modifiers) will most likely fail to control symptoms. Pediatr Pulmonol. 2003; 35:241-252.

Unresponsive wheezing to asthma therapy in a 32-year-old female

Repeat failure of any patient to respond to asthma therapy, particularly corticosteroids, should alert physicians to carry out further pulmonary evaluation. This will prevent unnecessary side effects of asthma therapy and provide prompt treatment for other diseases that may require urgent attention.

Nebulizers vs metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a pediatric emergency department

OBJECTIVE

To determine if administration of albuterol by a metered-dose inhaler with a spacer device is as efficacious as administration of albuterol by nebulizer to treat wheezing in children aged 2 years and younger.

DESIGN

Double-blind, randomized, placebo-controlled clinical trial.

SETTING

Pediatric emergency department.

PATIENTS

From a convenience sample of wheezing children aged 2 to 24 months, 85 patients were enrolled in the nebulizer group and 83 in the spacer group.

INTERVENTIONS

The nebulizer group received a placebo metered-dose inhaler with a spacer followed by nebulized albuterol. The spacer group received albuterol by a metered-dose inhaler with a spacer followed by nebulized isotonic sodium chloride solution. Treatments were given every 20 minutes by a single investigator blinded to group assignment.

MAIN OUTCOME MEASURES

The primary outcome was admission rate. Pulmonary Index score and oxygen saturation were measured initially and 10 minutes after each treatment.

RESULTS

The nebulizer group had a significantly higher mean (SD) initial Pulmonary Index score compared with the spacer group (7.6 [2.5] vs 6.6 [2.0]; P =.002). With the initial Pulmonary Index score controlled, children in the spacer group were admitted less (5% vs 20%; P =.05). Analyses also revealed an interaction between group and initial Pulmonary Index score; lower admission rates in the spacer group were found primarily in children having a more severe asthma exacerbation.

CONCLUSION

Our data suggest that metered-dose inhalers with spacers may be as efficacious as nebulizers for the emergency department treatment of wheezing in children aged 2 years or younger.

[Heliox in pediatrics]

Heliox is composed of oxygen and helium and its low specific gravity allows a modification of the gas flow within the airway. Breathing heliox favors a laminar flow and therefore decreases the work of breathing. Its usefulness in the child is established in croup or in post-extubation stridor. It can be considered if conventional treatment fails to improve the child's breathing pattern. Its major goal is to avoid invasive manoeuvers as much as possible.

Randomized controlled trial of fluticasone in preschool children with intermittent wheeze

Preschool children with intermittent wheeze are often prescribed inhaled corticosteroids, although there is no proven benefit. Measurement of airway resistance by the interrupter technique can be used to objectively assess response to treatment. If lung function improves, treatment may be justified. Children with intermittent wheeze aged 2 to <or= 5 years of age completed a 6-week randomized controlled crossover trial of fluticasone propionate (100 micro g, twice daily), followed by a 10-week parallel extension. The relationships between changes in resistance, serum immunoglobulin E and sensitization measured by skin prick testing were investigated. Sixty-one children completed the crossover trial and 44 (72%) completed the extension. After 6 weeks, geometric mean change in resistance was -16.0% (95% confidence interval, -7.0 to -25.0%, p = 0.003) in sensitized children and -3.5% (95% confidence interval, +0.7 to -7.6%, p = 0.1) in nonsensitized children. Changes in resistance were unrelated to immunoglobulin E. Sixteen weeks after stopping fluticasone, resistance returned to baseline. This is the first study of preschool children with intermittent wheeze that has related changes in lung function on treatment to aeroallergen sensitization. Lung function improved in sensitized children and deteriorated after stopping treatment. Treatment with inhaled steroids may be justified in sensitized children.

Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care

The management of 'death rattle' was reviewed by a task group on behalf of the Association for Palliative Medicine's Science Committee. Evidence was searched for the effectiveness of various anti-muscarinic drugs in drying oropharyngeal and bronchial secretions in dying patients. Clinical guidelines were constructed based on evidence from volunteer and clinical studies. Death rattle occurs in half of all dying patients and some response occurs in around 80% of treated patients. Clinical studies demonstrate that subcutaneous hyoscine hydrobromide 400 microg is more effective at improving symptoms at 30 min than glycopyrronium 200 microg by the same route. Volunteer studies demonstrate that intramuscular glycopyrronium 400 microg is as effective in drying secretions at 30 min as a dose of 200 microg given intravenously. Duration of response is shortest for hyoscine butylbromide (1 h) and longest for glycopyrronium (more than 6 h). There is insufficient evidence to support the use of one drug over another in a continuous infusion and prescribers should base decisions on different characteristics of each anti-muscarinic drug.

Xylazine-induced attenuation of dorsal displacement of the soft palate associated with epiglottic dysfunction in a horse

An 18-month-old Quarter Horse filly was evaluated because of dorsal displacement of the soft palate associated with epiglottic dysfunction that caused exercise intolerance and an abnormal respiratory noise. The abnormality of the epiglottis was corrected by use of a sedative dose of xylazine hydrochloride. There was no familial predisposition to hyperkalemic periodic paralysis, which may cause similar laryngopharyngeal signs, and the horse did not respond to administration of acetazolamide. There was no known history of trauma that could have caused neuritis, which has also been suggested as a cause of laryngeal dysfunction. It was unusual that a complete response was obtained with xylazine hydrochloride, an alpha2-adrenergic agonist, although this drug has various effects on the respiratory tract in horses. It was also unusual that the response outlasted the sedative effect of the drug.

Detection of wheezing during maximal forced exhalation in patients with obstructed airways

STUDY OBJECTIVES

Wheezing is a common clinical finding in patients with asthma and COPD during episodes of severe airway obstruction, and can also be heard in normal subjects during forced expiratory maneuvers; however, the properties of wheezing are difficult to perceive and quantify during auscultation. We therefore developed and evaluated a new technique for recording and analyzing wheezing during forced expiratory maneuvers in a group of patients with obstructed airways (asthma, COPD) and a control group of healthy subjects.

MATERIAL AND METHODS

Sixteen patients with asthma (9 men and 7 women), 6 patients with COPD (6 men), and 15 healthy subjects (7 men and 8 women) were enrolled. The patients had moderate-to-severe obstruction (FEV(1) of 40 to 53% predicted). A contact sensor on the trachea was used to record sound during forced expiratory maneuvers. Wheeze detection was carried out by a modified algorithm in a frequency-time space after applying the fast Fourier transform.

RESULTS

More wheezes were recorded in patients with obstructed airways than in control subjects: asthma patients, 8.4 +/- 6.4 wheezes; COPD patients, 10.4 +/- 6.1 wheezes; and control subjects, 2.9 +/- 2.0 wheezes (mean +/- SD). The mean frequency of all detected wheezes was higher in control subjects than in patients with obstructed airways (asthma patients, 560.9 +/- 140.8 Hz; COPD patients, 669.4 +/- 250.1 Hz; and control subjects, 750.7 +/- 175.7 Hz). The total number of wheezes after terbutaline inhalation changed more in patients with obstructed airways than in control subjects.

CONCLUSIONS

The new method that we describe for studying airway behavior during forced expiratory maneuvers is able to identify and analyze wheeze segments generated in patients with obstructed airways, as evidenced by the greater number of wheezes detected in the patient group, the main finding of this study. This method clearly and objectively identifies the presence of obstructive disease.

Beclomethasone dipropionate and salbutamol by metered dose inhaler in infants and small children with recurrent wheezing

The efficacy of beclomethasone dipropionate (BDP) to control respiratory symptoms was evaluated in 31 children under age 2 years with recurrent wheezing. The study was conducted in a double-blind, parallel, and placebo-controlled fashion. The two study groups received either salbutamol plus BDP 200 microg bid by metered dose inhaler (MDI) with a spacer, or salbutamol MDI plus a placebo. Inhaled corticosteroid (IC) and placebo were administered for 8 weeks. Patients were seen every 2 weeks as outpatients, and their progress was evaluated by clinical examination and a daily symptom score card. At the end of the study, patients in both groups had significantly decreased symptoms. No significant difference was found between BDP and placebo groups regarding clinical score, number of salbutamol doses, sleep disturbances, number of symptom-free days, feelings of insecurity of mothers regarding the infants' life due to wheezing, and mothers' perceptions of progress in their infants' respiratory symptoms. We conclude that salbutamol plus 200 microg bid of BDP inhaled from an MDI with a spacer for 8 weeks is no better than salbutamol alone for decreasing recurrent wheezing in small children under age 24 months.