An inexpensive spacer for use with metered-dose bronchodilators in young asthmatic children

Acute asthma management in children: knowledge of the topic among health professionals at teaching hospitals in the city of Recife, Brazil

OBJECTIVE

Knowledge of acute asthma management in children is a subject that has rarely been explored. The objective of this study was to assess the level of such knowledge among health professionals in the city of Recife, Brazil.

METHODS

This was a cross-sectional survey involving 27 pediatricians and 7 nurses, all with at least two years of professional experience, at two large pediatric teaching hospitals in Recife. The participants completed a self-administered multiple-choice questionnaire.

RESULTS

The pediatricians and nurses all possessed insufficient knowledge regarding the use of metered dose inhalers, nebulization, and types/doses of medications, as well as techniques for decontamination and disinfection of the equipment.

CONCLUSIONS

Insufficient knowledge of acute asthma management in children can lead to less effective treatment in hospitals such as those evaluated here. Educational programs should be developed in order to minimize this problem.

Commercial versus home-made spacers in delivering bronchodilator therapy for acute therapy in children

BACKGROUND

Strong evidence supports the use of metered-dose inhalers combined with a spacer for delivering rapid-acting inhaled beta-2 agonists in the treatment of acute exacerbations of asthma in children. The high cost and lack of availability of commercially produced spacers however, have limited their use in developing countries.

OBJECTIVES

The aim of this review was to compare the response to inhaled beta-2 agonists delivered through metered-dose inhaler using home-made spacers, to the use of commercially produced spacers, in children with acute exacerbations of wheezing or asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library Issue 3, 2007,(up to August 2007) MEDLINE , EMBASE, CINHAL, LILACS and reference lists of included studies. We contacted authors and known experts in the field, and approached pharmaceutical companies that manufacture inhalation spacers to identify additional published or unpublished data. No language restrictions were applied.

SELECTION CRITERIA

Trials comparing treatment with rapid acting beta 2-agonists delivered though MDI attached to home-made spacers, with the same bronchodilator therapy delivered with MDI and commercially produced spacers, in children under 18 years with acute exacerbations of wheezing or asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated from information available in published reports.

MAIN RESULTS

Six trials with 658 participants met the inclusion criteria . At the time of this report, five trials were published in full text, and one study was available in abstract form only. No significant differences were demonstrated between the two delivery methods in terms of need for hospital admission (RR 1.00, 95% CI 0.63 to 1.59), change in oxygen saturation (SMD -0.03, 95% CI -0.39 to 0.33), PEFR (SMD 0.04, 95% CI -0.72 to 0.80), clinical score (WMD 0.00, 95% CI -0.37 to 0.37), in terms of need for additional treatment (RR 1.18, 95% CI 0.84 to 1.65), or regarding change in heart rate per minute (SMD 0.09, 95% CI -0.24 to 0.42).

AUTHORS' CONCLUSIONS

Overall, this review supports did not identify a difference between these two methods for delivering bronchodilator therapy to children with acute asthma or lower airways obstruction attacks. Care should be taken in the interpretation and applicability of our results because of the small number of RCTs along with few events available meeting the criteria for inclusion in the review, absence of the primary outcome of interest and other clinically important outcomes in the majority of included studies. The possible need for a face-mask in younger children using home-made spacers should also be considered in practice.

Performance of a corticosteroid inhaler with a spacer fashioned from a plastic cold-drink bottle: effects of changing bottle volume

Some clinicians advocate using metered-dose inhaler (MDI) spacers prepared from common household bottles. We evaluated the in vitro aerosol characteristics of fluticasone from the MDI alone and through spacers fashioned from 237-, 500-, 1000-, and 1500-mL polyethylene terephlate plastic cold drink bottles using a cascade impactor. Ten 110-microg actuations of fluticasone were sampled into the impactor during each of five runs with each configuration. The primary outcomes were the respirable dose (i.e., quantity aerosol 1.1-4.7 microm in size) and the quantity trapped in the oropharynx. The mean fluticasone respirable dose from the MDI alone (46.2 microg/actuation) was no different (p > 0.05) compared with the same MDI mated to any of the bottle spacers, regardless of volume. The mean quantity of fluticasone trapped in the oropharynx from the MDI alone (39.2 microg/actuation) was greater (p < 0.001) than the same MDI mated with any bottle spacer (range 1.5-3.5 microg/actuation). These data suggest that any of the bottle spacers tested would be an acceptable method to decrease the quantity of fluticasone that would deposit onto the oropharynx and thereby diminish the risk of topical adverse effects. Among the range of volumes tested, there was no relationship between spacer volume and respirable dose of fluticasone.

A 500-ml plastic bottle: an effective spacer for children with asthma

Inhaled therapy using a metered-dose inhaler (MDI) with attached spacer has been increasingly recognized as the optimal method for delivering asthma medication for acute attacks and chronic prophylaxis. However, in developing countries the cost and availability of commercially produced spacers limit the use of MDI-spacer delivery systems. A 500-ml plastic bottle has been recently adapted to function as a spacer. This article reviews the current data on the efficacy of this bottle-spacer and discusses its advantages and limitations. It is concluded that a modified 500-ml plastic bottle is an effective spacer; modification and use of this device should be incorporated into international guidelines for the management of children with asthma.

Acute asthma

OBJECTIVE: Asthma is the most common medical emergency in children. It is associated with significant morbidity and mortality rates and poses a tremendous societal burden worldwide. Management of the acute attack involves a stepwise approach that includes beta-agonist and steroid therapy, the mainstay of emergency treatment. Most patients will respond to this regime and can be discharged from the emergency department. Failure to respond to treatment necessitates hospital admission and sometimes admission to the intensive care unit (ICU). Management in the ICU involves intensification of pharmacologic therapy, including nonstandard therapies, in an attempt to avoid intubation and ventilation. When needed, mechanical ventilatory support can be rendered fairly safe with little morbidity if the likely cardiorespiratory physiologic derangements are appreciated and if appropriate ventilatory strategies are used. In the past two decades, the availability of newer potent medications and changes in approach to monitoring and ventilatory strategies have resulted in a decrease in ICU morbidity and mortality rates. Research endeavors are presently underway to further characterize the underlying mechanisms of the disease and are likely to lead to novel therapies. This article reviews the approach to management of acute severe asthma.

Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial

BACKGROUND

A metered-dose inhaler (MDI) with spacer is the best way to deliver bronchodilator therapy for treatment of acute asthma. In developing countries, commercially produced spacers are generally unavailable or too costly. We tested the efficacy of home-made spacers (500 mL plastic bottle, polystyrene cup) compared with a conventional spacer for delivery of a beta2 agonist via MDI for children with acute asthma.

METHODS

We studied children aged 5 to 13 years with acute asthma, stratified into those with mild airways obstruction (peak expiratory flow [PEF] 60-79% of predicted value) or moderate to severe airways obstruction (PEF 20-59% of predicted value). A beta2 agonist (fenoterol hydrobromide) was given via MDI and one of four randomly assigned spacers (conventional spacer, sealed 500 mL plastic bottle, unsealed 500 mL bottle, 200 mL polystyrene cup). Clinical score, pulmonary function tests, and oximetry were recorded at baseline and 15 min after treatment. If a second bronchodilator treatment was needed, nebulised fenoterol was given and the assessment repeated 15 min later. Primary outcome measures were changes in clinical score and pulmonary function, and need for and response to nebulisation.

FINDINGS

88 children were eligible for study. In 44 children with moderate to severe airways obstruction, a cup gave significantly less bronchodilation (median increase in: forced expiratory volume in 1 s [FEV1] 0%; PEF 12%) compared with the conventional spacer (37%; 59%), sealed bottle (33%; 36%), or unsealed bottle (18%; 21%, p<0.05 for difference between groups). Nebulisation was required by ten of 11 who had used a cup, nine of 11 who had used an unsealed bottle, eight of 11 who had used a sealed bottle, and only four of 11 who had used a conventional spacer. After nebulisation, improvement in FEV1 (15.5%) and PEF (26%) was more marked in children who had used a cup than in those who had used a conventional spacer (5.5% FEV1; 4% PEF), sealed bottle (3%; 0%), or unsealed bottle (7%; 9%). For 44 children with mild airways obstruction, response to bronchodilator was similar for all spacers and need for nebulisation was not associated with use of a particular spacer.

INTERPRETATION

A conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction. Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries.

Ipratropium bromide for symptomatic preterm infants

Twelve preterm infants, median gestational age 31.5 weeks, were entered into a randomised, placebo-controlled trial of bronchodilator therapy. Their postnatal age was a median of 17.5 months and all suffered from recurrent respiratory symptoms. The infants received either inhaled placebo or 40 micrograms of ipratropium bromide (active therapy) three times a day utilising a coffee cup as a spacer device. Each therapy was administered for 2 weeks. The symptom score during the active period was reduced by 59% compared to the placebo period (P less than 0.01) and this was associated with 38% improvement in lung function in the active period compared to a 20% change in functional residual capacity over the placebo period (P less than 0.01). We conclude inhaled ipratropium bromide appears to be an effective treatment for symptomatic infants at follow up.