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Payares-Salamanca L, Contreras-Arrieta S, Florez-García V, Barrios-Sanjuanelo A, Stand-Niño I, Rodriguez-Martinez CE. Metered-dose inhalers versus nebulization for the delivery of albuterol for acute exacerbations of wheezing or asthma in children: A systematic review with meta-analysis. Pediatr Pulmonol 2020; 55:3268-3278. [PMID: 32940961 DOI: 10.1002/ppul.25077] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The benefits of metered-dose inhalers with a spacer (MDI+S) have increasingly been recognized as an alternative method of albuterol administration for treating pediatric asthma exacerbations. The aim of this systematic review was to compare the response to albuterol delivered through nebulization (NEB) with albuterol delivered through MDI+S in pediatric patients with asthma exacerbations. METHODS We conducted an electronic search in MEDLINE/PubMed, EMBASE, Ovid, and ClinicalTrials. To be included in the review, a study had to a randomized clinical trial comparing albuterol delivered via NEB versus MDI+S; and had to report the rate of hospital admission (primary outcome), or any of the following secondary outcomes: oxygen arterial saturation, heart rate (HR), respiratory rate (RR), the pulmonary index score (PIS), adverse effects, and need for additional treatment. RESULTS Fifteen studies (n = 2057) met inclusion criteria. No significant differences were found between the two albuterol delivery methods in terms of hospital admission (relative risk, 0.89; 95% confidence interval [CI], 0.55-1.46; I2 = 32%; p = .65). There was a significant reduction in the PIS score (mean difference [MD], -0.63; 95% CI, -0.91 to -0.35; I2 = 0%; p < .00001), and a significantly smaller increase in HR (better; MD -6.47; 95% CI, -11.69 to -1.25; I2 = 0%; p = .02) when albuterol was delivered through MDI+S than when it was delivered through NEB. CONCLUSIONS This review, an update of a previously-published meta-analysis, showed a significant reduction in the PIS and a significantly smaller increase in HR when albuterol was delivered through MDI+S than when it was delivered through NEB.
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Affiliation(s)
| | | | - Victor Florez-García
- Department of Public Health, Universidad del Norte, Barranquilla, Colombia.,Environmental Health Sciences, Joseph J. Ziber School of Public Health, University of Wisconsin- Milwaukee, Milwaukee, Wisconsin, USA
| | | | - Ivan Stand-Niño
- Department of Pediatric Pulmonology, School of Medicine, Universidad del Norte, Barranquilla, Colombia
| | - Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
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Single inhaler maintenance and reliever therapy in pediatric asthma. Curr Opin Allergy Clin Immunol 2020; 19:111-117. [PMID: 30640210 DOI: 10.1097/aci.0000000000000518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Asthma affects more than 25 million people worldwide and continues to grow in prevalence. According to a center for disease control and prevention (CDC) report, the total annual cost of asthma in the United States between 2008 and 2013, including medical care, absenteeism, and mortality, was $81.9 billion. Although the National Institute of Health guidelines recommend fixed inhaled corticosteroid (ICS) dosing, the 2008-2010 Medical Expenditure Panel Survey showed that asthma is still poorly controlled. Single inhaler maintenance and reliever therapy (SMART) offers a possible alternative management plan. This is a review of SMART vs. current treatment guidelines. RECENT FINDINGS SMART addresses variable inflammation with symptom-driven dosing of ICS. It relies on a combination inhaler that has a long-acting β-agonist, which has an immediate onset of action to provide quick relief, in combination with an ICS. Recent studies show that SMART decreases the frequency and severity of asthma exacerbations when compared to fixed ICS dosing. In addition, intermittent use of ICS gave a reduced effect on growth and permitted a lower total amount of ICS to be delivered. SUMMARY SMART appears to outperform treatment that is based on current guidelines in the United States. As inhalers capable of being used for SMART are already approved, what is needed is Food and Drug Administration approval of the SMART strategy.
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Gardiner MA, Wilkinson MH. Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma. J Pediatr 2019; 204:245-249.e2. [PMID: 30392872 DOI: 10.1016/j.jpeds.2018.08.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/03/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the efficacy of a breath-enhanced and a conventional jet nebulizer in the treatment of children with moderate to severe acute asthma. STUDY DESIGN We enrolled subjects between 6 and 18 years of age presenting to the emergency department (ED) with acute asthma and an initial forced expiratory volume in 1 second (FEV1) <70% of predicted. We excluded patients with chronic disease, who required immediate resuscitation, or failed spirometry. Subjects were randomized to breath-enhanced or conventional jet delivery of a 5-mg albuterol treatment. Our primary outcome was change in FEV1, and secondary outcomes included change in clinical asthma scores, ED length of stay, disposition, and side effects. Student t test and multivariable linear regression were used to evaluate the primary outcome. RESULTS In total, 497 patients were assessed for eligibility with 118 enrolled and 107 subjects available for analysis of the primary outcome. Improvement in FEV1 was significantly greater with conventional jet nebulizer (mean ΔFEV1 +13.8% vs +9.1%, P = .04). This difference remained significant after adjustment for baseline differences. Subgroup analysis of 57 subjects with spirometry meeting American Thoracic Society/European Respiratory Society guidelines yielded similar results (mean ΔFEV1 +14.5% vs +8.5%, P=.03). There were no significant differences in clinical asthma scores, ED length of stay, disposition, or side effects. CONCLUSIONS Albuterol delivered via conventional jet nebulizer resulted in significantly greater improvement in FEV1 than albuterol delivered by breath-enhanced nebulizer, without significant differences in clinical measures. Conventional jet nebulizers may deliver albuterol to children with acute asthma more effectively than breath-enhanced nebulizers. TRIAL REGISTRATION ClinicalTrials.gov: NCT02566902.
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Affiliation(s)
- Mike A Gardiner
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital-San Diego, La Jolla, CA.
| | - Matthew H Wilkinson
- Department of Pediatrics, University of Texas at Austin, Dell Children's Medical Center of Central Texas, Austin, TX
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Abaya R, Delgado EM, Scarfone RJ, Reardon AM, Rodio B, Simpkins D, Mehta V, Hayes K, Zorc JJ. Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler. J Asthma 2018; 56:1079-1086. [PMID: 30207821 DOI: 10.1080/02770903.2018.1514629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.
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Affiliation(s)
- Ruth Abaya
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eva M Delgado
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard J Scarfone
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ann Marie Reardon
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bonnie Rodio
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise Simpkins
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vaidehi Mehta
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katie Hayes
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Nian AL, Orr RJ, Schroeder SK. A Report of an Asthma Pathway Leading to Improved Resource Use. J Pediatr Pharmacol Ther 2018; 23:298-304. [PMID: 30181720 DOI: 10.5863/1551-6776-23.4.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Asthma pathways have been shown to improve resource use and decrease length of stay (LOS). A tertiary care hospital implemented an asthma pathway in May 2015 to standardize inpatient care. We predicted that the pathway would increase the use of albuterol metered-dose inhalers (MDIs) and steroids; decrease use of albuterol nebulizer, antibiotics, chest radiograph (CXR), and respiratory viral panel (RVP); and decrease LOS. METHODS This retrospective cohort study selected patients between the ages of 2 and 18 years who were admitted for asthma as a primary diagnosis between May 2014 and May 2016 (1 year preimplementation to 1 year postimplementation). Patients' complex chronic conditions were excluded. We analyzed use of albuterol nebulizer, MDI, and continuous nebulization, ipratropium bromide, oral steroids, antibiotics, inhaled steroids, CXR, and RVP. We also evaluated LOS and readmission rate. RESULTS There were 1131 and 925 patients identified before and after asthma pathway implementation, respectively. The percent that received albuterol nebulizer decreased from 14.1% to 6.1% (p < 0.001). The percent that received albuterol MDI increased from 97.0% to 99.4% (p < 0.001). The average number of MDI administrations decreased from 11.6 to 10.4 (p = 0.004). Continuous albuterol use increased from 52.3% to 59.1% (p = 0.002). There was no change in ipratropium bromide, oral steroid, inhaled steroid, or CXR use. Antibiotic (p = 0.049) and RVP (p = 0.03) use decreased. The average LOS decreased from 1.84 days to 1.71 days (p = 0.02). Readmission rates did not change significantly. CONCLUSIONS The asthma pathway improved inpatient albuterol MDI use. The LOS decreased while maintaining readmission rates.
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A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med 2018; 55:7-14. [PMID: 29716819 DOI: 10.1016/j.jemermed.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/19/2018] [Accepted: 03/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department. OBJECTIVE We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations. METHODS This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10. RESULTS We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority. CONCLUSIONS Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.
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Fitch KD. The enigma of inhaled salbutamol and sport: unresolved after 45 years. Drug Test Anal 2017; 9:977-982. [DOI: 10.1002/dta.2184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/03/2017] [Accepted: 03/05/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Ken D. Fitch
- School of Sports Science, Exercise and Health; University of Western Australia; Crawley WA 6009 Australia
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Management of Acute Loss of Asthma Control: The Yellow Zone. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2016.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hill-Taylor BJ, Hurley KF, Sketris I, O'Connell C, Sinclair D, Wing A. Evaluating a clinical practice intervention to promote delivery of salbutamol by metered-dose inhalers with holding chambers in a pediatric emergency department. CAN J EMERG MED 2016; 15:101-8. [PMID: 23458141 DOI: 10.2310/8000.2012.120880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention. METHODS PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained from the hospital's decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006. RESULTS There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute -7.25%: 95% CI -8.31 to -6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map. CONCLUSIONS A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be contextualized to inform change elsewhere.
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Moriates C, Feldman L. Nebulized bronchodilators instead of metered-dose inhalers for obstructive pulmonary symptoms. J Hosp Med 2015; 10:691-3. [PMID: 26121974 DOI: 10.1002/jhm.2386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/28/2015] [Accepted: 02/13/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Christopher Moriates
- Division of Hospital Medicine, University of California at San Francisco, San Francisco, California
| | - Leonard Feldman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Alhaider SA, Alshehri HA, Al-Eid K. Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources. Int J Pediatr Adolesc Med 2014; 1:26-30. [PMID: 32289071 PMCID: PMC7104032 DOI: 10.1016/j.ijpam.2014.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 08/17/2014] [Indexed: 02/05/2023]
Abstract
Background and objectives Metered-dose inhalers plus spacers (MDI-spacer) are as effective as, or better than, nebulizers in aerosol delivery. The selection of aerosol delivery system for hospitalized children can have a significant impact on the utilization of healthcare resources. Design and setting A quality improvement project to evaluate the impact of conversion to MDI-spacer to administer bronchodilators (BDs) and inhaled corticosteroids (ICSs) to hospitalized children on the utilization of hospital resources. The project was conducted in a tertiary pediatric ward from April to May 2013. Materials and methods The project was conducted over a six-week period. In the first two weeks, data were gathered from all hospitalized children receiving BDs and/or ICSs by nebulizers. This data collection was followed by a two-week washout period during which training of healthcare providers and operational changes were implemented to enhance the conversion to MDI-spacer. In the last two weeks, data were gathered from hospitalized children after conversion to MDI-spacer. The primary outcomes included the mean time (in minutes) of medication preparation and delivery. Secondary outcomes included the following: need for respiratory therapy assistance, estimated cost of treatment sessions, and patient/caregiver satisfaction. Results Five hundred seventy-five treatment sessions were enrolled (288 on nebulizers, 287 on MDI-spacer). The nebulizer group had more male predominance and were slightly older compared to the MDI-spacer group (male: 59% vs. 53% and mean age: 52 vs. 40 months respectively). The duration of treatment preparation and delivery was significantly lower in the MDI-spacer group (2 min reduction in preparation time and 5 min reduction in delivery time; p < 0.01). Caregivers mastered MDI-spacer use after an average of two observed sessions, eliminating the need for respiratory therapy assistance during the hospital stay. Medication cost analysis showed savings in favor of MDI-spacer (cost reduction per 100 doses: 50% for albuterol, 30% for ipratropium bromide, and 87% for ICSs). The patient satisfaction survey showed “very good” to “excellent” levels in both groups. Conclusions Conversion to MDI-spacer for BDs and ICSs administration in hospitalized children improve hospital resource utilization.
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Affiliation(s)
- S A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - H A Alshehri
- College of Medicine, Al-Imam University, Riyadh, Saudi Arabia
| | - K Al-Eid
- Department of Respiratory Care Services, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Dinakar C, Portnoy JM. Empowering the child and caregiver: yellow zone Asthma Action Plan. Curr Allergy Asthma Rep 2014; 14:475. [PMID: 25183364 DOI: 10.1007/s11882-014-0475-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Current guidelines, both national and international, elegantly describe evidence-based measures to attain and maintain long-term control of asthma. These strategies, typically discussed between the provider and patient, are provided in the form of written (or electronic) instructions as part of the green zone of the color-coded Asthma Action Plan. The red zone of the Asthma Action Plan has directives on when to use systemic corticosteroids and seek medical attention. The transition zone between the green zone of good control and the red zone of asthma exacerbation is the yellow zone. This zone guides the patient on self-management of exacerbations outside a medical setting. Unfortunately, the only recommendation currently available to patients per the current asthma guidelines is the repetitive use of reliever bronchodilators. This approach, while providing modest symptom relief, does not reliably prevent progression to the red zone. In this document, we present new, evidence-based, yellow zone intervention options.
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Affiliation(s)
- Chitra Dinakar
- Division of Allergy, Asthma and Immunology, Children's Mercy Hospitals, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA,
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Dinakar C, Oppenheimer J, Portnoy J, Bacharier LB, Li J, Kercsmar CM, Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D. Management of acute loss of asthma control in the yellow zone: a practice parameter. Ann Allergy Asthma Immunol 2014; 113:143-59. [PMID: 25065350 DOI: 10.1016/j.anai.2014.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
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Cohn RC. A review of the effects of medication delivery systems on treatment adherence in children with asthma. Curr Ther Res Clin Exp 2014; 64:34-44. [PMID: 24944355 DOI: 10.1016/s0011-393x(03)00002-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2002] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A patient's adherence to an appropriate treatment regimen is necessary to minimize morbidity and mortality associated with childhood asthma. Many factors influence the success of treatment adherence. OBJECTIVE The goal of this article was to examine the effect of the mode of medication delivery on the success of treatment adherence in children with asthma. METHODS Relevant clinical studies were identified through a MEDLINE search of articles published from 1966 to 2002, using the search terms adherence, aerosol, asthma, children, compliance, dry powder inhaler, metered-dose inhaler, nebulizer, and pediatric. RESULTS A relationship seems to exist between treatment adherence and the type of medication delivery system used in childhood asthma. The highest rates of adherence appear to be associated with oral medications. CONCLUSIONS Clinicians should consider the mode of medication delivery as 1 factor that can influence the success of treatment adherence.
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Affiliation(s)
- Robert C Cohn
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Kwok PCL, Chan HK. Delivery of inhalation drugs to children for asthma and other respiratory diseases. Adv Drug Deliv Rev 2014; 73:83-8. [PMID: 24270011 DOI: 10.1016/j.addr.2013.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/28/2013] [Accepted: 11/13/2013] [Indexed: 11/30/2022]
Abstract
Infants and children constitute a patient group that has unique requirements in pulmonary drug delivery. Since their lungs develop continuously until they reach adulthood, the airways undergo changes in dimensions and number. Computational models have been devised on the growth dynamics of the airways during childhood, as well as the particle deposition mechanisms in these growing lungs. The models indicate that total aerosol deposition in the body decreases with age, while deposition in the lungs increases with age. This has been observed on paediatric subjects in in vivo studies. Issues unique to children in pulmonary drug delivery include their lower tidal volume, highly variable breathing patterns, air leaks from facemasks, and the off-label or unlicensed use of pharmaceutical products due to lack of clinical data for this age group. The aerosol devices used are essentially those developed for adult patients that have been adapted to paediatric use. Facemasks should be used with nebulisers and spacers for infants and young children. An idealised throat that mimic the average particle deposition in paediatric throats has been designed to obtain more clinically relevant aerosol dispersion data in vitro. More effort should be spent on studying particle deposition in the paediatric lung and developing products specific for this subpopulation to meet their needs.
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Affiliation(s)
- Philip Chi Lip Kwok
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region.
| | - Hak-Kim Chan
- Faculty of Pharmacy, The University of Sydney, Camperdown, New South Wales 2006, Australia
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Neel S, Tauman A. Can Successful Implementation of the Common Canister Program Deliver Cost Containment and Improved Infection Control? Hosp Pharm 2012. [DOI: 10.1310/hpj4709-700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To review considerations for implementing the common canister program in hospitals, and to encourage a careful evaluation of a substantial financial and process improvement opportunity involving the common canister program. Background The common canister program has not received a comprehensive evaluation in the literature. It has not been compared to traditional inhaler administration, and the potential infectious risk of the traditional patient-specific inhaler administration process has not been considered. Ten microbiologic studies examining infection risk have been performed using a common canister protocol; no studies have been published with individual inhaler administration without a spacer. The results in all 10 of the common canister microbiologic studies indicated that this program was safe for patients when a multidisciplinary approach was followed and was accompanied by hospitalwide education. Conclusion Because of the opportunity to reduce inhaler expenditures by 50% and the theoretical concerns of contamination from the traditional inhaler process, this program should be evaluated. Best practice requires a relative assessment of all inhaler administration models to determine the safest and most efficacious practice. It may be surprising to learn how an inhaler, after touching a patient's mouth during the individual inhaler administration process, is handled, transported, and stored by staff, and the various contaminated surfaces the inhaler contacts in the retrieval, administration, and return to storage process.
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Affiliation(s)
- Scott Neel
- Implementation Manager, VHA Performance Services, Charlotte, North Carolina
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Lustosa GMDM, Britto MCAD, Bezerra PGDM. Acute asthma management in children: knowledge of the topic among health professionals at teaching hospitals in the city of Recife, Brazil. J Bras Pneumol 2012; 37:584-8. [PMID: 22042389 DOI: 10.1590/s1806-37132011000500004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 07/11/2011] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Giovanna Menezes de Medeiros Lustosa
- Instituto de Medicina Integral Prof. Fernando Figueira - IMIP, Professor Fernando Figueira Institute of Comprehensive Medicine - Recife, Brazil.
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Prabhakaran S, Shuster J, Chesrown S, Hendeles L. Response to albuterol MDI delivered through an anti-static chamber during nocturnal bronchospasm. Respir Care 2012; 57:1291-6. [PMID: 22348270 DOI: 10.4187/respcare.01572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Decreasing electrostatic charge on valved holding chambers increases the amount of drug delivered. However, there are no data demonstrating that this increases bronchodilatation. OBJECTIVE To investigate the influence of reducing electrostatic charge on the bronchodilator response to albuterol inhaler during nocturnal bronchospasm. METHODS This randomized double-blind, double-dummy crossover study included subjects, 18-40 years old, with nocturnal bronchospasm (20% overnight decrease in peak flow on 3 of 7 nights during run-in), FEV(1) 60-80% predicted during the day, and ≥ 12% increase after albuterol. Subjects slept in the clinical research center up to 3 nights for each treatment. FEV(1) and heart rate were measured upon awakening spontaneously or at 4:00 am, and 15 min after each dose of 1, 2, and 4 cumulative puffs of albuterol via metered-dose inhaler. The drug was administered through an anti-static valved holding chamber (AeroChamber Plus Z-Stat) or a conventional valved holding chamber containing a static charge (AeroChamber Plus). RESULTS Of 88 consented subjects, 11 were randomized and 7 completed the study. Most exclusions were due to lack of objective evidence of nocturnal bronchospasm. Upon awakening, FEV(1) was 44 ± 9% of predicted before the anti-static chamber and 48 ± 7% of predicted before the static chamber. The mean ± SD percent increase in FEV(1) after 1, 2, and 4 cumulative puffs using the anti-static versus the static chamber, respectively, were 52 ± 26% versus 30 ± 19%, 73 ± 28% versus 48 ± 26%, and 90 ± 34% versus 64 ± 35%. The point estimates for the differences (and 95% CIs) between the devices (anti-static vs static) were 21% (4-38%) (P = .03), 23% (6-41%) (P = .02), and 25% (7-42%) (P = .01) for 1, 2, and 4 cumulative puffs, respectively. There was no significant difference in heart rate between treatments. CONCLUSIONS Delivery of albuterol through an anti-static chamber provides a clinically relevant improvement in bronchodilator response during acute, reversible bronchospasm such as nocturnal bronchospasm.
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Affiliation(s)
- Sreekala Prabhakaran
- Pediatric Pulmonary Division, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
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Staggs L, Peek M, Southard G, Gracely E, Baxendale S, Cross KP, Kim IK. Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems. J Med Econ 2012; 15:704-11. [PMID: 22400716 DOI: 10.3111/13696998.2012.674587] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI+S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI+S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI+S vs NEB. METHODS A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1-18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded. RESULTS Three hundred and four patients were analyzed: 94 in the MDI+S group and 209 in the NEB group. Mean age in years for the MDI+S group was 9.57 vs 5.07 for the NEB group (p<0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI+S group vs 61.7% in the NEB group (p<0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI+S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p<0.001; 95% CI=3.8-31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of $213,532 annually using MDI+S vs NEB. CONCLUSION In mild asthma exacerbations, administering albuterol via MDI+S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput. LIMITATIONS The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.
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Affiliation(s)
- Lauren Staggs
- Pediatric Emergency Medicine Physician, University of Louisville Health Sciences Center–Pediatrics, 571 South Floyd Street, Louisville, Kentucky 40202, USA.
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Endpoints in respiratory diseases. Eur J Clin Pharmacol 2010; 67 Suppl 1:49-59. [PMID: 21104409 DOI: 10.1007/s00228-010-0922-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 10/10/2010] [Indexed: 10/18/2022]
Abstract
A wide range of outcome measures or endpoints has been used in clinical trials to assess the effects of treatments in paediatric respiratory diseases. This can make it difficult to compare treatment outcomes from different trials and also to understand whether new treatments offer a real clinical benefit for patients. Clinical trials in respiratory diseases evaluate three types of endpoints: subjective, objective and health-related outcomes. The ideal endpoint in a clinical trial needs to be accurate, precise and reliable. Ideally, the endpoint would also be measured with minimal risk and across all ages, easy to perform, and be inexpensive. As for any other disease, endpoints for respiratory diseases must be viewed in the context of the important distinction between clinical endpoints and surrogate endpoints. The association between surrogate endpoints and clinical endpoints must be clearly defined for any disease in order for them to be meaningful as outcome measures. The most common endpoints which are used in paediatric trials in respiratory diseases are discussed. For practical purposes, diseases have been separated into acute (bronchiolitis, acute viral-wheeze, acute asthma and croup) and chronic (asthma and cystic fibrosis). Further development of endpoints will enable clinical trials in children with respiratory diseases with the main objective of improving prognosis and safety.
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Clark NM, Houle C, Partridge MR, Leo HL, Paton JY. The puzzle of continued use of nebulized therapy by those with asthma. Chron Respir Dis 2010; 7:3-7. [PMID: 20103617 DOI: 10.1177/1479972309357496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Repeat dosing of albuterol via metered-dose inhaler in infants with acute obstructive airway disease: a randomized controlled safety trial. Pediatr Emerg Care 2010; 26:197-202. [PMID: 20179658 DOI: 10.1097/pec.0b013e3181d1e40d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Airway obstruction and bronchial hyperactivity often times lead to emergency department visits in infants. Inhaled short-acting beta2-agonist bronchodilators have traditionally been dispensed to young children via nebulizers in the emergency department. Delivery of bronchodilators via metered-dose inhalers (MDIs) in conjunction with holding chambers (spacers) has been shown to be effective. STUDY OBJECTIVE : Safety and efficacy evaluations of albuterol sulfate hydrofluoroalkane (HFA) inhalation aerosol in children younger than 2 years with acute wheezing caused by obstructive airway disease. METHODS A randomized, double-blind, parallel group, multicenter study of albuterol HFA 180 microg (n = 43) or 360 microg (n = 44) via an MDI with a valved holding chamber and face mask in an urgent-care setting. Assessments included adverse events, signs of adrenergic stimulation, electrocardiograms, and blood glucose and potassium levels. Efficacy parameters included additional albuterol use and Modified Tal Asthma Symptoms Score ([MTASS] reduction in MTASS representing improvement). RESULTS Overall, adverse events occurred in 4 (9%) and 3 (7%) subjects in the 180-microg and 360-microg groups, respectively. Drug-related tachycardia (360 microg) and ventricular extrasystoles (180 microg) were reported in 1 patient each. Three additional instances of single ventricular ectopy were identified from Holter monitoring. No hypokalemia or drug-related QT or QTc prolongation was seen; glucose values and adrenergic stimulation did not significantly differ between treatment groups. In the 180-microg and 360-microg groups, mean change from baseline in MTASS during the treatment period was -2.8 (-49.8%) and -2.9 (-48.4%), and rescue albuterol use occurred in 4 (9%) and 3 (7%) subjects, respectively. CONCLUSIONS Cumulative dosing with albuterol HFA 180 microg or 360 microg via MDI-spacer and face mask in children younger than 2 years did not result in any significant safety issues and improved MTASS by at least 48%.
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Rotta ET, Amantéa SL, Froehlich PE, Becker A. Plasma concentrations of salbutamol in the treatment of acute asthma in a pediatric emergency. Could age be a parameter of influence? Eur J Clin Pharmacol 2010; 66:605-10. [PMID: 20195589 DOI: 10.1007/s00228-010-0787-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Accepted: 01/12/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective was to determine if the plasma concentrations of salbutamol, obtained during inhalation treatment of infantile acute asthma, are influenced by age range and by the aerosol system used. METHOD A randomized clinical trial was conducted in 46 children (1-5 years of age) with a diagnosis of acute asthma crisis, established in an emergency room pediatric service. Twenty-five children received salbutamol using a pressurized metered-dose inhaler with spacer (50 microg/kg), and 21 children received salbutamol by nebulization (150 microg/kg),three times during a 1-h period. At the end of the treatment, one blood sample was drawn and the plasma was stored for later determination of salbutamol concentration (liquid chromatography). Salbutamol plasma concentrations were compared in two age groups (< or =2 years and >2 years of age). The type of device used (pressurized metered-dose inhaler or nebulizer) and the need of hospitalization were also tested. The Mann-Whitney U test was used with the level of significance set at 5% (P < 0.05). RESULTS No differences were detected regarding either the aerosol delivery system used or the need for hospitalization in relation to the plasma concentrations of salbutamol. However, higher plasma levels were found in patients >2 years vs patients < or =2 years [median (IQR): 9.40 (6.32-18.22) vs. 4.65 (2.77-10.10) ng/mL], demonstrating a significance difference (P = 0.05). CONCLUSION Salbutamol plasma concentrations were influenced by age group of the patients submitted to inhalation therapy, even with doses adjusted for body weight. After correcting for the differences in the biovailabilities of the delivery systems, the concentrations were independent of the aerosol delivery device used.
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Affiliation(s)
- Eloni T Rotta
- Pharmacy, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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Hedrick JA, Baker JW, Atlas AB, Naz AA, Lincourt WR, Trivedi R, Ellworth A, Davis AM. Safety of daily albuterol in infants with a history of bronchospasm: a multi-center placebo controlled trial. Open Respir Med J 2009; 3:100-6. [PMID: 19639035 PMCID: PMC2714526 DOI: 10.2174/1874306400903010100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 06/12/2009] [Accepted: 06/16/2009] [Indexed: 11/24/2022] Open
Abstract
Introduction: Inhaled short-acting bronchodilators are recommended for the quick relief of bronchospasm symptoms in children including those less than five years of age. However, limited safety data is available in this young population. Methods: Safety data were analyzed from a randomized, double-blind, parallel group, placebo-controlled multicenter, study evaluating albuterol HFA 90µg or 180µg versus placebo three times a day for 4 weeks using a valved holding chamber, Aerochamber Plus and facemask in children birth ≤24 months old with a history of bronchospasm. Results: The overall incidence of adverse events (AE) during treatment was: albuterol 90µg (59%), albuterol 180µg (76%) and placebo (71%). The most frequently reported AEs were pyrexia in 7 (24%), 2 (7%), and 3 (11%) subjects in the albuterol 180µg, albuterol 90µg, and placebo groups, respectively. Upper respiratory tract infection (URTI) occurred in 5 (17%) and 3 (11%) subjects in the albuterol 180µg and placebo groups, respectively. Sinus tachycardia occurred in 5 (17%), 2 (7%) and 2 (7%) subjects receiving albuterol 180µg, albuterol 90µg and placebo, respectively. One subject in each of the albuterol treatment groups experienced drug related agitation and/or restlessness or mild sinus arrhythmia. No drug-related QT prolongation or abnormal serum potassium and glucose levels were reported in the albuterol treatment groups. Conclusion: This study provides additional albuterol HFA safety information for the treatment of children aged birth ≤24 months with a history of bronchospasm.
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Affiliation(s)
- James A Hedrick
- Kentucky Pediatric/Adult Research, 201 South 5 Street, Suite 102; Bardstown, Kentucky 40004, USA
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Abstract
PURPOSE OF REVIEW Asthma continues to be a major chronic disease in children, and acute asthma exacerbations are common. Although the basic therapy of asthma exacerbations has not changed, recent studies have demonstrated improved outcomes with different modes of delivery of medications, improved patients' self-management of their asthma, and recognition of risk factors for severe exacerbations. RECENT FINDINGS Recent studies in children have shown that written action plans based on symptom recognition are more effective than action plans based on peak expiratory flows. Bronchodilator administration by metered-dose inhaler is becoming the preferred therapy for treating mild-to-moderate asthma exacerbations in the emergency department, but nebulizers may still have a role in home and inpatient asthma management. High-dose inhaled corticosteroids may be as effective as oral corticosteroids for acute asthma exacerbations. A novel treatment strategy has titrated combination therapy with budesonide and formoterol for both maintenance and relief of symptoms. Lastly, the contributions of obesity and genetic variation to severe asthma exacerbations are becoming known, and noninvasive positive pressure ventilation has become an option for patients in severe asthma exacerbations. SUMMARY Improvements in management strategies can significantly improve outcomes in children with asthma.
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Stavreska V, Verheggen M, Oostryck J, Stick SM, Hall GL. Determining the time to maximal bronchodilator response in asthmatic children. J Asthma 2009; 46:25-9. [PMID: 19191133 DOI: 10.1080/02770900802460555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The interval between bronchodilator administration and post-bronchodilator lung function testing is critical for accurate interpretation of the bronchodilator response. The time course of this response in children is not well documented. We aimed to document the time taken to achieve maximal lung function following salbutamol inhalation. METHODS Eighteen asthmatic children between 7 and 18 years of age with a history of bronchodilator responsiveness were recruited. Spirometry was performed before and at 0, 10, 15, 20, 40, 60, and 90 minutes after salbutamol inhalation 600 microg (Ventolin; GlaxoSmithKline) via a spacer (Volumatic; GlaxoSmithKline). RESULTS Spirometric indices significantly increased after salbutamol inhalation (p < 0.001). The group median time to maximal response in forced expiratory volume in 1 second (FEV(1)) was 17.5 (10-60: 10th-90th centiles) minutes after salbutamol. The magnitude of group response in FEV(1) was significantly higher at 15 and 20 minutes than at 0 and 10 minutes post-salbutamol inhalation (repeat measures analysis of variance [ANOVA] on ranks; p < 0.05). CONCLUSION We conclude that a minimal interval of 20 minutes, before re-testing spirometry, is required to document the maximal response to bronchodilators in the majority of asthmatic children.
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Affiliation(s)
- Vaska Stavreska
- Respiratory Medicine Department, Princess Margaret Hospital for Children, Perth, Australia
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Becker AB. Asthma in the preschool child: still a rose by any other name? J Allergy Clin Immunol 2009; 122:1136-7. [PMID: 19084109 DOI: 10.1016/j.jaci.2008.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 10/23/2008] [Indexed: 11/19/2022]
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Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med 2008; 40:247-55. [PMID: 19081697 DOI: 10.1016/j.jemermed.2008.06.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 05/30/2008] [Accepted: 06/22/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice. OBJECTIVES We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population. METHODS This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test. RESULTS Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03-$10.28) vs. $18.26 ($9.88-$22.45) in the spacer and nebulizer groups, respectively (p < 0.001). CONCLUSION There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.
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Affiliation(s)
- Michael J Welch
- From the Allergy and Asthma Medical Group and Research Center, San Diego, California 92123, USA.
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Hartling L, Scott-Findlay S, Johnson D, Osmond M, Plint A, Grimshaw J, Klassen TP. Bridging the Gap between Clinical Research and Knowledge Translation in Pediatric Emergency Medicine. Acad Emerg Med 2007. [DOI: 10.1111/j.1553-2712.2007.tb02375.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hurley KF, Sargeant J, Duffy J, Sketris I, Sinclair D, Ducharme J. Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma. Ann Emerg Med 2007; 51:70-7. [PMID: 17559971 DOI: 10.1016/j.annemergmed.2007.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Revised: 03/29/2007] [Accepted: 04/06/2007] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change. METHODS This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes. RESULTS At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED. CONCLUSION Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.
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Affiliation(s)
- Katrina F Hurley
- Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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Kemp J, Turck CJ, York JM. Evaluation of albuterol 1.25 mg and 0.62 mg for nebulization in 6- to 12-year-old children with moderately severe asthma. Adv Ther 2007; 24:463-77. [PMID: 17660154 DOI: 10.1007/bf02848768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To assess the efficacy and safety of 2 different strengths of a manufactured albuterol solution for nebulization (AccuNeb(R); DEY, L.P., Napa, Calif), 349 children with moderate to severe asthma were enrolled in this prospective, multicenter, double-blind, placebo-controlled study. For 4 wk, children 6 to 12 y old were randomly assigned to 1.25 mg (A1) or 0.62 mg (A2) albuterol or placebo (P), nebulized 3 times daily for 4 weeks. Pulmonary function and safety were evaluated at weeks 0, 2, and 4 (visits 2-4). Nonparametric tests (Kruskal-Wallis and Wilcoxon's rank-sum) were used to compare treatments. Primary endpoint (week 4, %Delta area under the curve [AUC] forced expiratory volume in 1 sec [FEV(1)]) results for A1, A2, and P were 90.3% x h*, 73.6% x h*, and 34.2% x h. Secondary assessments for A1, A2, and P were as follows: (1) week 2, %DeltaAUC FEV1 (99.5%*h*, 104.5% x h*, and 43.6% x h); (2) maximum FEV1 (28.6%*, 26.3%*, and 13.4%); and (3) duration of effect (116.8 min*, 115.9 min*, and 39.2 min). A2 was more effective in children 10 y of age or younger and in children 11 to 12 y of age who weighed </=40 kg or had less severe asthma; A1 was more effective in children 11 to 12 y of age who weighed >40 kg or had more severe asthma. Adverse events (occurring in 47% of children) were considered unrelated to drug treatment. Observations on electrocardiogram (notably QTc interval) were similar to those for placebo. A1 and A2 appeared effective in improving pulmonary function and were well tolerated in children aged 6 to 12 y.
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Affiliation(s)
- James Kemp
- Department of Pediatrics, Division of Immunology and Allergy, University of California at San Diego, California
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Sannier N, Timsit S, Cojocaru B, Leis A, Wille C, Garel D, Bocquet N, Chéron G. Traitement aux urgences des crises d’asthme par nébulisations versus chambres d’inhalation. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.allerg.2005.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Blake K. Review of guidelines and the literature in the treatment of acute bronchospasm in asthma. Pharmacotherapy 2007; 26:148S-55S. [PMID: 16945061 DOI: 10.1592/phco.26.9part2.148s] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Asthma is a common chronic condition that disproportionately affects persons younger than 45 years. Asthma exacerbations can be sudden and severe, requiring treatment in the emergency department or hospitalization. Children younger than 15 years are 2-4 times more likely to have asthma as the first-listed hospital discharge diagnosis compared with those in other age groups. An estimated 12.8 million missed school days and 24.5 million lost work days due to asthma occurred in 2003. Drugs used in the treatment of acute asthma include inhaled beta(2)-agonists, oral corticosteroids, and inhaled anticholinergics. Levalbuterol was evaluated in several recent trials for treatment of asthma in the emergency department, for its effect in improving pulmonary function and on hospitalization rate. Theophylline, intravenous beta(2)-agonists, intravenous magnesium sulfate, and inhaled anesthetics have not been proven useful in the emergency management of asthma. The effectiveness of inhalation devices is dependent on age, cooperation of the patient, and technique.
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Affiliation(s)
- Kathryn Blake
- Center for Clinical Pediatric Pharmacology Research, Nemours Children's Clinic, Jacksonville, Florida 32247, USA
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Ferguson C, Gidwani S. Best evidence topic reports. Delivery of bronchodilators in acute asthma in children. Emerg Med J 2006; 23:471-2. [PMID: 16714515 PMCID: PMC2564350 DOI: 10.1136/emj.2006.037598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Butz AM, Tsoukleris MG, Donithan M, Hsu VD, Zuckerman I, Mudd KE, Thompson RE, Rand C, Bollinger ME. Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma. ACTA ACUST UNITED AC 2006; 160:622-8. [PMID: 16754825 PMCID: PMC2269706 DOI: 10.1001/archpedi.160.6.622] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine the effectiveness of a home-based asthma education intervention in increasing appropriate nebulizer use and reducing symptom frequency, emergency department (ED) visits, and hospitalizations over 12 months. DESIGN A randomized clinical trial. Settings Pediatric primary care, pulmonary/allergy, and ED practices associated with the University of Maryland Medical System and The Johns Hopkins Hospital, Baltimore. PARTICIPANTS Children with persistent asthma, aged 2 to 9 years, with regular nebulizer use and an ED visit or hospitalization within the past 12 months. Children were randomized into the intervention (n = 110) or control (n = 111) group. Follow-up data were available for 95 intervention and 86 control children. INTERVENTION Home-based asthma education, including symptom recognition, home treatment of acute symptoms, appropriate asthma medication, and nebulizer practice. MAIN OUTCOME MEASURES Estimates of mean differences in asthma symptom frequency, number of ED visits and hospitalizations and appropriate quick relief, controller medication, and nebulizer practice over 12 months. RESULTS Of the 221 children, 181 (81.9%) completed the study. There were no significant differences in home nebulizer practice, asthma morbidity, ED visits, or hospitalizations between groups (P range, .11-.79). Although most children received appropriate nonurgent asthma care (mean, 2 visits per 6 months), more than one third of all children received at least 6 quick-relief medication prescriptions during 12 months, with no difference by group. CONCLUSIONS A nebulizer education intervention had no effect on asthma severity or health care use. Of concern is the high quick-relief and low controller medication use in young children with asthma seen nearly every 3 months for nonurgent care.
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Affiliation(s)
- Arlene M Butz
- Division of General Pediatrics, Department of Pulmonary and Critical Care, The Johns Hopkins University Medical Institutions, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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Benito Fernández J, Trebolazabala Quirante N, Landa Garriz M, Mintegi Raso S, González Díaz C. [Bronchodilators via metered-dose inhaler with spacer in the pediatric emergency department: what is the dosage?]. An Pediatr (Barc) 2006; 64:46-51. [PMID: 16539916 DOI: 10.1016/s1695-4033(06)70008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Bronchodilators administrated through a metered-dose inhaler (MDI) with spacer are as effective as nebulizers in the treatment of acute asthma exacerbations in childhood. However, consensus is lacking on the most suitable dosage. OBJECTIVE To assess the effectiveness of distinct salbutamol and terbutaline doses delivered via an MDI with spacer for the treatment of acute asthma in the pediatric emergency department. METHODS This was a prospective, double-blind randomized study. All consecutive children (n = 324) between 2 and 14 years of age with acute asthma exacerbations treated in the pediatric emergency department between October 1 and November 30, 2004, were included. Two treatment groups were established: one group received a number of puffs equivalent to half the child's weight (1 puff of salbutamol = 100 microg and 1 puff of terbutaline = 250 microg) and the other group received a number of puffs equivalent to one-third of the child's weight. RESULTS Three hundred twenty-four episodes were studied; there were 164 children in the first group and 160 in the second. There were no significant differences between the two groups in the mean (6 SD) age (58.34 +/- 34.72 vs 66.04 +/- 36.45 months), arterial oxygen saturation (95.49 +/- 1.93 vs 95.56 +/- 1.97) or pulmonary score (4.04 +/- 1.55 vs 3.97 +/- 1.51) at recruitment and after treatment in the emergency department (arterial oxygen saturation [96.34 +/- 1.60 vs 96.18 +/- 1.77], pulmonary score [1.87 +/- 1.33 vs 1.64 +/- 1.31]). The number of doses administered (2.17 +/- 0.91 vs 2.24 +/- 1.00) and the hospitalization rate (8.56 % vs 6.87 %) were also similar in both groups. CONCLUSIONS The distinct bronchodilator doses administered via an MDI with spacer showed similar effectiveness. These findings should contribute to a reevaluation of the use of high doses of bronchodilators, at least in most acute asthma exacerbations in children.
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Affiliation(s)
- J Benito Fernández
- Servicio de Urgencias de Pediatría, Hospital de Cruces, Baracaldo, Bilbao, Spain.
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Kelly HW. The Metered-Dose Inhaler Plus Spacer Versus Nebulizer Debate, or I Recently Met an Analysis With Which I Disagreed. ACTA ACUST UNITED AC 2006. [DOI: 10.1089/pai.2006.19.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Sannier N, Timsit S, Cojocaru B, Leis A, Wille C, Garel D, Bocquet N, Chéron G. [Metered-dose inhaler with spacer vs nebulization for severe and potentially severe acute asthma treatment in the pediatric emergency department]. Arch Pediatr 2006; 13:238-44. [PMID: 16423517 DOI: 10.1016/j.arcped.2005.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Accepted: 12/17/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma. METHODS In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later. RESULTS Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P<0.02). The overall length of stay in the emergency department was significantly shorter (148+/-20 vs 108+/-13 min, P<10(-9)). CONCLUSIONS The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.
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Affiliation(s)
- N Sannier
- Université Paris-Descartes, Faculté de Médecine, APHP, Hôpital Necker-Enfants-malades, Département des Urgences Pédiatriques, 149, rue de Sèvres, 75743 Paris cedex 15, France
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41
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Butz AM, Syron L, Johnson B, Spaulding J, Walker M, Bollinger ME. Home-based asthma self-management education for inner city children. Public Health Nurs 2005; 22:189-99. [PMID: 15982192 DOI: 10.1111/j.0737-1209.2005.220302.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Optimal home self-management in young children with asthma includes accurate symptom identification followed by timely and appropriate treatment. The objective of this study was to evaluate a home-based asthma educational intervention targeting symptom identification for parents of children with asthma. Two hundred twenty-one children with asthma were enrolled into an ongoing home-based clinical trial and randomized into either a standard asthma education (SAE) or a symptom/nebulizer education intervention (SNEI). Data included home visit records and parent's self-report on questionnaires. Symptom identification and self-management skills significantly improved from preintervention to postintervention for parents in both groups with the exception of checking medications for expiration dates and the frequency of cleaning nebulizer device and equipment. However, significantly more parents of children in the SNEI group reported treating cough symptoms as compared with the SAE group (p = 0.05). Of concern is that only 38% of all parents reported having an asthma action plan in the home. A targeted home-based asthma education intervention can be effective for improving symptom identification and appropriate use of medications in children with asthma. Home asthma educational programs should address accurate symptom identification and a demonstration of asthma medication delivery devices.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Chipps BE, Murphy KR. Assessment and treatment of acute asthma in children. J Pediatr 2005; 147:288-94. [PMID: 16182663 DOI: 10.1016/j.jpeds.2005.04.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 12/29/2004] [Accepted: 04/21/2005] [Indexed: 11/18/2022]
Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, California, USA.
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Hendeles L, Hatton RC, Coons TJ, Carlson L. Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber. Am J Health Syst Pharm 2005; 62:1053-61. [PMID: 15901590 DOI: 10.1093/ajhp/62.10.1053] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Evidence supporting the delivery of bronchodilators with a metered-dose inhaler and a valved holding chamber (MDI+VHC) in place of a small-volume nebulizer (SVN) is discussed, and the steps taken to accomplish such a conversion program at one institution are described. SUMMARY Double-blind, randomized studies in patients with acute exacerbations of asthma have demonstrated that higher doses of albuterol delivered by MDI+VHC (4-10 puffs per dose) are as effective as 2.5 mg of albuterol sulfate delivered by SVN. Three double-blind studies support the conclusion that the two methods are equivalent with respect to both efficacy and adverse effects in patients with chronic obstructive pulmonary disease. MDI+VHC offers practical advantages over SVN, including the capacity for home use by the patient, portability, less setup time, and no need for daily disinfection. Pharmacists and respiratory therapists obtained approval through the pharmacy and therapeutics committee for respiratory therapists to convert orders for bronchodilators delivered by SVN to administration by MDI+VHC. The conversion policy allows physicians to override it, but none have exercised this option. On intensive care units (ICUs), the policy resulted in a 53% increase in the use of MDI+VHC during the six-month period after it went into effect. Respiratory therapists have been less thorough in implementing the policy for non-ICU patients. CONCLUSION Delivery of bronchodilators by MDI+VHC is as effective as delivery by SVN but offers several advantages. A policy to switch patients from SVN to MDI+VHC for bronchodilator administration met with limited success.
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Affiliation(s)
- Leslie Hendeles
- Pharmacy and Pediatrics, University of Florida (UF), Gainesville, USA.
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Deerojanawong J, Manuyakorn W, Prapphal N, Harnruthakorn C, Sritippayawan S, Samransamruajkit R. Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing. Pediatr Pulmonol 2005; 39:466-72. [PMID: 15786440 DOI: 10.1002/ppul.20204] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- J Deerojanawong
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand R, Rau JL, Smaldone GC, Guyatt G. Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines. Chest 2005; 127:335-71. [PMID: 15654001 DOI: 10.1378/chest.127.1.335] [Citation(s) in RCA: 475] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Evidence-based guidelines for the selection of the appropriate aerosol delivery device in specific clinical settings are needed. AIM (1) To compare the efficacy and adverse effects of treatment using nebulizers vs pressurized metered-dose inhalers (MDIs) with or without a spacer/holding chamber vs dry powder inhalers (DPIs) as delivery systems for beta-agonists, anticholinergic agents, and corticosteroids for several commonly encountered clinical settings and patient populations, and (2) to provide recommendations to clinicians to aid them in selecting a particular aerosol delivery device for their patients. METHODS A systematic review of pertinent randomized, controlled clinical trials (RCTs) was undertaken using MEDLINE, EmBase, and the Cochrane Library databases. A broad search strategy was chosen, combining terms related to aerosol devices or drugs with the diseases of interest in various patient groups and clinical settings. Only RCTs in which the same drug was administered with different devices were included. RCTs (394 trials) assessing inhaled corticosteroid, beta2-agonist, and anticholinergic agents delivered by an MDI, an MDI with a spacer/holding chamber, a nebulizer, or a DPI were identified for the years 1982 to 2001. A total of 254 outcomes were tabulated. Of the 131 studies that met the eligibility criteria, only 59 (primarily those that tested beta2-agonists) proved to have useable data. RESULTS None of the pooled metaanalyses showed a significant difference between devices in any efficacy outcome in any patient group for each of the clinical settings that was investigated. The adverse effects that were reported were minimal and were related to the increased drug dose that was delivered. Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation. CONCLUSIONS Devices used for the delivery of bronchodilators and steroids can be equally efficacious. When selecting an aerosol delivery device for patients with asthma and COPD, the following should be considered: device/drug availability; clinical setting; patient age and the ability to use the selected device correctly; device use with multiple medications; cost and reimbursement; drug administration time; convenience in both outpatient and inpatient settings; and physician and patient preference.
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Affiliation(s)
- Myrna B Dolovich
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
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Benito-Fernández J, González-Balenciaga M, Capapé-Zache S, Vázquez-Ronco MA, Mintegi-Raso S. Salbutamol via metered-dose inhaler with spacer versus nebulization for acute treatment of pediatric asthma in the emergency department. Pediatr Emerg Care 2004; 20:656-9. [PMID: 15454738 DOI: 10.1097/01.pec.0000142948.73512.81] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the effectiveness of salbutamol delivered via a metered-dose inhaler with spacer versus a nebulizer for acute asthma treatment in the pediatric emergency department. METHODS All consecutive children younger than 14 years old who required treatment of acute asthma exacerbation in the emergency department during May 2002 (prospective cohort, n = 321) and May 2001(retrospective cohort, n = 259) were included. Inhaled salbutamol was administered by metered-dose inhaler with a spacer (and a face mask in children younger than 2 years old) in the prospective cohort and by nebulizer in the retrospective cohort. RESULTS There were no significant differences between the two cohorts in the mean (+/-SD) age (44.50 +/- 38.64 vs. 48.37 +/- 43.55 months) and asthma treatment, arterial oxygen saturation (96.34 +/- 2.12% vs. 96.19 +/- 6.32%), and heart rate (123.71 +/- 23.63 vs. 129.41 +/- 34.55 beats/min) before emergency department consultation. The number of doses of inhaled bronchodilators was also similar (1.42 +/- 1.01 vs. 1.45 +/- 0.98) as well as the number of children that required a stay in the observation unit, admission to the hospital, or returned for medical care. The overall mean length of stay in the emergency department was slightly shorter in the prospective cohort (82 +/- 48 vs. 89 +/- 52 minutes). CONCLUSIONS The administration of bronchodilators using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with acute asthma exacerbations in the emergency department.
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Affiliation(s)
- Javier Benito-Fernández
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital de Cruces, Barakaldo, Bizkaia, Spain.
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Castro-Rodriguez JA, Rodrigo GJ. 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. J Pediatr 2004; 145:172-7. [PMID: 15289762 DOI: 10.1016/j.jpeds.2004.04.007] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- José A Castro-Rodriguez
- Pediatric Pulmonary Section, Department of Pediatrics, School of Medicine, University of Chile, Santiago, Chile.
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Benito-Fernández J, Onis-González E, Alvarez-Pitti J, Capapé-Zache S, Vázquez-Ronco MA, Mintegi-Raso S. Factors associated with short-term clinical outcomes after acute treatment of asthma in a pediatric emergency department. Pediatr Pulmonol 2004; 38:123-8. [PMID: 15211695 DOI: 10.1002/ppul.20031] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Outcomes of emergency room treatment of children with asthma have not been well-documented. The purpose of this study was to describe the short-term clinical course of children aged 0-14 years after standard treatment for an acute asthma exacerbation in a pediatric emergency department, and to determine factors associated with follow-up morbidity. This was a prospective cohort study of a randomly selected sample of children with asthma who required treatment for an acute asthma exacerbation during the year 2002. A clinical chart was filled out by the attending pediatrician during the emergency department visit. Participants were interviewed by telephone at 7 and 15 days after the pediatric emergency visit. The study population included 258 children; 125 of them (48.4%) were <2 years old. Eighty-nine percent of children reported a visit with his/her primary asthma care provider during the first week after discharge from the emergency department. A total of 185 children missed 1 or more days of school, with a mean of 3.1 +/- 2.7 days (range, 1-23 days). Twenty-nine patients (11%) returned for medical care at the emergency department, 22 (8.5%) of them during the first week after discharge, and 4 (1.6%) required hospitalization. At the first follow-up control (day 7), 111 patients (43%) reported persistent symptoms and/or difficult breathing, and 157 (61%) were still using asthma medication. At the second follow-up control (day 15), 53 patients (20.5%) reported persistent respiratory symptoms, and 69 (26.7%) used asthma medication. In children >2 years of age, the percentage of patients with respiratory symptoms on day 7 was significantly lower among those who reported maintenance therapy with inhaled steroids (23.7% vs. 46%, P = 0.006). On day 7, asthma symptoms were more frequent in children <2 years of age compared to older children showed a higher percentage of asthma symptoms (50% vs. 36%, P = 0.014). Children <2 years old compared to older children also missed more days school or day nursery (4.48 +/- 4.62 days vs. 2.4 +/- 2.19 days). The short-term outcome of asthma children attended at the emergency department is worse than expected, according to rates of rehospitalization and return for medical care after discharge. Maintenance treatment with inhaled steroids favored a prompt recovery in children older than 2 years of age, whereas the short-term outcome of children aged <2 years was not influenced by any variable.
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Affiliation(s)
- Javier Benito-Fernández
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital de Cruces, Barakaldo, Bizkaia, Spain.
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Ho SA, Ball R, Morrison LJ, Brownlee KG, Conway SP. Clinical value of obtaining sputum and cough swab samples following inhaled hypertonic saline in children with cystic fibrosis. Pediatr Pulmonol 2004; 38:82-7. [PMID: 15170878 DOI: 10.1002/ppul.20035] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prompt detection and treatment of lower respiratory tract infection are essential in the management of patients with cystic fibrosis (CF), who often have signs or symptoms of respiratory infection without any pathogens being isolated from sputum or cough swab specimens. The aims of this study were to assess the efficacy and clinical value of obtaining sputum and oropharyngeal cough swab samples following induction with hypertonic saline (HS) in this group of patients. Forty-three outpatients with CF, mean age 7.2 years (range, 1.8-12.9 years), were recruited over a 2-year period. Nebulized salbutamol was administered, followed by 6% HS. Sputum was preferentially obtained before and after HS induction if possible. If the patient was not able to expectorate, oropharyngeal cough swabs were taken instead. Four patients were able to expectorate sputum before and 19 after HS induction. The procedure was tolerated in 41 of 43 patients. Pathogens were isolated from 13 patients' HS-induced samples, but not from their corresponding preinduced specimens, and 4 patients' preinduced specimens cultured organisms which were not identified from their HS-induced samples. Significant changes were made in the management of 13 (30.2%) patients directly resulting from the positive culture of pathogens only from HS-induced samples. Cultures from oropharyngeal cough swab or expectorated sputum specimens following inhalation of HS provide additional microbiological information which is of clinical value and may lead to changes in patient management.
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Affiliation(s)
- S A Ho
- Department of Paediatrics, University of Leeds, UK
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