Is nebulized aerosol treatment necessary in the pediatric emergency department?

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

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.

Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta(2)-agonists are often administered by nebuliser to relieve bronchospasm, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting.

OBJECTIVES

To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta(2)-agonists for acute asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Trial Register and reference lists of articles. We contacted the authors of studies to identify additional trials. Date of last search: February 2013.

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where spacer beta(2)-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied study inclusion criteria (one review author for the first version of the review), extracted the data and assessed risks of bias. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CIs).

MAIN RESULTS

This review includes a total of 1897 children and 729 adults in 39 trials. Thirty-three trials were conducted in the emergency room and equivalent community settings, and six trials were on inpatients with acute asthma (207 children and 28 adults). The method of delivery of beta(2)-agonist did not show a significant difference in hospital admission rates. In adults, the risk ratio (RR) of admission for spacer versus nebuliser was 0.94 (95% CI 0.61 to 1.43). The risk ratio for children was 0.71 (95% CI 0.47 to 1.08, moderate quality evidence). In children, length of stay in the emergency department was significantly shorter when the spacer was used. The mean duration in the emergency department for children given nebulised treatment was 103 minutes, and for children given treatment via spacers 33 minutes less (95% CI -43 to -24 minutes, moderate quality evidence). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -5% baseline (95% CI -8% to -2%, moderate quality evidence), as was the risk of developing tremor (RR 0.64; 95% CI 0.44 to 0.95, moderate quality evidence).

AUTHORS' CONCLUSIONS

Nebuliser delivery produced outcomes that were not significantly better than metered-dose inhalers delivered by spacer in adults or children, in trials where treatments were repeated and titrated to the response of the participant. Spacers may have some advantages compared to nebulisers for children with acute asthma.

Can Successful Implementation of the Common Canister Program Deliver Cost Containment and Improved Infection Control?

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.

Hypertonic saline and acute wheezing in preschool children

BACKGROUND

Most acute wheezing episodes in preschool children are associated with rhinovirus. Rhinovirus decreases extracellular adenosine triphosphate levels, leading to airway surface liquid dehydration. This, along with submucosal edema, mucus plaques, and inflammation, causes failure of mucus clearance. These preschool children do not respond well to available treatments, even oral steroids. This calls for pro-mucus clearance and prohydration treatments such as hypertonic saline in wheezing preschool children.

METHODS

Randomized, controlled, double-blind study. Forty-one children (mean age 31.9 ± 17.4 months, range 1-6 years) presented with wheezing to the emergency department were randomized after 1 albuterol inhalation to receive either 4 mL of hypertonic saline 5% (HS) (n = 16) or 4 mL of normal saline (NS) (n = 25), both with 0.5 mL albuterol, twice every 20 minutes in the emergency department and 4 times a day thereafter if hospitalized. The primary outcome measured was length of stay (LOS) and the secondary outcomes were admission rate (AR) and clinical severity score.

RESULTS

The LOS was significantly shorter in the HS than in the NS group: median 2 days (range 0-6) versus 3 days (range 0-5) days (P = .027). The AR was significantly lower in the HS than the NS group: 62.2% versus 92%. Clinical severity score improved significantly in both groups but did not reach significance between them.

CONCLUSIONS

Using HS inhalations significantly shortens LOS and lowers AR in preschool children presenting with an acute wheezing episode to the emergency department.

Efficacy of metered-dose inhalers for children with acute asthma exacerbations

OBJECTIVE

To compare the effectiveness of the administration of inhaled beta-agonists delivered via a metered-dose inhaler (MDI) with spacers--as part of an evidence-based asthma pathway developed to manage acute asthma exacerbations in children at the emergency room level and in inpatient management--against administration via nebulization.

DESIGN

Case with historical control.

SETTING

KK Women's and Children's Hospital (Singapore).

PARTICIPANTS

A total of 19,951 children (infants to older children) aged 18 years and younger who attended the emergency room for asthma exacerbations.

MAIN OUTCOME MEASURES

Average length of stay, proportion admitted to high dependency or intensive care, proportion readmitted for unresolved symptoms within 72 hr, cost per patient and overall.

RESULTS

There was no increase in the mean proportion of emergency room attendances admitted to inpatient care with use of an MDI (mean difference 0.97%, 95% CI: -1.6-3.5%, P = 0.447), nor of children admitted to intensive care (0.21 vs. 0.20 pre- and post-pathway, P = 0.827) or to high dependency units (2.21 vs. 1.37 pre- and post-pathway, P = 0.200) but a significant reduction in the within 72 hr re-attendance rate (mean difference 1.4%, 95% CI: 0.78-2.0%, P < 0.001) with use of an MDI. The average length and cost per patient for an inpatient stay for acute asthma exacerbations was reduced with use of an MDI.

CONCLUSIONS

The use of an MDI with spacer as part of an evidence-based asthma pathway was effective in the management of acute asthma exacerbations in the emergency room setting and for inpatient management.

Aerosol therapy in infants and toddlers: past, present and future

Infants and toddlers are a unique subpopulation with regard to aerosol therapy. There are various anatomical, physiological and emotional factors peculiar to this age group that present significant difficulties and challenges for aerosol delivery. Most studies on the factors determining lung deposition of therapeutic aerosols are based on data from adults or older children, which cannot simply be extrapolated directly to infants. The present review describes why infants/toddlers are very different with respect to two major issues - namely their anatomy/physiology and their behavior. We suggest possible solutions and future research directions aimed at improving clinical outcomes of aerosol therapy in this age group.

Advances in treating acute asthma exacerbations in children

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.

Influence of ambulatory inhaled treatment with different devices on the duration of acute asthma findings in children

BACKGROUND

Efficacy of bronchodilator treatment in children with asthma depends on the proper use of inhalation devices. The aim of this study was to compare the efficacy of inhaled bronchodilator treatment with a spacer and a nebulizer in children with acute asthma findings.

METHODS

Fifty-eight children with acute asthma findings who received ambulatory inhaled bronchodilator treatment with a nebulizer and 39 with a spacer were enrolled in the study. Duration of asthma, inhaled steroid treatment and the number of exacerbations during the previous year were recorded. Duration of current acute symptoms, exacerbation severity score and duration of respiratory findings after initiation of treatment were also recorded.

RESULTS

Children in both groups were similar in age (76.5 +/- 30.3 months using a nebulizer vs 83.1 +/- 25.1 in spacer group, p = 0.26). Duration after diagnosis of asthma, initiation of inhaled steroid treatment and exacerbation symptoms were similar between groups (p = 0.15, 0.76 and 0.93, respectively). Exacerbation severity score in the nebulizer group was not significantly different from the spacer group (2.6 +/- 0.7 vs 2.8 +/- 0.7 respectively, p = 0.19). Number of exacerbations in the previous year was not different (2.0 +/- 1.2 in the nebulizer group vs 1.6 +/- 0.9 in the spacer group, p = 0.08). Duration of acute asthma findings after initiation of inhaled bronchodilator treatment was similar between the two groups (6.5 +/- 2.9 vs 7.2 +/- 4.6 p = 0.34).

CONCLUSION

Nebulizers and spacers have similar influence on the duration of acute asthma findings in children when used in ambulatory home bronchodilator treatment.

Quality of care for children hospitalized with asthma

OBJECTIVES

The goals were (1) to identify evidence-based clinical process measures that are appropriate, feasible, and reliable for assessing the quality of inpatient asthma care for children and (2) to evaluate provider compliance with these measures.

METHODS

Key asthma quality measures were identified by using a modified Rand appropriateness method, combining a literature review of asthma care evidence with a consensus panel. The feasibility and reliability of obtaining these measures were determined through manual chart review. Provider compliance with these measures was evaluated through retrospective manual chart review of data for 252 children between 2 and 17 years of age who were admitted to a tertiary care children's hospital in 2005 because of asthma exacerbations.

RESULTS

Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance with these measures was as follows: acute asthma severity assessment at admission, 39%; use of systemic corticosteroid therapy, 98%; use of oral (not intravenous) systemic corticosteroid therapy, 87%; use of ipratropium bromide restricted to <24 hours after admission, 71%; use of albuterol delivered with a metered-dose inhaler (not nebulizer) for children >5 years of age, 20%; documented chronic asthma severity assessment, 22%; parental participation in an asthma education class, 33%; written asthma action plan, 5%; scheduled follow-up appointment with the primary care provider at discharge, 22%.

CONCLUSIONS

Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance across these measures was highly variable but generally low. Our study highlights opportunities for improvement in the provision of asthma care for hospitalized children. Future studies are needed to confirm these findings in other inpatient settings.

Review of optimal characteristics of face-masks for valved-holding chambers (VHCs)

Inhaled drugs are frequently given to infants and young children with a pressurized metered-dose inhaler (pMDI) attached to a valved-holding chamber (VHC) with face mask. In young children and infants who cannot breathe through a mouthpiece, the face mask serves as the interface between the patient and the VHC. Although the mask interface is one of the most important factors determining the dose of medication delivered from the VHC to the nose and mouth in these patients, its optimal characteristics are not well known. Recent studies clearly identify several face mask factors that determine the success or failure of drug delivery with these devices. This review summarizes the most important features of an optimal mask design such as: face seal/leak, volume of dead space, contour, flexibility, transparency, weight and cost. By optimizing these characteristics it should be possible to improve mask design. This will maximize the magnitude and reduce the variability of the dose presented to the respiratory tract while making the mask more comfortable and patient/caregiver-friendly.

Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma

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.

How pediatricians in Spain manage the first acute wheezing episode in an atopic infant. Results from the TRAP study

BACKGROUND

Although the treatment of asthma has been addressed in several guidelines, the management of the first acute wheezing episode in infants has not often been evaluated. We surveyed practicing pediatricians in Spain about the treatment they would provide in a simulated case.

MATERIAL AND METHODS

A random sample of 3000 pediatricians and physicians who normally treated children was surveyed. The questionnaire inquired about how they would treat a first mild-to-moderate wheezing attack in a 5-month-old boy with a personal and family history of allergy. Pediatricians were asked about their professional background.

RESULTS

A total of 2347 questionnaires were returned with useful data (78.2%). Most (90.4%) of the pediatricians would use a short-acting beta2 agonist (SABA) via a metered-dose inhaler with a spacer and a face mask or nebulizer. However, only 34.5% chose a SABA alone: 31.3% added an oral steroid and 27.6% added an inhaled corticosteroid (ICS). The factors associated with the use of ICS in the acute attack were: (1) lack of specific training in pediatrics (OR 1.45; 1.12-1.85) and (2) primary care health center setting (OR 1.31; 1.01-1.69) or rural setting (OR 1.28; 1.01-1.66). Forty-four percent did not recommend any follow-up treatment while 20.7% prescribed ICS as maintenance therapy. The factors related to this decision were the same as those described above.

CONCLUSIONS

The management of a first wheezing episode seems to meet published guidelines among Spanish pediatricians with formal training in pediatrics and in those who work in a hospital setting or in urban areas.

Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting.

OBJECTIVES

To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma.

SEARCH STRATEGY

We last searched the Cochrane Airways Group trials register in January 2006 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2005).

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI).

MAIN RESULTS

This review has been updated in January 2006 and four new trials have been added. 2066 children and 614 adults are now included in 25 trials from emergency room and community settings. In addition, six trials on in-patients with acute asthma (213 children and 28 adults) have been reviewed. Method of delivery of beta2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI 0.63 to 1.49). The relative risk for children was 0.65 (95% CI: 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of -0.47 hours (95% CI: -0.58 to -0.37). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -7.6% baseline (95% CI: -9.9 to -5.3% baseline).

AUTHORS' CONCLUSIONS

Metered-dose inhalers with spacer produced outcomes that were at least equivalent to nebuliser delivery. Spacers may have some advantages compared to nebulisers for children with acute asthma.

2003 canadian asthma consensus guidelines executive summary

BACKGROUND

Guidelines for the diagnosis and management of asthma have been published over the last 15 years; however, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian Asthma Consensus Report, important new studies, particularly in children, have highlighted the need to incorporate new information into the asthma guidelines. The objectives of this article are to review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the 1999 Canadian Asthma Consensus Report and its 2001 update, with a major focus on pediatric issues.

METHODS

The diagnosis of asthma in young children and prevention strategies, pharmacotherapy, inhalation devices, immunotherapy, and asthma education were selected for review by small expert resource groups. The reviews were discussed in June 2003 at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published through December 2004 were subsequently reviewed by the individual expert resource groups.

RESULTS

This report evaluates early-life prevention strategies and focuses on treatment of asthma in children, emphasizing the importance of early diagnosis and preventive therapy, the benefits of additional therapy, and the essential role of asthma education.

CONCLUSION

We generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This document is a guide for asthma management based on the best available published data and the opinion of health care professionals, including asthma experts and educators.

Impact of a criteria-based reimbursement policy on the use of respiratory drugs delivered by nebulizer and health care services utilization in Nova Scotia, Canada

BACKGROUND

In February 2000, the Nova Scotia Seniors' Pharmacare Program announced a change in the reimbursement of respiratory drugs that added specific reimbursement criteria for wet nebulization therapy. Policy implementation coincided with multifaceted interventions to assist patients and providers with the change.

OBJECTIVE

To assess the impact of the new policy and associated interventions on the use of wet nebulization and portable inhaler delivery systems of respiratory drugs and on the utilization of health services.

METHODS

The administrative claims database identified all beneficiaries (age > or = 65 yrs) who received at least one respiratory drug prescription in the 12 months before the study. These patients were then grouped into the wet nebulization cohort or the control cohort receiving a metered-dose or a dry-powder inhaler. The study period was from April 1998-February 2002. Use of respiratory drugs, physician visits, and hospitalizations were compared between study cohorts using an interrupted time-series design.

RESULTS

A sharp decrease was noted in use of wet nebulization after the policy announcement, along with an increase in use of short-acting beta2-agonists and anticholinergic agents delivered by metered-dose or drypowder inhaler. From December 1999 to December 2001, in the heavy wet nebulization cohort (a subset of the wet nebulization cohort), wet nebulization use dropped from 100% to 35%; in the wet nebulization cohort, wet nebulization use decreased from 67% to 20%. Rates of spacer device use were 42%, 31%, and 17% in the heavy wet nebulization, wet nebulization, and control cohorts, respectively, in December 2001. Rates of general practitioner visits and hospitalizations for respiratory conditions did not increase in the intervention cohorts after the policy announcement. In fact, relative to the control cohort, health services use in response to the policy and interventions in the wet nebulization cohort decreased.

CONCLUSION

The reimbursement policy resulted in decreased use of respiratory drugs delivered by wet nebulization without a negative impact on general practitioner visits and hospitalizations for respiratory conditions.

Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber

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.

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

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

Using standardized patient outcome to measure the effect of teaching asthma-related patient education and information-giving skills to medical students

BACKGROUND

Patient education and giving information is a core skill that improves patient adherence and medical outcomes.

PURPOSE

To evaluate the impact of a teaching intervention on 3rd-year students' competency in patient education and information giving about asthma medication delivery.

METHODS

Students (n=81) completed a 1-hr teaching intervention of didactics followed by role playing of asthma patient education scenarios. Using a standardized patient post intervention, patient education and information-giving skills about spacer/metered dose inhalers were scored overall and on a 12-item checklist and compared to a control group (n=70). Students' knowledge was evaluated using a short answer test.

RESULTS

The performance of intervention students on overall patient education, 10 of the 12 checklist items, and the test was significantly higher than controls but did not approach competency.

CONCLUSIONS

The 1-hr intervention improved clinical performance and knowledge, but students did not become competent. Future studies should investigate how competence in this and other core patient education skills can be successfully achieved.

Comparison of efficiency and preference of metal and plastic spacers in preschool children

BACKGROUND

The metal NebuChamber valved holding chamber (VHC) has gained wide acceptance among children with asthma. Due to its nonelectrostatic properties and larger volume, the 250-mL, metal NebuChamber delivers a greater mass of aerosol to a filter at the mouth compared with the commonly used 150-mL polypropylene AeroChamber VHC. Such in vitro results have been used to suggest that this may provide increased efficacy with the NebuChamber. No comparative efficacy data exist for preschool children with asthma.

OBJECTIVE

To compare efficiency and preference of metal and plastic spacers in preschool children.

METHODS

Children with mild-to-moderate persistent asthma received 200 microg of budesonide twice daily by NebuChamber or AeroChamber, both with the mask provided in a randomized, 2-month, crossover trial. Symptom diary cards, beta-agonist use, and preference by children and parents were compared.

RESULTS

Thirty children (mean +/- SD age, 4.3 +/- 0.3 years) completed the study. There was no difference between the AeroChamber and NebuChamber in clinical efficacy outcomes. There was no difference between the AeroChamber and NebuChamber in parents' view of ease of use, design, acceptability by the children, and overall satisfaction.

CONCLUSIONS

Despite a greater total dose delivered to the mouth, the NebuChamber appears no more effective than the AeroChamber and it is not preferred by patients or parents. More parents chose to continue to use the NebuChamber after the study.

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

OBJECTIVE

To compare the efficacy of beta-agonists given by metered-dose inhaler with a valved holding chamber (MDI+VHC) or nebulizer in children under 5 years of age with acute exacerbations of wheezing or asthma in the emergency department setting.

STUDY DESIGN

Published (1966 to 2003) randomized, prospective, controlled trials were retrieved through several different databases. The primary outcome measure was hospital admission.

RESULTS

Six trials (n=491) met criteria for inclusion. Patients who received beta-agonists by MDI+VHC showed a significant decrease in the admission rate compared with those by nebulizer (OR, 0.42; 95% CI, 0.24-0.72; P=.002); this decrease was even more significant among children with moderate to severe exacerbations (OR, 0.27; 95% CI, 0.13-0.54; P=.0003). Finally, measure of severity (eg, clinical score) significantly improved in the group who received beta-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, -0.44; 95% CI, -0.68 to -0.20; P=.0003).

CONCLUSIONS

The use of an MDI+VHC was more effective in terms of decreasing hospitalization and improving clinical score than the use of a nebulizer in the delivery of beta-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma.

Redesigned face mask improves "real life" aerosol delivery for Nebuchamber

The currently available facemask interface for the Nebuchamber (N) valved-holding chamber (VHC) provides a very poor seal to the face, which, on average, decreases the aerosol dose and was previously shown to increase the variability of aerosol delivery. The efficiency of a redesigned mask (RD) for the Nebuchamber with a potentially better seal was compared to the standard mask (SM) supplied with the N in a randomized real-life crossover clinical trial. Twenty children (mean age, 26 +/- 10 months) were randomized to use the Nebuchamber for 1 week with the old mask and then for another week with the newer mask, and vice versa. Filters, changed daily, inserted between the mask and the VHC, trapped the delivered drug (budesonide). The dose of budesonide was quantified by high-performance liquid chromatography (HPLC). Use of the redesigned mask improved aerosol delivery to the filter by 30%, compared to the SM (mean 28.1 +/- 7.7% of nominal dose with RD vs. 21.6 +/- 9.6% with SM, P = 0.017). The relatively high within-subject variability in aerosol delivery (36-38%) did not change, however. Facemasks are arguably the most important determinants of aerosol delivery. The newly developed RD for the Nebuchamber proved to be considerably more efficient than the SM for aerosol delivery to young children. Patient-related factors may be more important with respect to the variability observed.

Severity of acid gastroesophageal reflux assessed by pH metry: is it associated with respiratory disease?

About 50% of children with chronic respiratory diseases (RD) have "silent" gastroesophageal reflux (GER). Our purpose was to evaluate the possibility that RD in patients with GER reflects the presence of more severe acid reflux. We compared the severity of parameters from pH studies in children with chronic RD and "silent" GER, to children with signs of symptomatic gastrointestinal (GI) GER with and without RD. This study included 236 children (aged 1 month to 15 years) with abnormal 24-hr pH monitoring among 718 patients studied for suspected diagnosis of GER. Patients were divided into three groups. Group 1 consisted of children with chronic RD but without any GI symptoms of GER. Group 2 was comprised of children with symptomatic GI presentation of GER such as regurgitation, vomiting, heartburn, and failure to thrive, but without any signs or symptoms of RD. Group 3 included children with prevalent RD and concomitant signs of symptomatic GER. Patients with predominant GI manifestations (group 2) had a significantly higher fraction of time with pH <4 (P < 0.01), total time value of pH <4 (P < 0.05), and longest episode with pH <4 (P < 0.05). Esophageal clearance was significantly longer in group 1 patients than in the other two groups (P < 0.05). Patients with mixed disease (group 3) were similar to patients in group 2. Patients with GI symptoms had significantly worse scores for all parameters evaluated except esophageal clearance score, compared to patients without GI symptoms. Longer esophageal clearance was the only parameter associated with respiratory signs in patients with respiratory symptoms compared to those without. In conclusion, the presence of RD in pediatric patients with silent GER is related to longer esophageal clearance, but is not related to severity of reflux.

Holding chambers versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta-2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. In the community setting nebulisers are more expensive, require a power source and need regular maintenance.

OBJECTIVES

To assess the effects of holding chambers compared to nebulisers for the delivery of beta-2-agonists for acute asthma.

SEARCH STRATEGY

We last searched the Cochrane Airways Group trials register in November 2002 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002).

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where holding chamber beta-2-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI).

MAIN RESULTS

This review has been updated in 2003 and has now analysed 1076 children and 444 adults included in 22 trials from emergency room and community settings. In addition, five trials on in-patients with acute asthma (184 children and 28 adults) have been added to the review. Method of delivery of beta-2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for holding chamber versus nebuliser was 0.88 (95% CI 0.56 to 1.38). The relative risk for children was 0.65 (95% CI 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the holding chamber was used, with a weighted mean difference of -0.47 hours, (95% CI -0.58 to -0.37 hours). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for holding chamber in children, weighted mean difference -7.6% baseline (95% CI -9.9 to -5.3% baseline).

REVIEWER'S CONCLUSIONS

Metered-dose inhalers with holding chamber produced outcomes that were at least equivalent to nebuliser delivery. Holding chambers may have some advantages compared to nebulisers for children with acute asthma.

The efficacy of metered-dose inhalers with a spacer device in the pediatric setting

PURPOSE

To systematically review the published research and report on the efficacy of using a metered-dose inhaler with a spacer (MDI-S) device in a pediatric setting to treat acute exacerbations of asthma.

DATA SOURCES

A literature search was conducted on the CINAHL, Medline, and Cochrane databases; additional searches were made by hand from the reference lists in each study retrieved from databases and from review articles written on the same topic.

CONCLUSION

This critical appraisal of the research demonstrates the MDI-S is as effective as the nebulizer, faster in the delivery of medication, and cost-effective.

IMPLICATIONS FOR PRACTICE

No significant difference between the MDI-S and nebulizer in delivering medication in an acute exacerbation of asthma was found in this analysis. The practitioner's choice of delivery methods should reflect the family's preference, the practice situation, and economic considerations.

Antiasthmatic drug delivery in children

Asthma therapy can be administered to children via a number of routes, including oral, inhaled (via a multiplicity of devices), rectal, intravenous, subcutaneous, and intramuscular. The inhaled route is used most often. This can reduce, but never eliminate, systemic absorption. Swallowed aerosolized medication is subject to hepatic first-pass metabolism, but this metabolic route is bypassed by the drug impacting on the airway, including the pharynx. Although there are a large number of studies from a laboratory setting about drug deposition characteristics, there is very little evidence from community-based studies about what families think actually works well in the everyday treatment of the child. However, it is clear that altering the inhaler device can result in marked changes in the dose administered, and any such change should be part of a review of the dose of prescribed medication. Nebulizers are being used much less frequently, and in particular, all but the most severe exacerbations can be treated at least as effectively with equivalent dosages of beta(2)-adrenoceptor agonists from a large volume spacer.

Management of acute, severe asthma in children

OBJECTIVE

To briefly present the current options available for the treatment of acute, severe asthma in children, with a special focus on emergency department and inpatient treatment, and to describe newer therapies that may aid treatment in the future.

DATA SOURCES AND STUDY SELECTION

A MEDLINE search (1966-May 2001) of the English-language literature pertaining to drug therapy of acute asthma was performed. Key word searches included acute asthma, albuterol, ipratropium, corticosteroids, magnesium, and theophylline. Additional articles from these sources and published national guidelines were identified. Relevant studies pertaining to current therapy of acute asthma in pediatric patients were selected; if there were minimal pediatric data, adult data were included.

DATA SYNTHESIS

Asthma is a chronic, inflammatory disorder of the airways. Acute exacerbations can occur and are challenging to manage. Albuterol, ipratropium, and systemic corticosteroids have been shown to be effective in acute asthma exacerbations. Because some patients do not respond to maximal therapy, older therapies such as magnesium and theophylline are being reevaluated. Theophylline may have some therapeutic effect, but given its toxicity profile, it is unclear whether it offers any advantage over maximal beta(2)-agonist therapy. There are only minimal published data evaluating the use of magnesium in pediatrics, and most are small trials or case reports. Newer therapies such as ventilation strategies with heliox and intravenous leukotriene modifiers currently being evaluated may or may not prove to be beneficial in the future.

CONCLUSIONS

beta(2)-agonists, ipratropium, and corticosteroids remain the most useful therapeutic agents for acute asthma exacerbations in pediatric patients. However, these agents are not ideal in all patients and, given the existing questions regarding safety and/or efficacy of available alternatives, more effective options are needed.

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

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

Contemporary approach to the emergency department management of pediatric asthma

Asthma continues to be an enormous health problem and economic burden in US society. EDs probably will continue to provide a substantial amount of care for those affected by the disease. Pediatric asthma patients frequently are encountered in EDs. Emergency physicians must remain current in their approach to providing expert care while the management of acute asthma exacerbations continues to evolve, older therapies are challenged and new therapies are developed, tested, and implemented.