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Abstract
Medications delivered through oral inhalation represent the cornerstone of pharmacotherapy for asthma and chronic obstructive pulmonary diseases. Several options exist as methods of delivering aerosols to the lung, including metered-dose inhalers, metered-dose inhalers attached to spacers or valved holding chambers, dry powder inhalers, and nebulizers. Delivery of aerosols to the lung is affected by numerous factors including characteristics of aerosol particles, patients’ ventilatory patterns, and physical condition of the lung. It has become increasingly clear that the device used to deliver the medication is an important factor in the extent of deposition and the ultimate therapeutic effect. Further, the same therapeutic agent may exhibit differing effects depending on which delivery device is used. Each inhalation device has specific instructions for use, and the techniques for use vary significantly among the available products. In each case, patients should be instructed and observed to ensure that they have the proper technique of use to achieve an optimal effect.
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Affiliation(s)
- Tina Penick Brock
- Beard Hall CB#7360, School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599
| | - Dennis M. Williams
- Division of Pharmacotherapy, School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599,
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2
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Abstract
Respiratory emergencies are 1 of the most common reasons parents seek evaluation for the their children in the emergency department (ED) each year, and respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients. Whereas many respiratory illnesses are mild and self-limiting, others are life threatening and require prompt diagnosis and management. Therefore, it is imperative that emergency clinicians be able to promptly recognize and manage these illnesses. This article reviews ED diagnosis and management of foreign body aspiration, asthma exacerbation, epiglottitis, bronchiolitis, community-acquired pneumonia, and pertussis.
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Special Considerations for Infants and Young Children. PEDIATRIC ALLERGY: PRINCIPLES AND PRACTICE 2016. [PMCID: PMC7271152 DOI: 10.1016/b978-0-323-29875-9.00032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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4
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Abstract
Pediatric asthma is a disease that is managed across outpatient physicians, hospitalists, critical care physicians, and emergency department (ED) physicians. Scoring systems may facilitate a rapid assessment of the child with asthma in the ED. Short-acting beta agonists are still the mainstay of therapy for acute exacerbations along with corticosteroids and ipratropium bromide. ED providers must also know the indications for noninvasive ventilation and intubation. Most patients can be treated and discharged from the ED after acute exacerbation, and should be given a plan for going home that provides educational material and emergency scenarios to help prevent future acute incidents.
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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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Abstract
Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.
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Affiliation(s)
- Joseph Choi
- McGill University FRCP Emergency Medicine Residency Program, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.62, Montreal, Quebec, Canada H3A 1A1.
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Goh AEN, Tang JPL, Ling H, Hoe TO, Chong NK, Moh CO, Huak CY. Efficacy of metered-dose inhalers for children with acute asthma exacerbations. Pediatr Pulmonol 2011; 46:421-7. [PMID: 21194171 DOI: 10.1002/ppul.21384] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 11/01/2010] [Accepted: 11/05/2010] [Indexed: 11/08/2022]
Abstract
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.
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8
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Abstract
Asthma is a chronic inflammatory disease that renders individuals vulnerable to acute exacerbations. A wide variety of allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, avoidance of relapses, and prevention of future episodes. A written asthma home management plan is essential to minimize the severity of exacerbations. Short-acting beta-agonists, oxygen, and corticosteroids remain fundamental to early intervention in acute asthma exacerbations. Anticholinergics and magnesium sulfate can help nonresponders. Combination inhalers of the long-acting beta-agonist formoterol and inhaled steroid budesonide have been effective in flexible dosing in treating early acute exacerbations and as a daily controller medication outside the United States. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, trigger avoidance, and prompt follow-up can help prevent relapses. Listening to patient preferences and concerns enhances adherence, and regular follow-up care can help prevent future episodes.
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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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11
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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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Castro-Rodríguez JA, Escribano Montaner A, Garde Garde J, Morell Bernabé JJ, Pellegrini Belinchón J, Garcia-Marcos L. How pediatricians in Spain manage the first acute wheezing episode in an atopic infant. Results from the TRAP study. Allergol Immunopathol (Madr) 2006; 33:317-25. [PMID: 16371219 DOI: 10.1016/s0301-0546(05)73250-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- J A Castro-Rodríguez
- Pediatric Respiratory Medicine Dept., School of Medical Sciences, University of Santiago de Chile, Chile
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Abstract
Inhalational drug delivery is the primary mode of asthma therapy in children and is the main focus of this article. Pressurized metered dose inhalers (pMDIs) are now the method of choice in infants and children under 5 years old, when used in combination with an appropriate valved holding chamber or spacer. Spacers are particularly important for steroid inhalation to maximize lung deposition and minimize unwanted oropharyngeal deposition. Optimal inhalation technique with a pMDI-spacer in infants is to inhale the drug by breathing tidally through the spacer. Drug delivery to the lungs using pMDIs can vary greatly, depending on the formulation used and the age of the child. Dry powder inhalers (DPIs) are driven by the peak inspiratory flow of the patient and are usually not appropriate for children under 5 or 6 years of age. Nebulizers continue to play a role in the treatment of acute asthma where high doses of bronchodilator are required, though multiple doses via pMDI spacer may suffice. Important drug delivery issues specific to children include compliance, use of mask versus mouthpiece, lower tidal volumes and inspiratory flows, determination of appropriate dosages, and minimization of adverse local and systemic effects.
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Affiliation(s)
- Sunalene G Devadason
- School of Paediatrics and Child Health, University of Western Australia, Princess Margaret Hospital for Children, Perth, Australia.
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Becker A, Lemière C, Bérubé D, Boulet LP, Ducharme F, Fitzgerald M, Kovesi T. 2003 canadian asthma consensus guidelines executive summary. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2006; 2:24-38. [PMID: 20529217 PMCID: PMC3238210 DOI: 10.1186/1710-1492-2-1-24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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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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Berger WE, Shapiro GG. The use of inhaled corticosteroids for persistent asthma in infants and young children. Ann Allergy Asthma Immunol 2004; 92:387-399; quiz 399-402, 463. [PMID: 15104189 DOI: 10.1016/s1081-1206(10)61773-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review pediatric trials of inhaled corticosteroid (ICS) therapy and summarize data on the pediatric use of devices to facilitate delivery of ICSs. DATA SOURCES Relevant articles regarding ICS treatment of persistent asthma in children younger than 5 years were identified from MEDLINE and reference lists of review articles. STUDY SELECTION Key articles were selected by the authors. RESULTS Clinical trials from the United States and Europe consistently demonstrated that ICS therapy is the most favorable treatment option with regard to safety and efficacy for infants and young children with persistent asthma. This contention is supported by numerous trials of budesonide inhalation suspension in children ranging from 6 months through 8 years of age and data from older children treated with fluticasone propionate. CONCLUSIONS As the only corticosteroid available in the United States as a nebulized formulation and the only ICS product extensively studied in young children and infants, budesonideinhalation suspension is an appropriate first-line therapy for treatment of persistent asthma in this population.
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Affiliation(s)
- William E Berger
- Allergy and Asthma Associates of Southern California, Mission Viejo, California 92691, USA.
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19
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Abstract
All patients with asthma are at risk of having asthma exacerbations characterized by worsening symptoms, airflow obstruction, and an increased requirement for rescue bronchodilators. The goals of managing an asthma exacerbation are prompt recognition and rapid reversal of airflow obstruction to avert relapses and future episodes. Short-acting beta-agonists, oxygen, and corticosteroids form the basis of management of acute asthma exacerbation, but a role is emerging for anticholinergics and newer agents such as levalbuterol and formoterol. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, avoidance of likely triggers, and timely follow-up care prevent setbacks. Acceptance of current treatment guidelines by physicians and adherence to the recommended clinical regimens by patients are essential for effective management of asthma. The physician should strive to establish a constructive relationship with the patient by addressing the patient's concerns, reaching agreement on the goals of therapy, and developing a written action plan for patient self-management.
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Affiliation(s)
- Sitesh R Roy
- Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado 80206, USA
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20
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Abstract
Asthma is a chronic inflammatory disease that renders individuals prone to acute exacerbations. Several allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, prevention of relapses, and forestalling future episodes. A written asthma home-management plan is essential to minimize the severity of exacerbations. Short-acting b-agonists, oxygen, and corticosteroids are fundamental to early intervention in acute asthma exacerbation. Anticholinergics and magnesium sulfate can help nonresponders. Newer agents such as levalbuterol and long-acting b-agonists might be future additions to our armamentarium of drugs to treat acute exacerbations. Initiation or intensification of long-term controller therapy, treatment of co-morbid conditions, and avoidance of possible triggers along with prompt follow-up can help prevent relapses. Listening to patient preferences and concerns to enhance adherence and regular follow-up care can help prevent future episodes.
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Affiliation(s)
- Sitesh R Roy
- Department of Pediatrics, National Jewish Medical & Research Center, 1400 Jackson Street, Denver, CO 80206, USA
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Abstract
Aim of our study was to evaluate if the type of nebulizer can influence the effects of steroid aerosol therapy. We considered 27 asthmatics allergic to grasses with FEV1<80% of the predictive value or methacholine PD20 FEV1<750 mcg. The patients were divided into three groups in relation to the type of nebulizer they used and treated 9 weeks by aerosol therapy with beclomethasone dipropionate bid (800 mcg). Respect to the values recorded at the beginning and at the end of the therapy we found different variations of spirometric indeces and PD20 values among the three groups. We can conclude that the type of nebulizer influences steroid aerosol therapy and, particularly, jet nebulizers seem more efficient than ultrasonic nebulizers.
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Affiliation(s)
- C Terzano
- Department of Cardiovascular and Respiratory Sciences, University La Sapienza, Rome, Italy.
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Buxton LJ, Baldwin JH, Berry JA, Mandleco BL. The efficacy of metered-dose inhalers with a spacer device in the pediatric setting. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2002; 14:390-7. [PMID: 12375358 DOI: 10.1111/j.1745-7599.2002.tb00140.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Chavasse R, Seddon P, Bara A, McKean M. Short acting beta agonists for recurrent wheeze in children under 2 years of age. Cochrane Database Syst Rev 2002; 2010:CD002873. [PMID: 12137663 PMCID: PMC8456461 DOI: 10.1002/14651858.cd002873] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Wheeze is a common symptom in infancy and is a common cause for both primary care consultations and hospital admission. Beta2-adrenoceptor agonists (b2-agonists) are the most frequently used as bronchodilator but their efficacy is questionable. OBJECTIVES To determine the effectiveness of b2-agonist for the treatment of infants with recurrent and persistent wheeze. SEARCH STRATEGY Relevant trials were identified using the Cochrane Airways Group database (CENTRAL), Medline and Pubmed. The database search used the following terms: Wheeze or asthma and Infant or Child and Short acting beta-agonist or Salbutamol (variants), Albuterol, Terbutaline (variants), Orciprenaline, Fenoterol SELECTION CRITERIA Randomised controlled trials comparing the effect of b2-agonist against placebo in children under 2 years of age who had had two or more previous episodes of wheeze, not related to another form of chronic lung disease. DATA COLLECTION AND ANALYSIS Eight studies met the criteria for inclusion in this meta-analysis. The studies investigated patients in three settings: at home (3 studies), in hospital (2 studies) and in the pulmonary function laboratory (3 studies). The main outcome measure was change in respiratory rate except for community based studies where symptom scores were used. MAIN RESULTS The studies were markedly heterogeneous and between study comparisons were limited. Improvement in respiratory rate, symptom score and oxygen saturation were noted in one study in the emergency department following two salbutamol nebulisers but this had no impact on hospital admission. There was a reduction in bronchial reactivity following salbutamol. There was no significant benefit from taking regular inhaled salbutamol on symptom scores recorded at home. REVIEWER'S CONCLUSIONS There is no clear benefit of using b2-agonists in the management of recurrent wheeze in the first two years of life although there is conflicting evidence. At present, further studies should only be performed if the patient group can be clearly defined and there is a suitable outcome parameter capable of measuring a response.
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Affiliation(s)
- R Chavasse
- Kings Healthcare NHS Trust, Kings College Hospital, Bessemer Road, Denmark Hill, London, UK, SE5 9RS.
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Al-Sallami HS, Ball PA, Davey AK. Metered-Dose Inhaler with Spacer versus Nebuliser for Acute Exacerbation of Asthma-A Literature Review. ACTA ACUST UNITED AC 2001. [DOI: 10.1002/jppr2001313189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Singhal T, Garg H, Arora HS, Lodha R, Pandey RM, Kabra SK. Efficacy of a home-made spacer with acute exacerbation of bronchial asthma: a randomized controlled trial. Indian J Pediatr 2001; 68:37-40. [PMID: 11237234 DOI: 10.1007/bf02728855] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Metered dose inhaler (MDI) with spacer is the preferred method for administration of aerosolized medications in pediatric asthma. The expense of commercial spacers limits their use and indigenous alternatives have therefore been developed. Information on the clinical efficacy of home-made spacers is limited. This study was conducted to compare the efficacy of a valve-less home-made spacer with a commercial spacer in delivering salbutamol via MDI in acute asthma. Asthmatic children aged 5-15 years who presented with an acute exacerbation to the pediatric chest clinic of a tertiary care hospital were enrolled in a single blinded randomized parallel group study. The study patients received 10 puffs of salbutamol (100 microg/puff) via MDI-home-made spacer or MDI-commercial spacer. Pre and post inhalation measurements of peak expiratory flow rate (PEFR), oxygen saturation (SaO2), respiratory rate (RR), pulse rate (PR) were made and compared. Sixty children were enrolled in the study, 31 were administered salbutamol via the home-made spacer and 29 via the commercial spacer. The median increase in PEFR was similar in both the groups (20.8% vs 22.2%, p=0.4), clinical improvement being satisfactory in all patients. The valve-less home-made spacer is equally efficacious and cheaper than the commercial spacer in administering bronchodilators in acute exacerbations of asthma. Further studies on the efficacy of home-made spacer in delivery of inhaled steroids are needed.
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Affiliation(s)
- T Singhal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
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Fily A. [Role of bronchodilators in the treatment of acute infant bronchiolitis]. Arch Pediatr 2001; 8 Suppl 1:149S-156S. [PMID: 11232434 DOI: 10.1016/s0929-693x(01)80175-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A Fily
- Service de réanimation néonatale, hôpital Jeanne-de-Flandre, CHRU, 2, place Oscar-Lambret, 59037 Lille, France
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Mandelberg A, Tsehori S, Houri S, Gilad E, Morag B, Priel IE. Is nebulized aerosol treatment necessary in the pediatric emergency department? Chest 2000; 117:1309-13. [PMID: 10807815 DOI: 10.1378/chest.117.5.1309] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Infants and small children admitted to the pediatric emergency department (PED) with acute wheezing episodes (AWE) are currently treated with nebulized wet aerosol (NWA). OBJECTIVE To determine the efficacy of MDI with Nebuchamber (Astra AB; Lund, Sweden), a nonelectrostatic spacer device (NESD), as compared to NWA in the treatment of an unselected population of babies and small children with AWE. DESIGN Randomized, double-blind, placebo-controlled trial. Forty-two children referred to the PED (median age +/- SD, 16 +/- 15 months) with AWE received either placebo MDI through a NESD (four puffs) and salbutamol 0.5 mL (2.5 mg) as a NWA (group I, n = 19), or salbutamol MDI and 0.5 mL of saline solution administered in the same manner as above (group II, n = 23). This treatment was repeated three times every 20 min. RESULTS The respiratory rates (RRs) at baseline were as follows: group I, 45 +/- 11.2 breaths/min; and group II, 52.3 +/- 11.3 breaths/min (p = not significant [NS]). After the first, second, and third interventions, the percent fall from baseline of the RR were as follows: group I, 8.9, 13.1, and 17.9%, respectively; group II, 8. 6, 14.6, and 18.6%, respectively. There was no significant difference at any time in the results between the two groups. The clinical scores (CSs) at baseline were as follows: group I, 6.6 +/- 1.3; group II, 6.8 +/- 1.49 (p = NS). After the first, second, and third interventions, the percent fall from baseline of the CS were as follows: group I, 9.1, 17.9, and 23.2%, respectively; group II, 8. 6, 18.9, and 24.7%, respectively. These results, also, did not differ significantly at any time between the two groups. Hospitalization rate and side effects did not differ between the two groups. CONCLUSIONS We conclude that even in the group of unselected very young children (mean age < 2 years) with AWE, the use of MDI with NESD is at least as effective as the use of NWA. As opposed to data from an adult population, no plateau was reached in the dose-response curve using the above doses over time.
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Affiliation(s)
- A Mandelberg
- Pediatric Pulmonary Unit, Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, Israel.
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Rubilar L, Castro-Rodriguez JA, Girardi G. Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age. Pediatr Pulmonol 2000; 29:264-9. [PMID: 10738013 DOI: 10.1002/(sici)1099-0496(200004)29:4<264::aid-ppul5>3.0.co;2-s] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of this study was to compare the efficacy of salbutamol delivered via a metered-dose inhaler with a spacer and facial mask (MDI-S) vs. a nebulizer (NEB) for the treatment of acute exacerbations of wheezing in children. In a single-blind, prospective, randomized clinical trial, 123 outpatients (1-24 months of age), presenting with "moderate to severe" wheezing, were seen in the emergency department. Children were randomly assigned to one of two salbutamol treatment groups. In the first hour, the MDI-S group received 2 puffs (100 microg/puff) every 10 min for 5 doses, and the NEB group received 0.25 mg/kg every 13 min for 3 doses. If the clinical score was >5 at the end of the first hour, the patients received another hour of the same treatment and also betamethasone (0.5 mg/kg intramuscular). On enrollment and after the first and the second hour of treatment each child had a validated clinical score assigned by a blinded investigator. There were no differences at the time of admission to the emergency department between groups in clinical score or demographic data. Success (clinical score </=5) after the first hour of treatment was 90% (56/62) in the MDI-S group and 71% (43/61) in the NEB group (odds ratio 3.9, 95% confidence interval 1.5-10.4, P = 0.01). After the second hour, the success was 100% in the MDI-S and 94% in the NEB (P > 0.05). We conclude that in this study population, children less than 2 years of age with moderate-severe exacerbations of wheezing responded faster to salbutamol delivered by MDI with a spacer and facial mask than to salbutamol delivered by nebulizer.
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Affiliation(s)
- L Rubilar
- Pediatric Pulmonology Unit, Department of Pediatrics, Exequiel González Cortes Children's Hospital, University of Chile, Santiago, Chile
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Abstract
Aerosolized medications for the treatment of asthma are now considered to be the delivery system of choice. Despite their popularity, traditional pressurized metered dose inhalers are associated with a variety of drawbacks. This article reviews the aerosolized drug delivery systems currently available, along with their advantages and disadvantages. Patient technique in the use of these agents is addressed. Special considerations in children and the elderly are discussed, with specific recommendations tailored to these age groups, followed by practical suggestions for general inhaler use.
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Affiliation(s)
- J A Pongracic
- Department of Pediatrics and Medicine, Northwestern University Medical School, Children's Memorial Hospital, Chicago, IL, USA
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