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

Current Practices in Pediatric Asthma Care

This article is a comprehensive review of the latest knowledge and developments on pediatric asthma. It serves as a guide for general practitioners and subspecialists who treat asthma. The pathophysiology and critical features of asthma that should be addressed and the latest therapies available are discussed. The areas where further investigation is needed are also highlighted.

Critical reappraisal of short-acting bronchodilators for pediatric respiratory diseases

Short-acting bronchodilators are a class of medications commonly used to treat asthma, chronic obstructive pulmonary disease, and other respiratory conditions. The use of these medications has evolved over time as we have gained a better understanding of their effectiveness and safety in the pediatric population. This comprehensive review synthesizes the current understanding of short-acting β2-agonists and short-acting anticholinergics in children. It addresses indications, contraindications, safety considerations, and highlights areas where further research is needed to guide the most effective use of short-acting bronchodilators.

All shook up: how the COVID-19 pandemic rocked pediatric asthma care

PURPOSE OF REVIEW

Asthma management is a crucial aspect of public health. The landscape of asthma management underwent significant change in the wake of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. These changes greatly affected existing patients, individuals suffering with undiagnosed illness, providers, and the healthcare system as a whole.

RECENT FINDINGS

Providers had to navigate through the potential risk of exposure while weighing the benefit of office visits for patients. This promoted the rapid uptake of telemedicine and virtual outreach, as well as modifications to acute management and controller therapies. Telehealth allowed for the remote monitoring of these patient populations, increased compliance with home-based self-management, and an emphasis on patient education. Furthermore, the pandemic underscored the importance of proactive asthma management as many individuals were left untreated or undiagnosed for various reasons. It is evident that the SARS-CoV-2 pandemic reshaped the landscape of various components of the healthcare system, including asthma management, necessitating innovative approaches to monitoring and patient education.

SUMMARY

Understanding the lessons learned from this time period is crucial for enhancing the resilience of our health system in the wake of future challenges that may be posed against our system.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Assessment and management of asthma exacerbations in an emergency department unit

BACKGROUND

The Pediatric Respiratory Assessment Measure (PRAM) score is a useful tool for the assessment of asthma exacerbations in children. This study aimed to estimate the risk of hospitalization in children, assessed with the PRAM score and having mild-moderate asthma exacerbation, who were treated with salbutamol delivered via a metered-dose inhaler and spacer (MDI/S).

METHODS

The study population consisted of children aged 3-16 years with mild-moderate asthma exacerbations. All children received 1mg/kg prednisolone p.o. (max 40 mg) and 4-6 puffs of salbutamol via MDI/S.

RESULTS

Fifty patients participated in the study. Admission was associated positively with the initial PRAM score (OR: 18.91, CI: 2.42-123.12, P = 0.005) and negatively with the improvement in PRAM score (OR: 0.52, CI: 0.01-0.78, P = 0.032).

CONCLUSION

PRAM is a reliable tool that can be used effectively to estimate the asthma exacerbation severity.

Intermittent Tiotropium Bromide for Episodic Wheezing: A Randomized Trial

BACKGROUND AND OBJECTIVES

Options to treat and prevent episodic wheezing in children are scarce. Our objective was to assess the efficacy of intermittent tiotropium bromide treatment in early childhood episodic wheezing.

METHODS

This 48-week, randomized, open-label, controlled, parallel-group trial was conducted at 4 hospitals in Finland. Children aged 6 to 35 months with 2 to 4 physician-confirmed episodes of wheeze and/or shortness of breath were considered eligible. Study participants were randomly allocated to receive 1 of 3 treatments: once-daily tiotropium bromide 5 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 27), twice-daily fluticasone propionate 125 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 25), or as-needed albuterol sulfate 0.2 mg alone (n = 28). The primary outcome was efficacy, assessed as intention-to-treat by comparing the proportion of episode-free days (the days lacking symptoms or treatments) between the treatment groups.

RESULTS

The proportion of episode-free days was higher in those receiving intermittent tiotropium bromide (median 97% [interquartile range, 93% to 99%]) than in those receiving intermittent fluticasone propionate (87% [78% to 93%], P = .002), or with as-needed albuterol sulfate alone (88% [79% to 95%], P = .003). Adjustment with allergic sensitization, the baseline number of physician-confirmed episodes of wheeze and/or shortness of breath, or short-course glucocorticoid treatment in the 2 weeks before the enrollment, did not affect the result. Intervention-related adverse events were not seen.

CONCLUSIONS

Intermittent tiotropium bromide treatment may be an effective alternative to current therapies for episodic wheezing. Before implementation of use, further research on safety and efficacy is indicated.

Management of Preschool Wheezing: Guideline from the Emilia-Romagna Asthma (ERA) Study Group

Preschool wheezing should be considered an umbrella term for distinctive diseases with different observable and measurable phenotypes. Despite many efforts, there is a large gap in knowledge regarding management of preschool wheezing. In order to fill this lack of knowledge, the aim of these guidelines was to define management of wheezing disorders in preschool children (aged up to 5 years). A multidisciplinary panel of experts of the Emilia-Romagna Region, Italy, addressed twelve different key questions regarding the management of preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes) and systematic reviews have been conducted on PubMed to answer these specific questions, with the aim of formulating recommendations. The GRADE approach has been used for each selected paper, to assess the quality of the evidence and the degree of recommendations. These guidelines represent, in our opinion, the most complete and up-to-date collection of recommendations on preschool wheezing to guide pediatricians in the management of their patients, standardizing approaches. Undoubtedly, more research is needed to find objective biomarkers and understand underlying mechanisms to assess phenotype and endotype and to personalize targeted treatment.

School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review

BACKGROUND

Children with asthma should have immediate access to rescue medication. Yet, <15% of children have access to this life-saving drug while at school.

METHODS

A search was conducted in the all states database of Westlaw to identify which the US states, territories, and the District of Columbia have a law for K-12 schools. Terms searched included (inhaler or asthma/s medic!) and school and (prescription or order) from conception to December 2020. Demographic data from states with and without a policy were compared. All policies were examined for the following components: (1) type of law (statute or regulation); (2) type of school (charter, private/parochial or public); (3) training requirements; (4) devices; (5) prescriptive authority/safe harbor; (6) medication requirements; and (7) mandated documentation, reporting and funding.

RESULTS

Our systematic search revealed 15 locations with existing laws. States with a law had a higher percentage of children under 17-years than states without a law (p = .02). Common components described were the applicability to various types of schools, training requirements for those empowered to administer, and civil liability protections for trained school personnel.

CONCLUSIONS

Existing stock inhaler laws differ vastly across the United States that may impact access to stock albuterol for children at their schools.

An overview on the RSV-mediated mechanisms in the onset of non-allergic asthma

Respiratory syncytial virus (RSV) infection is recognized as an important risk factor for wheezing and asthma, since it commonly affects babies during lung development. While the role of RSV in the onset of atopic asthma is widely recognized, its impact on the onset of non-atopic asthma, mediated via other and independent causal pathways, has long been also suspected, but the association is less clear. Following RSV infection, the release of local pro-inflammatory molecules, the dysfunction of neural pathways, and the compromised epithelial integrity can become chronic and influence airway development, leading to bronchial hyperreactivity and asthma, regardless of atopic status. After a brief review of the RSV structure and its interaction with the immune system and neuronal pathways, this review summarizes the current evidence about the RSV-mediated pathogenic pathways in predisposing and inducing airway dysfunction and non-allergic asthma development.

2020 NAEPP Guidelines Update and GINA 2021-Asthma Care Differences, Overlap, and Challenges

The 2020 National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (NAEPP [2020 Focused Asthma Update]) guidelines and the Global Initiative for Asthma (GINA) 2021 strategy report are compared in this Rostrum article. The methodologies of each publication are described. Subsequently, 4 different selected pharmacological recommendations are compared in the 2 documents: step 1 for children 0 to 4 years of age with viral-induced wheezing, step 2 in ages 12 years and older with the intermittent use of inhaled corticosteroid, steps 3 and 4 with single-inhaler maintenance and reliever therapy with inhaled corticosteroids-formoterol (SMART), and steps 3, 4, and 5 with add-on long-acting muscarinic antagonist therapy. Nonpharmacological recommendations are also considered and contrasted, including for exhaled nitric oxide, environmental control, immunotherapy, and bronchial thermoplasty. Similarities and differences in these 2 documents are highlighted, and recommendations are made about harmonizing the approaches where possible.

Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative

BACKGROUND

Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative.

METHODS

We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach.

RESULTS

We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening.

CONCLUSIONS

The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.

Cost-effectiveness analysis of phenotypic-guided versus guidelines-guided bronchodilator therapy in viral bronchiolitis

OBJECTIVES

Although recent evidence suggests that management of viral bronchiolitis requires something other than guidelines-guided therapy, there is a lack of evidence supporting the economic benefits of phenotypic-guided bronchodilator therapy for treating this disease. The aim of the present study was to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis.

METHODS

A decision analysis model was developed to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. Phenotypic-guided bronchodilator therapy was defined as the administration of albuterol in infants exhibiting a profile of increased likelihood of response to bronchodilators. The effectiveness parameters and costs of the model were obtained from systematic reviews of the literature with meta-analyses and electronic medical records. The main outcome was the avoidance of hospital admission after initial care in the emergency department.

RESULTS

Compared to guidelines-guided strategy, treating patients with viral bronchiolitis with the phenotypic-guided bronchodilator therapy strategy was associated with lower total costs (US$250.99; 95% uncertainty interval [UI]: US$184.37 to $336.51 vs. US$263.46; 95% UI: US$189.81 to $349.19 average cost per patient) and a higher probability of avoidance of hospital admission (0.7902; 95% UI: 0.7315-0.8356 vs. 0.7638; 95% UI: 0.7062-0.8201), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

Compared to guidelines-guided strategy, treating infants with viral bronchiolitis using the phenotypic-guided bronchodilator therapy strategy is a more cost-effective strategy, because it involves a lower probability of hospital admission at lower total treatment costs.

Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature

Our aim was to synthesize the published literature on factors that potentially affect the delivery of bronchodilators using valved holding chambers (VHC) in preschool children. We also aimed to identify those attributes that are not yet incorporated or clearly stated in the guidelines and those topics that are still lacking sufficient data. There is strong evidence supporting several recommendations in current guidelines. Based on present knowledge, bronchodilators should be delivered by VHC administering each puff separately. Face mask should be omitted as soon as the child can hold the mouthpiece of the VHC tightly between the lips and teeth. Based on the review, we suggest adding a specific note to current guidelines about the effect of chamber volume and the impact of co-operation during drug administration. Calming the child and securing a tight face-to-mask seal is critical for successful drug delivery. There is not enough evidence to make specific recommendations on the most reliable VHC and face mask for children. There is an urgent need for studies that evaluate and compare the effectiveness of VHCs in various clinical settings in wide age-groups and respiratory patterns. In addition, there is insufficient data on ideal chamber volume, material, and effective antistatic treatment. What is Known: • Valved holding chambers (VHC) should not be considered interchangeable when used with pressurized metered dose inhalers (pMDI). • Drug delivery is influenced by VHC volume, aerodynamic and electrostatic properties; mask fit; respiratory pattern and co-operation during inhalation; and the number of puffs actuated. What is New: • The impact of co-operation, VHC volume, and good mask-to-face fit during drug inhalation is not stressed enough in the guidelines. • Studies are urgently needed to evaluate the effectiveness of different VHCs in various clinical settings focusing on VHC electrostatic properties, respiratory patters, face masks, and ideal pMDI+VHC combinations.

Emergency department treatment of asthma in children: A review

Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.

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.

The use of β2-adrenoreceptor agonists in viral bronchiolitis: scientific rationale beyond evidence-based guidelines

Despite scientific evidence proving that inhaled β₂-adrenergic receptor (β₂-AR) agonists can reverse bronchoconstriction in all ages, current guidelines advocate against the use of β₂-AR bronchodilators in infants with viral bronchiolitis because clinical trials have not demonstrated an overall clinical benefit. However, there are many different types of viral bronchiolitis, with variations occurring at an individual and viral level. To discard a potentially helpful treatment from all children regardless of their clinical features may be unwarranted. Unfortunately, the clinical criteria to identify the infants that may benefit from bronchodilators from those who do not are not clear. Thus, we summarised the current understanding of the individual factors that may help clinicians determine the highest probability of response to β₂-AR bronchodilators during viral bronchiolitis, based on the individual immunobiology, viral pathogen, host factors and clinical presentation.

There are several factors that may help clinicians determine the highest probability of response to β₂-AR bronchodilators during viral bronchiolitis, based on the individual immunobiology, viral pathogen, host factors and clinical presentationhttps://bit.ly/30CoHcH

Commercial valved spacers versus home-made spacers for delivering bronchodilator therapy in pediatric acute asthma: a cost-effectiveness analysis

Objective: Although valved spacers are the preferred method for administering metered-dose inhaler bronchodilators such as albuterol in pediatric acute asthma, their high cost and their lack of availability have limited their use, especially in low- and middle-income countries (LMICs). Because of this, it is a common practice to use home-made spacers, although a formal analysis evaluating their cost-effectiveness is lacking. Therefore, the objective of this study was to analyze the cost-effectiveness of home-made spacers compared to commercial valved spacers for delivering bronchodilator therapy in pediatric acute asthma.Methods: A decision-analysis model was used to estimate health outcomes and costs of a simulated cohort of pediatric patients treated for acute asthma. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was avoidance of hospital admission.Results: Base-case analysis showed that compared to commercial valved spacers, administering bronchodilators with home-made spacers results in lower overall treatment costs (US$126.75 vs. US$128.59 average cost per patient) without a significant difference in the probability of hospitalization avoided (0.8500 vs. 0.8500).Conclusions: The present study shows that in Colombia, an MIC, compared with commercial valved spacers, the use of home-made spacers for administering bronchodilator therapy is more cost-effective because it yields a similar probability of hospital admission at lower overall treatment costs.

Preschool Wheezing: Trajectories and Long-Term Treatment

Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.

The impact of viral bronchiolitis phenotyping: Is it time to consider phenotype-specific responses to individualize pharmacological management?

Although recent guidelines recommend a minimalist approach to bronchiolitis, there are several issues with this posture. First, there are concerns about the definition of the disease, the quality of the guidelines, the method of administration of bronchodilators, and the availability of tools to evaluate the response to therapies. Second, for decades it has been assumed that all cases of viral bronchiolitis are the same, but recent evidence has shown that this is not the case. Distinct bronchiolitis phenotypes have been described, with heterogeneity in clinical presentation, molecular immune signatures and clinically relevant outcomes such as respiratory failure and recurrent wheezing. New research is critically needed to refine viral bronchiolitis phenotyping at the molecular and clinical levels as well as to define phenotype-specific responses to different therapeutic options.

Metered-dose inhalers vs nebulization for the delivery of albuterol in pediatric asthma exacerbations: A cost-effectiveness analysis in a middle-income country

OBJECTIVES

Although the benefits of albuterol delivered via metered-dose inhalers with a spacer (MDI+S) have been increasingly recognized, the evidence regarding the cost-effectiveness of MDI+S compared to nebulization (NEB) is not sufficient, especially in less-affluent countries, where the clinical and economic burden of the disease is the greatest. The aim of the present study was to evaluate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations.

METHODS

A decision-analysis model was developed to estimate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was the avoidance of hospital admission.

RESULTS

For the base-case analysis, the model showed that compared to NEB, using MDI+S for the delivery of albuterol was associated with lower total costs (US$96.68 vs US$121.41 average cost per patient) and a higher probability of hospital admission avoided (0.9219 vs 0.8900), thus leading to dominance.

CONCLUSIONS

This study shows that in Colombia, an MIC, compared with NEB, the use of MDI+S for delivering albuterol for the treatment of pediatric asthma exacerbations is the preferred strategy because it is associated with a lower probability of hospital admission at lower total treatment costs.

Association of various weight-based doses of continuous albuterol on hospital length of stay

Introduction: Continuous albuterol is a mainstay in management of pediatric status asthmaticus. While the National Heart Lung and Blood Institute Asthma Guidelines suggest 0.5 mg/kg/h as the recommended dosage, there is a paucity of evidence comparing different weight-based rates on hospital outcomes.Methods: Patients requiring continuous albuterol for asthma exacerbation from January 2015 to December 2016 were identified using ICD codes. The concentration of albuterol (5 mg/h-20 mg/h) and the duration of treatment were used to determine total albuterol administration. After dividing by patient weight, average weight-based doses were divided into equal quintiles. Unadjusted and length of stay adjusted for age, initial asthma severity score, and administration of magnesium were compared among the quintiles. The same multivariate analysis was used for duration of continuous albuterol.Results: Five hundred thirty-three hospitalizations for asthma were identified of which 289 received continuous albuterol. Weight-based dosage quintiles ranged from lowest (0.07-0.29 mg/kg/h) to the highest (>0.76-3.2 mg/kg/h). Baseline characteristics were similar aside from age, race, and magnesium administration. There was no difference in adjusted length of stay or adjusted duration of continuous albuterol therapy among the five quintiles.Conclusion: No optimal weight-based dose of continuous albuterol was found. Further investigation is needed to see if lower amounts of continuous albuterol may be as efficacious as higher doses. This could improve cost of status asthmaticus management and limit the number of adverse events associated with high exposure to continuous albuterol.

Nebulized Inhaled Corticosteroids in Asthma Treatment in Children 5 Years or Younger: A Systematic Review and Global Expert Analysis

Although nebulized corticosteroids (NebCSs) are a key treatment option for young children with asthma or viral-induced wheezing (VIW), there are no uniform recommendations on their best use. This systematic review aimed to clarify the role of NebCSs in children 5 years or younger for the management of acute asthma exacerbations, asthma maintenance therapy, and the treatment of VIW. Electronic databases were used to identify relevant English language articles with no date restrictions. Studies reporting efficacy data in children 5 years or younger, with a double-blind, placebo- or open-controlled, randomized design, and inclusion of 40 or more participants (no lower patient limit for VIW) were included. Ten articles on asthma exacerbation, 9 on asthma maintenance, and 7 on VIW were identified. Results showed NebCSs to be at least as efficacious as oral corticosteroids in the emergency room for the management of mild to moderate asthma exacerbations. In asthma maintenance, nebulized budesonide, the agent of focus in all trials analyzed, significantly reduced the risk of further asthma exacerbations compared with placebo, cromolyn sodium, and montelukast. Intermittent NebCS treatment of VIW was as effective as continuous daily treatment. In summary, NebCSs are effective and well tolerated in patients 5 years or younger for the management of acute and chronic asthma.

A Novel, Portable MESH Nebulizer-An Alternative to Metered Dose Inhaler: Efficacy and Usability in Preschool Wheezers

Introduction and Objectives: Wheezing episodes are the first causes of doctor's consultation in preschool age. Treatment is usually administered with a metered dose inhaler (MDI) spacer. At variance, many parents and doctors prefer to use a compressor nebulizer, which cannot be easily carried. The study is aimed at testing whether a pocket mesh nebulizer has similar efficacy and acceptability than a standard MDI device. Materials and Methods: The IPAC study was a randomized, controlled, non-inferiority trial (number: 1616/2018, Ospedale Pediatrico Bambino Gesu'-IRCCS). The study had two arms: cases, using MicroAIR U100, and controls, using MDI+spacer device. Both devices were adopted for long-term treatment and for exacerbations. Follow-up was organized with clinical visits and a daily e-diary connected to an application for mobile phone. Results: One hundred patients were enrolled. The frequency of asthmatic symptoms showed a non-inferiority for MicroAIR U100 group vs. MDI. Accordingly, no significant difference was found in the average % of days with cough, wheezing, breathlessness after exercise, days lost at school, and not-programmed visits. Considering only patients with >1 day with symptoms, no significant sdifferences were found in the number of exacerbations nor in the cumulative days with symptoms. The acceptance and usability of both devices have been favorable. However, the MDI+AeroChamber® device showed better acceptability. Conclusions: Our study shows that MicroAIR U-100, a mesh nebulizer, has similar clinical efficacy but lower acceptance and usability than an MDI plus Aerochamber® in delivering therapy in preschool wheezers. Therefore, MicroAIR U-100 might be a valuable second choice, when the delivery of medication with an MDI plus Aerochamber® is not accepted, or wrongly used by the parents.

Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial

INTRODUCTION

In moderate-severe asthma exacerbation, salbutamol by inhaler (MDI) is superior to salbutamol delivered by nebulizer (NEB); however, to our knowledge, no studies in children with exclusively severe exacerbations were performed.

OBJECTIVE

To compare the efficacy of salbutamol and ipratropium bromide by MDI versus by NEB in severe asthma exacerbations.

METHODS

We performed a clinical trial enrolling 103 children (2-14 years of age) with severe asthma exacerbations (defined by the Pulmonary Score ≥ 7) seen at the emergency room in Asuncion, Paraguay. One group received salbutamol and ipratropium (two puff every 10 min for 2 h and then every 30 min for 2 h more) by MDI with a valved-holding chamber and mask along with oxygen by a cannula separately (MDI-SIB); and the other received nebulization with oxygen (NEB-SIB) of salbutamol and ipratropium (1 every 20 min for 2 h and then every 30 min for 2 h more). Primary outcome was the rate of hospitalization (Pulmonary Score ≥ 7) after 4 h and secondary outcome was oxygen saturation.

RESULTS

Fifty two children received MDI-SIB and 51 NEB-SIB. After the 4th hour, children on MDI-SIB had significantly (P = 0.003) lower rate of hospital admission than on NEB-SIB (5.8% vs 27.5%, RR: 0.21 [0.06-0.69], respectively). Similarly, a significant improved clinical score after 60 min and increase in oxygen saturation after 90 min of treatment was observed in MDI-SIB versus NEB-SIB group (4.46 ± 0.7 vs 5.76 ± 0.65, P < 0.00001; and 90.5 ± 1.7 vs 88.43 1 ± 1, P < 0.00001, respectively).

CONCLUSION

Even in severe asthma exacerbations administration of salbutamol and ipratropium by MDI with valved-holding chamber and mask along with oxygen by a cannula separately was more effective than by a nebulizer.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers

BACKGROUND

Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department.

OBJECTIVE

We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations.

METHODS

This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10.

RESULTS

We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority.

CONCLUSIONS

Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.

Optimizing the Delivery of Inhaled Medication for Respiratory Patients: The Role of Valved Holding Chambers

Valved holding chambers (VHCs) have been used with pressurized metered-dose inhalers since the early 1980s. They have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce side effects such as throat irritation, dysphonia, and oral candidiasis that are common with use of pressurized metered-dose inhalers (pMDIs) alone. VHCs act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a two-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. The design of VHC devices can have an impact on performance. Features such as antistatic properties, effective face-to-facemask seal feedback whistles indicating correct inhalation speed, and inhalation indicators all help improve function and performance, and have been demonstrated to improve asthma control, reduce the rate of exacerbations, and improve quality of life. Not all VHCs are the same, and they are not interchangeable. Each pairing of a pMDI device plus VHC should be considered as a unique delivery system.

The effect of montelukast on early-life wheezing: A randomized, double-blinded placebo-controlled study

BACKGROUND

Cysteinyl-leukotrienes are increased in the airways of infants with virus-associated wheezing. We aimed to determine the effects of a cysteinyl-leukotriene-1 receptor antagonist on symptoms during an early-life wheezing illness and to investigate the factors that affect the response to this drug.

METHOD

This placebo-controlled double-blinded randomized controlled trial recruited children aged 3-36 months with wheezing illness and randomized to active drug or placebo for 56 days. A symptom score diary (SSD) was kept by the children's caregivers.

RESULTS

One-hundred patients completed the study, and 62 (30 montelukast and 32 placebo) were analyzed. There were no significant differences in the percent of symptom-free days, symptom scores, and the need for rescue salbutamol between the two groups. However, the percent of symptom-free days within the first week was significantly higher for the montelukast than for the placebo group (13.8 ± 4.1% vs. 5.4 ± 3.4%; P = 0.028); wheezing score at 7th day was significantly lower for the montelukast than for the placebo group (0.5 ± 0.1 vs. 1.4 ± 0.2; P = 0.002). In addition, the number of inhaled ß₂ -agonist rescue episodes per day during the first week was significantly lower for the montelukast compared with the placebo group (12.7 ± 1.8 vs. 19.2 ± 1.6; P = 0.013). Conclusions Our results indicate that montelukast may be effective for reducing caregiver-observed wheezing and the need for salbutamol during the first week of treatment for early-life wheezing. The impact for caregivers and the optimal duration of treatment will need to be explored in studies of larger size.

A Retrospective Study of the Effectiveness of the AeroChamber Plus® Flow-Vu® Antistatic Valved Holding Chamber for Asthma Control

Introduction

Electrostatic charge in valved holding chambers (VHCs) may lead to inconsistent metered-dose inhaler (MDI) asthma drug delivery. We compared the AeroChamber Plus^® Flow Vu^® Antistatic Valved Holding Chamber (AC⁺FV AVHC) with non-antistatic control VHCs in terms of asthma exacerbations, resource use, and cost in an asthma population.

Methods

Patients included in an adjudicated claims database with AC⁺FV AVHC or non-antistatic VHC (control VHC) use between 1/2010 and 8/2015 (index) who were treated with an inhaled corticosteroid (ICS) or a combination of an ICS and a long-acting β2 agonist MDI within 60 days before or after the index date, were diagnosed with asthma, and had ≥12 months of pre- and ≥30 days of post-index health plan enrollment were included. Cohorts were matched 1:1 using propensity scores. We compared incidence rates (IR) of exacerbation, time to first exacerbation using Kaplan–Meier survival analysis, occurrence of exacerbations, and healthcare resource use and costs using generalized linear models.

Results

9325 patients in each cohort were identified. The IR of exacerbations per 100 person-days (95% CI) was significantly higher in the control VHC cohort than the AC⁺FV AVHC cohort [0.161 (0.150–0.172) vs. 0.137 (0.128–0.147)]. A higher proportion of exacerbation-free patients was observed in the AC⁺FV AVHC cohort. Among the 4293 patients in each cohort with ≥12 months of follow-up, AC⁺FV AVHC patients were found to be 10–12% less likely than control VHC patients to experience an exacerbation throughout the study period. A lower proportion of the AC⁺FV AVHC patients had an ED visit compared to the control VHC patients (10.8% vs. 12.4%). Exacerbation-related costs for the AC⁺FV AVHC cohort were 23%, 25%, 20%, and 12% lower than those for the control VHC cohort at 1, 6, 9, and 12 months, respectively.

Conclusions

The AC⁺FV AVHC was associated with lower exacerbation rates, delayed time to first exacerbation, and lower exacerbation-related costs when compared to control non-antistatic VHCs.

Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews

International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short-acting bronchodilators to treat asthma and wheeze exacerbations in children 0-18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short-acting beta-agonist (SABA) delivered by metered-dose inhaler as first-line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short-acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.

Albuterol via metered-dose inhaler in children: Lower doses are effective, and higher doses are safe

BACKGROUND

The ideal dosing of albuterol via metered-dose inhalers for acute childhood asthma is not well established. We hypothesized that greater doses of albuterol would result in less time in the hospital and lower admission rates.

METHODS

This was a randomized controlled double-blind multicenter study, conducted in emergency rooms (ER). We included patients with 2-17 years old with moderate to severe acute asthma (Pediatric Respiratory Assessment Measure, PRAM, score ≥5). Dosages administered during the first hour included: 6 (up to 25 kg) or 12 puffs (>25 kg) in the control group and 9 (up to 15 kg), 12 (>15-20 kg), 15 (>20-25 kg), or 18 puffs (>25 kg) in the study group. Several efficacy (changes in PRAM score, pulse oximetry, and FEV₁ , length of stay, and admission rates) and safety (albuterol plasma levels, heart rate, serum potassium, glucose and bicarbonate levels, EKG, and tremor rates) outcome measures were assessed.

RESULTS

We included 119 patients with similar baseline conditions, and no significant differences were observed between groups in the length of stay (P = 0.48) or admission rate (P = 0.55). No significant differences were observed in FEV₁ , PRAM score, and pulse oximetry changes after 1 hr and at discharge or admission. No significant differences were observed in safety outcomes between groups.

CONCLUSIONS

Higher albuterol dosage regimens did not result in lower admission rate or shorter length of stay in the ER, but showed similar safety profile for children with moderate to severe acute asthma. Pediatr Pulmonol. 2016;51:1122-1130. © 2016 Wiley Periodicals, Inc.

Improving Resident Knowledge of Spacers

Studies show the delivery of inhaled medications is maximized when a metered-dose inhaler (MDI) with a spacer is utilized. Our residents expressed concern with their knowledge of MDIs and spacers. This study was designed to address those concerns. Residents were given a 12-question pre-intervention, self-assessment questionnaire that explored their overall knowledge and comfort in utilizing MDI with spacers. Participants then received educational intervention via multimedia videos and a demonstration of proper use of MDI with spacer. Participants were given the same questionnaire immediately following the education and again 3 months later. Improvement was significant (P < .05) for each element studied as derived from the 12 questions. Improvement remained significant when these variables were assessed in the 3-month follow-up. In this study, we successfully improved the ability of our residents to deliver quality care by improving their knowledge and confidence in utilizing MDIs with spacers.

Spacers versus nebulizers in treatment of acute asthma - a prospective randomized study in preschool children

OBJECTIVE

To compare administration of bronchodilators by nebulizers with delivery by metered dose inhalers (MDIs) with spacers and to evaluate the clinical effect of the treatment of acute asthma in preschool children.

METHODS

A prospective randomized clinical trial in a pediatric emergency department (PED). Preschool children who were admitted for virus induced wheezing or acute asthma exacerbation were randomly allocated to receive bronchodilator treatment by nebulizer or by metered dose inhaler. The accompanying parents completed a questionnaire.

RESULTS

The length of stay in the PED and the hospitalization rate were similar and no difference was seen in the parents' view of ease of use and device acceptance. Baseline data were similar for both groups apart from the family history of asthma and atopic disease that was greater in the nebulizer group. No significant differences were seen in heart rate, respiratory rate and oxygen saturation at baseline and after the treatment. According to the parents 40% of the participants had asthma diagnosis though up to 66% had some kind of asthma medication.

CONCLUSIONS

Our data suggests that MDIs with spacers are at least as effective as nebulizers in the delivery of beta agonists to treat preschool children with virus induced wheezing or acute exacerbations of asthma in the PED. Parents may underestimate the gravity of their children's asthma. It is mandatory to provide adequate information to the staff and parents in order to treat pediatric acute asthma successfully.

Finnish guidelines for the treatment of laryngitis, wheezing bronchitis and bronchiolitis in children

Evidence-based guidelines are needed to harmonise and improve the diagnostics and treatment of children's lower respiratory tract infections. Following a professional literature search, an interdisciplinary working group evaluated and graded the available evidence and constructed guidelines for treating laryngitis, bronchitis, wheezing bronchitis and bronchiolitis.

CONCLUSION

Currently available drugs were not effective in relieving cough symptoms. Salbutamol inhalations could relieve the symptoms of wheezing bronchitis and should be administered via a holding chamber. Nebulised adrenaline or inhaled or oral glucocorticoids did not reduce hospitalisation rates or relieve symptoms in infants with bronchiolitis and should not be routinely used.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Wheeze in childhood: is the spacer good enough?

Max was treated with SABA using an MDI and spacer with facemask and responded well to the initial treatment. You explained to the parents that nebulisers are neither required nor recommended in the treatment of wheezing in their child's situation. You advised the parents on the proper technique of MDI use with spacer and facemask, as well as care of the equipment. You also gave them a clearly written action plan regarding the efficient management of the next episode of wheeze with MDI and spacer. You further explained the side effects of oral bronchodilators and nebulisers, and why you refrained from using them. Max was given a follow-up appointment to assess his progress, and his parents were advised on the situations when they should go to a doctor or the emergency department.

Principal findings of systematic reviews of acute asthma treatment in childhood

OBJECTIVE

The objective of this study is to summarize the principal findings in the literature about acute asthma management in children.

METHODS

Systematic reviews of randomized clinical trials (SRCTs) with or without meta-analysis in children (1-18 years) admitted to the emergency department (ED) were retrieved using five data bases. Methodological quality was determined using the AMSTAR tool.

RESULTS

One hundred and three studies were retrieved. Among those, 28 SRCTs were included: seven SRCTs related to short-acting beta2-agonists (SABA), three to ipratropium bromide (IB), eight to corticosteroids, one to racemic adrenaline, one to leukotriene receptor antagonists (LTRA), four to magnesium sulfate, one to intravenous (IV) SABA, one to IV aminophylline, one to IV ketamine, and one to antibiotics. It was determined that administering SABA by MDI-VHC is superior to using a nebulizer, because it decreases the hospital admission rate, improves the clinical score, results in a shorter time in the ED, and causes fewer adverse effects. Levalbuterol and albuterol were similar. In patients with moderate to severe exacerbations, IB+SABA was superior to SABA, decreasing hospital admission and improving the clinical score. SABA heliox administered by nebulizer decreased exacerbation severity compared to oxygen. Inhaled corticosteroids (ICS), especially administered by nebulizer, showed results similar to oral corticosteroids (OCS) with respect to reducing hospital admission, unscheduled visits, and the requirement of additional systemic corticosteroids. ICS or OCS following ED discharge was similar with regard to relapse. Compared with a placebo, IV magnesium reduced hospital admission and improved lung function.

CONCLUSIONS

SRCTs are useful for guiding decisions in acute asthma treatment.

Special considerations--asthma in children

BACKGROUND

Asthma is among the most common chronic diseases of childhood. Management of pediatric asthma requires an understanding of the issues that uniquely effect children. This review provides the reader with the current state and future directions of pediatric asthma.

METHODS

Review of the pediatric asthma literature was undertaken with emphasis on randomized controlled trials and systematic reviews.

RESULTS

The prevalence of pediatric asthma remains elevated and is increasingly being appreciated in select global regions. Effective treatment in any setting begins with a focused medical history that queries key asthma features that inform both diagnostic and monitoring strategies. A thorough medical history may yield comorbid upper airway disorders and allergic triggers that could potentially exacerbate airway inflammation. Pre-bronchodilator and post-bronchodilator lung function testing is a preferable diagnostic strategy to quantitatively assess obstructive pulmonary disease among children capable of performing the testing maneuvers. Pediatric asthmatics who continue to have poor disease control require monitoring of medication adherence and drug delivery techniques, because both are often linked with disease outcomes. Therapeutic strategies in children are notably distinct from adults due to the possible effects of inhaled corticosteroids on reduced bone mineral density and growth. Adolescents may also require more time to address the psychosocial complexities that may complicate the required daily usage of asthma medicines.

CONCLUSION

Asthmatic children are distinct from their adult counterparts due to limitations inherent in the pediatric age group. A unified and evidence-based approach to pediatric asthma may improve clinical outcomes.

Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources

Background and objectives

Metered-dose inhalers plus spacers (MDI-spacer) are as effective as, or better than, nebulizers in aerosol delivery. The selection of aerosol delivery system for hospitalized children can have a significant impact on the utilization of healthcare resources.

Design and setting

A quality improvement project to evaluate the impact of conversion to MDI-spacer to administer bronchodilators (BDs) and inhaled corticosteroids (ICSs) to hospitalized children on the utilization of hospital resources. The project was conducted in a tertiary pediatric ward from April to May 2013.

Materials and methods

The project was conducted over a six-week period. In the first two weeks, data were gathered from all hospitalized children receiving BDs and/or ICSs by nebulizers. This data collection was followed by a two-week washout period during which training of healthcare providers and operational changes were implemented to enhance the conversion to MDI-spacer. In the last two weeks, data were gathered from hospitalized children after conversion to MDI-spacer. The primary outcomes included the mean time (in minutes) of medication preparation and delivery. Secondary outcomes included the following: need for respiratory therapy assistance, estimated cost of treatment sessions, and patient/caregiver satisfaction.

Results

Five hundred seventy-five treatment sessions were enrolled (288 on nebulizers, 287 on MDI-spacer). The nebulizer group had more male predominance and were slightly older compared to the MDI-spacer group (male: 59% vs. 53% and mean age: 52 vs. 40 months respectively). The duration of treatment preparation and delivery was significantly lower in the MDI-spacer group (2 min reduction in preparation time and 5 min reduction in delivery time; p < 0.01). Caregivers mastered MDI-spacer use after an average of two observed sessions, eliminating the need for respiratory therapy assistance during the hospital stay. Medication cost analysis showed savings in favor of MDI-spacer (cost reduction per 100 doses: 50% for albuterol, 30% for ipratropium bromide, and 87% for ICSs). The patient satisfaction survey showed “very good” to “excellent” levels in both groups.

Conclusions

Conversion to MDI-spacer for BDs and ICSs administration in hospitalized children improve hospital resource utilization.

Asthma update

Asthma continues to be one of the most common reasons for emergency department visits and a leading cause of hospitalization. Acute management involves severity-based treatment of bronchoconstriction and underlying airway inflammation. Optimal treatment has been defined and standardized through randomized controlled trials, systematic reviews, and consensus guidelines. Implementation of clinical practice guidelines may improve clinical, quality, and safety outcomes. Asthma morbidity is disproportionately high in poor, urban, and minority children. Children treated in emergency departments commonly have persistent chronic severity, significant morbidity, and infrequent follow-up and primary asthma care, and prescription of inhaled corticosteroids is appropriate.

Contemporary topics in pediatric pulmonology for the primary care clinician

Disorders of the respiratory system are commonly encountered in the primary care setting. The presentations are myriad and this review will discuss some of the more intriguing or vexing disorders that the clinician must evaluate and treat. Among these are dyspnea, chronic cough, chest pain, wheezing, and asthma. Dyspnea and chest pain have a spectrum ranging from benign to serious, and the ability to effectively form a differential diagnosis is critical for reassurance and treatment, along with decisions on when to refer for specialist evaluation. Chronic cough is one of the more common reasons for primary care office visits, and once again, a proper differential diagnosis is necessary to assist the clinician in formulating an appropriate treatment plan. Infant wheezing creates much anxiety for parents and accounts for a large number of office visits and hospital admissions. Common diagnoses and evaluation strategies of early childhood wheezing are reviewed. Asthma is one of the most common chronic diseases of children and adults. The epidemiology, diagnosis, evaluation, treatment, and the patient/parent education process will be reviewed. A relatively new topic for primary care clinicians is cystic fibrosis newborn screening. The rationale, methods, outcomes, and implications will be reviewed. This screening program may present some challenges for clinicians caring for newborns, and an understanding of the screening process will help the clinician communicate effectively with parents of the patient.

Asthma medication delivery: mists and myths

Asthma is usually treated with inhaled corticosteroids (ICS) and bronchodilators generated from pressurized metered dose inhalers (pMDI), dry powder inhalers (DPI), or nebulizers. The target areas for ICS and beta 2-agonists in the treatment of asthma are explained. Drug deposition not only depends on particle size, but also on inhalation manoeuvre. Myths regarding inhalation treatments lead to less than optimal use of these delivery systems. We discuss the origin of many of these myths and provide the background and evidence for rejecting them.

Management of status asthmaticus in children

Recent literature on paediatric status asthmaticus (PSA) confirms an increasing percentage of admissions to paediatric intensive care units. PSA is a medical emergency that can be fatal and needs careful and prompt intervention. The severity of PSA is mainly determined by clinical judgement of signs and symptoms. Peak flow measurements and serial lung function measurements are not reliable in PSA. Validated clinically useful instruments are lacking. The three main factors that are involved in the pathophysiology of PSA, bronchoconstriction, mucus plugging and airway inflammation need to be addressed to optimise treatment. Initial therapies include supplementation of oxygen, repetitive administration of rapid acting β2-agonists, inhaled anticholinergics in combination with systemic glucocorticosteroids and intravenous magnesium sulphate. Additional treatment modalities may include methylxanthines, DNase, ketamine, sodium bicarbonate, heliox, epinephrine, non-invasive respiratory support, mechanical ventilation and inhalational anaesthetics.