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González-Bellido V, Veláz-Baza V, Rama-Suárez N, Jimeno-Esteo C, Sirvent-Gomez J, Cuenca-Zaldívar JN, Mayorales-Lises S, Donadio MVF, Fernández-Carnero S. Effects and safety of hypertonic saline combined with airway clearance in non-hospitalized children with recurrent wheezing. Hong Kong Physiother J 2023; 43:105-115. [PMID: 37583920 PMCID: PMC10423675 DOI: 10.1142/s1013702523500105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/27/2023] [Indexed: 08/17/2023] Open
Abstract
Background The International Study of Wheezing in Infants defines recurrent wheezing as the presence of three or more medically documented episodes of wheezing within one year. To date, there is no evidence on the use of hypertonic saline (HS) combined with airway clearance techniques (ACT) for children with recurrent wheezing treated in an outpatient setting. Therefore, this is the first study to explore the use of such interventions in infants with recurrent wheezing. Objectives To evaluate the effects and safety of a three-month protocol including HS and ACT for non-hospitalized infants with recurrent wheezing. Methods Randomized, double-blind, controlled trial, including outpatient infants with recurrent wheezing. Children were randomized to either 3% HS or 0.9% saline groups and were treated with bronchodilator and nebulized with the respective solutions before ACT. The primary outcome was the Wang score. Secondary outcomes included the number of hospitalizations and respiratory crisis, need for rescue medication, and school absences. All variables were measured during the three previous months from inclusion and during intervention period. The study protocol was registered at ClinicalTrials.gov (NCT04331496) on March, 31, 2020. Results Forty children were included. Regarding immediate effects, significant differences (p < 0 . 001 ) were found for time, but not for group or interaction (group × time), in all outcome variables (increase in SpO2, decrease in heart and respiratory rate, wheezing episodes, retraction, and Wang score). Comparing the previous three months with the study period, there were significant differences in both groups for the severity of crisis (p < 0 . 001 ) and medication steps (p = 0 . 002 ). Conclusion A three-month protocol including HS and ACT for outpatient infants with recurrent wheezing was safe and reduced morbidity. No differences were found between the use of HS and 0.9% saline.
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Affiliation(s)
| | | | | | | | | | - Juan Nicolás Cuenca-Zaldívar
- Universidad de Alcalá, Facultad de Medicina y Ciencias de la Salud Departamento de Enfermería y Fisioterapia, Grupo de Investigación en Fisioterapia y Dolor, 28801 Alcalá de Henares, Spain
- Research Group in Nursing and Health Care Puerta de Hierro Health Research Institute - Segovia de Arana (IDIPHISA), Madrid, Spain
- Primary Health Center "El Abajón", Las Rozas de Madrid, Madrid, Spain
| | | | - Márcio Vinícius Fagundes Donadio
- Laboratory of Pediatric Physical Activity, Centro Infant Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
- Departmento de Fisioterapia, Facultad de Medicina y Ciencias de la Salud Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Samuel Fernández-Carnero
- Universidad de Alcalá, Facultad de Medicina y Ciencias de la Salud Departamento de Enfermería y Fisioterapia, Grupo de Investigación en Fisioterapia y Dolor, 28801 Alcalá de Henares, Spain
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Dai J, Wang L, Wang F, Wang L, Wen Q. Noninvasive positive-pressure ventilation for children with acute asthma: a meta-analysis of randomized controlled trials. Front Pediatr 2023; 11:1167506. [PMID: 37187583 PMCID: PMC10175617 DOI: 10.3389/fped.2023.1167506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Background Noninvasive positive-pressure ventilation (NPPV) can be effective in children with acute asthma. However, clinical evidence remains limited. The objective of the meta-analysis was to systematically assess NPPV's effectiveness and safety in treating children with acute asthma. Methods Relevant randomized controlled trials were obtained from electronic resources, including PubMed, Embase, Cochrane's Library, Wanfang, and CNKI databases. The influence of potential heterogeneity was taken into account before using a random-effect model to pool the results. Results A total of 10 RCTs involving 558 children with acute asthma were included in the meta-analysis. Compared to conventional treatment alone, additional use of NPPV significantly improved early blood gas parameters such as the oxygen saturation (mean difference [MD]: 4.28%, 95% confidence interval [CI]: 1.51 to 7.04, p = 0.002; I2 = 80%), partial pressure of oxygen (MD: 10.61 mmHg, 95% CI: 6.06 to 15.16, p < 0.001; I2 = 89%), and partial pressure of carbon dioxide (MD: -6.29 mmHg, 95% CI: -9.81 to -2.77, p < 0.001; I2 = 85%) in the arterial blood. Moreover, NPPV was also associated with early reduced respiratory rate (MD: -12.90, 95% CI: -22.21 to -3.60, p = 0.007; I2 = 71%), improved symptom score (SMD: -1.85, 95% CI: -3.65 to -0.07, p = 0.04; I2 = 92%), and shortened hospital stay (MD: -1.82 days, 95% CI: -2.32 to -1.31, p < 0.001; I2 = 0%). No severe adverse events related to NPPV were reported. Conclusions NPPV in children with acute asthma is associated with improved gas exchange, decreased respiratory rates, a lower symptom score, and a shorter hospital stay. These results suggest that NPPV may be as effective and safe as conventional treatment for pediatric patients with acute asthma.
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Affiliation(s)
- Jiajia Dai
- Department of Respiratory Medicine, National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Libo Wang
- Department of Respiratory Medicine, National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Fang Wang
- Department of Pediatrics, Jinshan Hospital, Fudan University, Shanghai, China
| | - Lu Wang
- Department of Respiratory Medicine, National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Qingfen Wen
- Department of Pediatrics, Jinshan Hospital, Fudan University, Shanghai, China
- Correspondence: Qingfen Wen
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Craig SS, Dalziel SR, Powell CV, Graudins A, Babl FE, Lunny C. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2020; 8:CD012977. [PMID: 32767571 PMCID: PMC8078579 DOI: 10.1002/14651858.cd012977.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Asthma is an illness that commonly affects adults and children, and it serves as a common reason for children to attend emergency departments. An asthma exacerbation is characterised by acute or subacute worsening of shortness of breath, cough, wheezing, and chest tightness and may be triggered by viral respiratory infection, poor compliance with usual medication, a change in the weather, or exposure to allergens or irritants. Most children with asthma have mild or moderate exacerbations and respond well to first-line therapy (inhaled short-acting beta-agonists and systemic corticosteroids). However, the best treatment for the small proportion of seriously ill children who do not respond to first-line therapy is not well understood. Currently, a large number of treatment options are available and there is wide variation in management. OBJECTIVES Main objective - To summarise Cochrane Reviews with or without meta-analyses of randomised controlled trials on the efficacy and safety of second-line treatment for children with acute exacerbations of asthma (i.e. after first-line treatments, titrated oxygen delivery, and administration of intermittent inhaled short-acting beta2-agonists and oral corticosteroids have been tried and have failed) Secondary objectives - To identify gaps in the current evidence base that will inform recommendations for future research and subsequent Cochrane Reviews - To categorise information on reported outcome measures used in trials of escalation of treatment for acute exacerbations of asthma in children, and to make recommendations for development and reporting of standard outcomes in future trials and reviews - To identify relevant randomised controlled trials that have been published since the date of publication of each included review METHODS: We included Cochrane Reviews assessing interventions for children with acute exacerbations of asthma. We searched the Cochrane Database of Systematic Reviews. The search is current to 28 December 2019. We also identified trials that were potentially eligible for, but were not currently included in, published reviews. We assessed the quality of included reviews using the ROBIS criteria (tool used to assess risk of bias in systematic reviews). We presented an evidence synthesis of data from reviews alongside an evidence map of clinical trials. Primary outcomes were length of stay, hospital admission, intensive care unit admission, and adverse effects. We summarised all findings in the text and reported data for each outcome in 'Additional tables'. MAIN RESULTS We identified 17 potentially eligible Cochrane Reviews but extracted data from, and rated the quality of, 13 reviews that reported results for children alone. We excluded four reviews as one did not include any randomised controlled trials (RCTs), one did not provide subgroup data for children, and the last two had been updated and replaced by subsequent reviews. The 13 reviews included 67 trials; the number of trials in each review ranged from a single trial up to 27 trials. The vast majority of comparisons included between one and three trials, involving fewer than 100 participants. The total number of participants included in reviews ranged from 40 to 2630. All studies included children; 16 (24%) included children younger than two years of age. Most of the reviews reported search dates older than four years. We have summarised the published evidence as outlined in Cochrane Reviews. Key findings, in terms of our primary outcomes, are that (1) intravenous magnesium sulfate was the only intervention shown to reduce hospital length of stay (high-certainty evidence); (2) no evidence suggested that any intervention reduced the risk of intensive care admission (low- to very low-certainty evidence); (3) the risk of hospital admission was reduced by the addition of inhaled anticholinergic agents to inhaled beta2-agonists (moderate-certainty evidence), the use of intravenous magnesium sulfate (high-certainty evidence), and the use of inhaled heliox (low-certainty evidence); (4) the addition of inhaled magnesium sulfate to usual bronchodilator therapy appears to reduce serious adverse events during hospital admission (moderate-certainty evidence); (5) aminophylline increased vomiting compared to placebo (moderate-certainty evidence) and increased nausea and nausea/vomiting compared to intravenous beta2-agonists (low-certainty evidence); and (6) the addition of anticholinergic therapy to short-acting beta2-agonists appeared to reduce the risk of nausea (high-certainty evidence) and tremor (moderate-certainty evidence) but not vomiting (low-certainty evidence). We considered 4 of the 13 reviews to be at high risk of bias based on the ROBIS framework. In all cases, this was due to concerns regarding identification and selection of studies. The certainty of evidence varied widely (by review and also by outcome) and ranged from very low to high. AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on interventions for escalation of therapy for acute exacerbations of asthma in children from Cochrane Reviews of randomised controlled trials. A vast majority of comparisons involved between one and three trials and fewer than 100 participants, making it difficult to assess the balance between benefits and potential harms. Due to the lack of comparative studies between various treatment options, we are unable to make firm practice recommendations. Intravenous magnesium sulfate appears to reduce both hospital length of stay and the risk of hospital admission. Hospital admission is also reduced with the addition of inhaled anticholinergic agents to inhaled beta2-agonists. However, further research is required to determine which patients are most likely to benefit from these therapies. Due to the relatively rare incidence of acute severe paediatric asthma, multi-centre research will be required to generate high-quality evidence. A number of existing Cochrane Reviews should be updated, and we recommend that a new review be conducted on the use of high-flow nasal oxygen therapy. Important priorities include development of an internationally agreed core outcome set for future trials in acute severe asthma exacerbations and determination of clinically important differences in these outcomes, which can then inform adequately powered future trials.
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Affiliation(s)
- Simon S Craig
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Emergency Research, Murdoch Children's Research Institute, Parkville, Australia
- Paediatric Emergency Department, Monash Medical Centre, Monash Emergency Service, Monash Health, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
- School of Medicine, Cardiff University, Cardiff, UK
| | - Andis Graudins
- Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Monash Emergency Service, Monash Health, Dandenong Hospital, Dandenong, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Parkville, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics and Centre for Integrated Critical Care, University of Melbourne, Parkville, Australia
| | - Carole Lunny
- Cochrane Hypertension Group, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Felicio-Júnior EL, Barnabé V, de Almeida FM, Avona MD, de Genaro IS, Kurdejak A, Eller MCN, Vergani KP, Rodrigues JC, Tibério IDFLC, Martins MDA, Saraiva-Romanholo BM. Randomized trial of physiotherapy and hypertonic saline techniques for sputum induction in asthmatic children and adolescents. Clinics (Sao Paulo) 2020; 75:e1512. [PMID: 31994616 PMCID: PMC6970279 DOI: 10.6061/clinics/2020/e1512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/19/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES This study aimed to analyze the efficiency of physiotherapy techniques in sputum induction and in the evaluation of pulmonary inflammation in asthmatic children and adolescents. Although hypertonic saline (HS) is widely used for sputum induction (SI), specific techniques and maneuvers of physiotherapy (P) may facilitate the collection of mucus in some asthmatic children and adolescents. METHODS A randomized crossover study was performed in patients with well-controlled asthma, and 90 sputum samples were collected. Children and adolescents were assessed using spirometry and randomized at entry into one of three sputum induction techniques: (i) 3% hypertonic saline - HS technique; (ii) physiotherapy (oscillatory positive expiratory pressure, forced expiration, and acceleration of expiratory flow) - P technique; and (iii) hypertonic saline + physiotherapy - HSP technique. ClinicalTrials.gov: NCT03136042. RESULTS The total cells (mL) and the percentage (%) of differential inflammatory cells were similar in all techniques. The sputum weight (g) in the HSP technique was significantly higher than that in the HS technique. In all techniques, the percentage of viable cells was >50%, and there was no difference between the HS and P techniques. Moreover, sputum induction did not cause any alterations in the pulmonary function of patients. CONCLUSION The physiotherapy sputum collection technique was effective in obtaining viable cells from mucus samples and yielded the same amount of sputum as the gold standard technique (hypertonic saline). In addition, the physiotherapy maneuvers were both safe and useful for sputum induction in asthmatic children and adolescents with well-controlled asthma.
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Affiliation(s)
- Egberto Luiz Felicio-Júnior
- Hospital do Servidor Publico do Estado de Sao Paulo (IAMSPE), Sao Paulo, SP, BR
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Viviani Barnabé
- Hospital do Servidor Publico do Estado de Sao Paulo (IAMSPE), Sao Paulo, SP, BR
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, BR
| | - Francine Maria de Almeida
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | | | | | - Miriam Cardoso Neves Eller
- Departamento de Pediatria e Pneumologia, Instituto da Criança, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Karina Pierantozzi Vergani
- Departamento de Pediatria e Pneumologia, Instituto da Criança, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Joaquim Carlos Rodrigues
- Departamento de Pediatria e Pneumologia, Instituto da Criança, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Milton de Arruda Martins
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Beatriz Mangueira Saraiva-Romanholo
- Hospital do Servidor Publico do Estado de Sao Paulo (IAMSPE), Sao Paulo, SP, BR
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Sekiguchi H, Kondo Y, Fukuda T, Hanashiro K, Baba M, Sato Y, Kukita I, Matumoto T. Noninvasive positive pressure ventilation for treating acute asthmatic attacks in three pregnant women with dyspnea and hypoxemia. Clin Case Rep 2019; 7:881-887. [PMID: 31110708 PMCID: PMC6509929 DOI: 10.1002/ccr3.2117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 11/05/2022] Open
Abstract
In our case reports, we mentioned about the utility of NPPV therapy in addition to standard pharmacologic therapy for acute asthma exacerbations in pregnant women with dyspnea and hypoxemia compared with that of oxygen therapy alone. Careful patient selection and clinicians' NPPV experience are crucial in optimizing patient outcomes.
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Affiliation(s)
- Hiroshi Sekiguchi
- Pulmonary MedicineTomishiro Central HospitalTomigusukuJapan
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
| | - Yutaka Kondo
- Department of Emergency MedicineJuntendo University Urayasu HospitalChibaJapan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
| | - Kazuhiko Hanashiro
- Department of Public Health and Hygiene, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
| | - Motoo Baba
- Pulmonary MedicineOhama Daiichi HospitalNahaJapan
| | - Yoko Sato
- Pulmonary MedicineTomishiro Central HospitalTomigusukuJapan
| | - Ichiro Kukita
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineUniversity of the RyukyusNishiharaJapan
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