1
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Almutairi AK, AlGhamdi FA, Althawadi D, Alkhofi MA, Yousef AA. Emergency physicians' preferences in bronchodilator delivery for asthma exacerbations: a cross-sectional study. J Asthma 2024:1-7. [PMID: 39231028 DOI: 10.1080/02770903.2024.2400605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 08/18/2024] [Accepted: 08/30/2024] [Indexed: 09/06/2024]
Abstract
OBJECTIVE Asthma is a chronic respiratory disorder characterized by airway inflammation and narrowing often leading to acute exacerbations that necessitate a visit to the emergency department (ED). While life threatening cases usually require bronchodilator delivery by nebulizers, mild to moderate acute asthma exacerbations can be treated by bronchodilators delivered either by metered dose inhalers (MDI). Numerous studies have attempted to compare between the two modalities and have drawn similar conclusions in that both are comparable in efficacy with minimal differences. What is evident, however, is that physicians remain inclined to favor nebulizers in the majority of acute asthma exacerbations. METHODS In this questionnaire-based study, a survey was distributed to physicians who treat asthma exacerbations to examine demographics, knowledge, beliefs, and current practice in regard to bronchodilator therapy. RESULTS The majority (90.8%) of physicians prefer short-acting beta agonists via nebulizer, with 9.2% favoring MDI + spacer. Participants include consultants, residents, and specialists across various emergency disciplines. While 90.1% find MDI + spacer equally effective as nebulizers, advantages cited include cost-effectiveness (49.6%), shorter ED stays (63.4%), quicker administration (67.9%), and ease of use (58.8%). Challenges include availability (66.4%) and ineffectiveness in younger patients (45%). Despite this, 65.6% are willing to switch to MDI for initial asthma management in the ED, while 34.4% are resistant. CONCLUSION Concerns about availability and effectiveness in younger patients remain barriers. However, a significant number are willing to adopt MDIs with spacers, indicating potential for broader use with better availability and training.
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Affiliation(s)
- Abdullah K Almutairi
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- King Fahd Hospital of the University, Al-Khobar, Saudi Arabia
| | - Faisal A AlGhamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Dana Althawadi
- Department of Emergency, King Hamad University Hospital, Al Sayh, Bahrain
| | - Mohammad A Alkhofi
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- King Fahd Hospital of the University, Al-Khobar, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- King Fahd Hospital of the University, Al-Khobar, Saudi Arabia
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2
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Guérin M, Lepeltier E. Nanomedicines via the pulmonary route: a promising strategy to reach the target? Drug Deliv Transl Res 2024; 14:2276-2297. [PMID: 38587757 DOI: 10.1007/s13346-024-01590-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/09/2024]
Abstract
Over the past decades, research on nanomedicines as innovative tools in combating complex pathologies has increased tenfold, spanning fields from infectiology and ophthalmology to oncology. This process has further accelerated since the introduction of SARS-CoV-2 vaccines. When it comes to human health, nano-objects are designed to protect, transport, and improve the solubility of compounds to allow the delivery of active ingredients on their targets. Nanomedicines can be administered by different routes, such as intravenous, oral, intramuscular, or pulmonary routes. In the latter route, nanomedicines can be aerosolized or nebulized to reach the deep lung. This review summarizes existing nanomedicines proposed for inhalation administration, from their synthesis to their potential clinical use. It also outlines the respiratory organs, their structure, and particularities, with a specific emphasis on how these factors impact the administration of nanomedicines. Furthermore, the review addresses the organs accessible through pulmonary administration, along with various pathologies such as infections, genetic diseases, or cancer that can be addressed through inhaled nanotherapeutics. Finally, it examines the existing devices suitable for the aerosolization of nanomedicines and the range of nanomedicines in clinical development.
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Affiliation(s)
- Mélina Guérin
- Univ Angers, INSERM, CNRS, MINT, SFR ICAT, 49000, Angers, France
| | - Elise Lepeltier
- Univ Angers, INSERM, CNRS, MINT, SFR ICAT, 49000, Angers, France.
- Institut Universitaire de France (IUF), Paris, France.
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3
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Singh DP, Raghunathan V, Dhaliwal MS, Singh R, Kumar A. Acute Levalbuterol Toxicity With Use of Metered Dose Inhaler. Clin Pediatr (Phila) 2024; 63:297-299. [PMID: 37246788 DOI: 10.1177/00099228231177143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
| | - Veena Raghunathan
- Department of Pediatric Critical Care, Medanta-The Medicity, Gurgaon, India
| | | | - Ruby Singh
- Department of Pediatric Critical Care, Medanta-The Medicity, Gurgaon, India
| | - Arvind Kumar
- Department of Pediatric Critical Care, Medanta-The Medicity, Gurgaon, India
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4
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Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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5
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Payares-Salamanca L, Contreras-Arrieta S, Florez-García V, Barrios-Sanjuanelo A, Stand-Niño I, Rodriguez-Martinez CE. Metered-dose inhalers versus nebulization for the delivery of albuterol for acute exacerbations of wheezing or asthma in children: A systematic review with meta-analysis. Pediatr Pulmonol 2020; 55:3268-3278. [PMID: 32940961 DOI: 10.1002/ppul.25077] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The benefits of metered-dose inhalers with a spacer (MDI+S) have increasingly been recognized as an alternative method of albuterol administration for treating pediatric asthma exacerbations. The aim of this systematic review was to compare the response to albuterol delivered through nebulization (NEB) with albuterol delivered through MDI+S in pediatric patients with asthma exacerbations. METHODS We conducted an electronic search in MEDLINE/PubMed, EMBASE, Ovid, and ClinicalTrials. To be included in the review, a study had to a randomized clinical trial comparing albuterol delivered via NEB versus MDI+S; and had to report the rate of hospital admission (primary outcome), or any of the following secondary outcomes: oxygen arterial saturation, heart rate (HR), respiratory rate (RR), the pulmonary index score (PIS), adverse effects, and need for additional treatment. RESULTS Fifteen studies (n = 2057) met inclusion criteria. No significant differences were found between the two albuterol delivery methods in terms of hospital admission (relative risk, 0.89; 95% confidence interval [CI], 0.55-1.46; I2 = 32%; p = .65). There was a significant reduction in the PIS score (mean difference [MD], -0.63; 95% CI, -0.91 to -0.35; I2 = 0%; p < .00001), and a significantly smaller increase in HR (better; MD -6.47; 95% CI, -11.69 to -1.25; I2 = 0%; p = .02) when albuterol was delivered through MDI+S than when it was delivered through NEB. CONCLUSIONS This review, an update of a previously-published meta-analysis, showed a significant reduction in the PIS and a significantly smaller increase in HR when albuterol was delivered through MDI+S than when it was delivered through NEB.
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Affiliation(s)
| | | | - Victor Florez-García
- Department of Public Health, Universidad del Norte, Barranquilla, Colombia.,Environmental Health Sciences, Joseph J. Ziber School of Public Health, University of Wisconsin- Milwaukee, Milwaukee, Wisconsin, USA
| | | | - Ivan Stand-Niño
- Department of Pediatric Pulmonology, School of Medicine, Universidad del Norte, Barranquilla, Colombia
| | - Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
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6
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Venkat AR, Prish C, Brown A, Dozor AJ. Left to Their Own Devices: A Glance Into the Byzantine World of Obtaining Asthma Spacing Devices. Clin Pediatr (Phila) 2020; 59:337-339. [PMID: 31958980 DOI: 10.1177/0009922819901003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Amy Brown
- Boston Children's Health Physicians, Valhalla, NY, USA.,Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, USA.,New York Medical College, Valhalla, NY, USA
| | - Allen J Dozor
- Boston Children's Health Physicians, Valhalla, NY, USA.,Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, USA.,New York Medical College, Valhalla, NY, USA
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7
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Al-Moamary MS, Alhaider SA, Alangari AA, Al Ghobain MO, Zeitouni MO, Idrees MM, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2019; 14:3-48. [PMID: 30745934 PMCID: PMC6341863 DOI: 10.4103/atm.atm_327_18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Respiratory Division, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah F Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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8
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Abaya R, Delgado EM, Scarfone RJ, Reardon AM, Rodio B, Simpkins D, Mehta V, Hayes K, Zorc JJ. Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler. J Asthma 2018; 56:1079-1086. [PMID: 30207821 DOI: 10.1080/02770903.2018.1514629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.
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Affiliation(s)
- Ruth Abaya
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eva M Delgado
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard J Scarfone
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ann Marie Reardon
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bonnie Rodio
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise Simpkins
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vaidehi Mehta
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katie Hayes
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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9
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Abstract
"It is a basic truth of the human condition that everybody lies. The only variable is about what." In paediatric asthma, patients don't take their treatments and doctors rarely ask the right questions. The end result is far too many child deaths. http://ow.ly/OaGK30kFtsD.
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Affiliation(s)
- Mark Rosenthal
- Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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10
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Roncada C, Andrade J, Bischoff LC, Pitrez PM. COMPARISON OF TWO INHALATIONAL TECHNIQUES FOR BRONCHODILATOR ADMINISTRATION IN CHILDREN AND ADOLESCENTS WITH ACUTE ASTHMA CRISIS: A META-ANALYSIS. ACTA ACUST UNITED AC 2018; 36:364-371. [PMID: 29995144 PMCID: PMC6202895 DOI: 10.1590/1984-0462/;2018;36;3;00002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/12/2017] [Indexed: 01/30/2023]
Abstract
Objective: To compare the efficacy of pediatric asthma treatment by nebulizer and
metered-dose inhaler with the use of a spacer (MDI-spacer) in rescue
techniques for asthmatic patients assisted at pediatric emergency units. Data sources: A systematic review was conducted to identify the most relevant randomized
controlled trials comparing the administration of a bronchodilator (β-2
agonist) by two inhalation techniques (nebulization and MDI-spacer) to treat
asthma in children at pediatric emergency units. The following databases
were searched: PubMed, Scientific Electronic Library Online (SciELO), and
ScienceDirect. Two researchers independently applied the eligibility
criteria, and only randomized controlled trials that compared both
inhalation techniques (nebulization and MDI-spacer) for asthma treatment at
pediatric emergency units were included. Data synthesis: 212 articles were pre-selected, of which only nine met the eligibility
criteria and were included in meta-analysis. Results show no differences
between inhalation techniques for any of the four outcomes analyzed: heart
rate (difference - Df: 1.99 [95% confidence interval - 95%CI -2.01-6.00]);
respiratory rate (Df: 0.11 [95%CI -1.35-1.56]); O2 saturation
(Df: -0.01 [95%CI -0.50-0.48]); and asthma score (Df: 0.06 [95%CI
-0,26-0.38]). Conclusions: The findings demonstrate no differences in cardiorespiratory frequency,
O2 saturation, and asthma scores upon administration of β-2
agonist by both inhalation techniques (nebulization and MDI-spacer) to
asthmatic patients assisted at pediatric emergency units.
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Affiliation(s)
- Cristian Roncada
- Centro Universitário da Serra Gaúcha, Caxias do Sul, RS, Brasil.,Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Julia Andrade
- Centro Universitário da Serra Gaúcha, Caxias do Sul, RS, Brasil
| | | | - Paulo Márcio Pitrez
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
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11
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Chow KE, Tyrrell D, Yang M, Abraham LA, Anderson GA, Mansfield CS. Scintigraphic Assessment of Deposition of Radiolabeled Fluticasone Delivered from a Nebulizer and Metered Dose Inhaler in 10 Healthy Dogs. J Vet Intern Med 2017; 31:1849-1857. [PMID: 28961322 PMCID: PMC5697178 DOI: 10.1111/jvim.14832] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/17/2017] [Accepted: 08/21/2017] [Indexed: 11/30/2022] Open
Abstract
Background Aerosolized medications are increasingly being used to treat respiratory diseases in dogs. No previous studies assessing respiratory tract deposition of radiolabeled aerosols have been performed in conscious dogs. Hypothesis/Objectives Assess respiratory tract deposition of radiolabeled, inhalant corticosteroid (fluticasone propionate labeled with 99mTc) delivered from a nebulizer and metered dose inhaler (MDI) to healthy dogs. Animals Ten healthy Foxhounds. Methods Prospective, randomized, cross‐over pilot study. Initial inhalation method (nebulizer or MDI) was randomly assigned. Treatments were crossed over after a 7‐day washout period. Treatments initially were performed using sedation. Dogs were imaged using 2‐dimensional planar scintigraphy, with respiratory tract deposition quantified by manual region‐of‐interest analysis. Deposition calculated as percentage of delivered dose. Six of 10 dogs were randomly selected and reassessed without sedation. Results Inhalation method had significant effect on respiratory tract deposition (P = 0.027). Higher deposition was achieved by nebulization with mean deposition of 4.2% (standard deviation [SD], 1.4%; range, 1.9–6.1%); whereas MDI treatment achieved a mean of 2.3% (SD, 1.4%; range, 0.2–4.2%). Nebulization achieved higher respiratory tract deposition than MDI in 7 of 10 dogs. No statistical difference (P = 0.68) was found between mean respiratory tract deposition achieved in dogs when unsedated (3.8%; SD, 1.5%) or sedated (3.6%; SD, 1.7%). Conclusions and Clinical Importance Study confirms respiratory tract deposition of inhalant medications delivered from a nebulizer and MDI in healthy dogs, breathing tidally with and without sedation. Respiratory tract deposition in these dogs was low compared to reported deposition in adult humans, but similar to reported deposition in children.
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Affiliation(s)
- K E Chow
- Translational Research and Animal Clinical TrialS (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Vic., Australia
| | - D Tyrrell
- Translational Research and Animal Clinical TrialS (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Vic., Australia
| | - M Yang
- Faculty of Pharmacy, The University of Sydney, Camperdown, NSW, Australia
| | - L A Abraham
- Translational Research and Animal Clinical TrialS (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Vic., Australia
| | - G A Anderson
- Translational Research and Animal Clinical TrialS (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Vic., Australia
| | - C S Mansfield
- Translational Research and Animal Clinical TrialS (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Vic., Australia
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12
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Sugimoto M, Suzuki S, Natsume O, Arakawa H. CQ6 Are pMDIs with spacers more effective than nebulizers in the multiple-dose inhalation of beta2-agonists for treating acute asthma exacerbation in children? ACTA ACUST UNITED AC 2017. [DOI: 10.3388/jspaci.31.326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Osamu Natsume
- Department of Pediatrics, Hamamatsu University School of Medicine
| | - Hirokazu Arakawa
- Department of Pediatrics, Gunma University Graduate School of Medicine
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13
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Al-Moamary MS, Alhaider SA, Idrees MM, Al Ghobain MO, Zeitouni MO, Al-Harbi AS, Yousef AA, Al-Matar H, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2016; 11:3-42. [PMID: 26933455 PMCID: PMC4748613 DOI: 10.4103/1817-1737.173196] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Pulmonary Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, University of Dammam, Dammam, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Medicine, Respiratory Division, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013; 2013:CD000052. [PMID: 24037768 PMCID: PMC7032675 DOI: 10.1002/14651858.cd000052.pub3] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In acute asthma inhaled beta(2)-agonists are often administered by nebuliser to relieve bronchospasm, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting. OBJECTIVES To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta(2)-agonists for acute asthma. SEARCH METHODS We searched the Cochrane Airways Group Trial Register and reference lists of articles. We contacted the authors of studies to identify additional trials. Date of last search: February 2013. SELECTION CRITERIA Randomised trials in adults and children (from two years of age) with asthma, where spacer beta(2)-agonist delivery was compared with wet nebulisation. DATA COLLECTION AND ANALYSIS Two review authors independently applied study inclusion criteria (one review author for the first version of the review), extracted the data and assessed risks of bias. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CIs). MAIN RESULTS This review includes a total of 1897 children and 729 adults in 39 trials. Thirty-three trials were conducted in the emergency room and equivalent community settings, and six trials were on inpatients with acute asthma (207 children and 28 adults). The method of delivery of beta(2)-agonist did not show a significant difference in hospital admission rates. In adults, the risk ratio (RR) of admission for spacer versus nebuliser was 0.94 (95% CI 0.61 to 1.43). The risk ratio for children was 0.71 (95% CI 0.47 to 1.08, moderate quality evidence). In children, length of stay in the emergency department was significantly shorter when the spacer was used. The mean duration in the emergency department for children given nebulised treatment was 103 minutes, and for children given treatment via spacers 33 minutes less (95% CI -43 to -24 minutes, moderate quality evidence). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -5% baseline (95% CI -8% to -2%, moderate quality evidence), as was the risk of developing tremor (RR 0.64; 95% CI 0.44 to 0.95, moderate quality evidence). AUTHORS' CONCLUSIONS Nebuliser delivery produced outcomes that were not significantly better than metered-dose inhalers delivered by spacer in adults or children, in trials where treatments were repeated and titrated to the response of the participant. Spacers may have some advantages compared to nebulisers for children with acute asthma.
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Affiliation(s)
- Christopher J Cates
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | - Emma J Welsh
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | - Brian H Rowe
- University of AlbertaDepartment of Emergency MedicineRoom 1G1.43 Walter C. Mackenzie Health Sciences Centre8440 112th StreetEdmontonABCanadaT6G 2B7
- University of AlbertaSchool of Public HeathEdmontonCanada
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Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012; 7:175-204. [PMID: 23189095 PMCID: PMC3506098 DOI: 10.4103/1817-1737.102166] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 09/19/2012] [Indexed: 11/15/2022] Open
Abstract
This an 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 SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Respiratory Division, Department of Medicine, Medical College, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O. Al-Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Pulmonary Division, Department of Medicine, Military Hospital, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Military Hospital, Riyadh, Saudi Arabia
| | - Maha M. Al Dabbagh
- Department of Pediatrics, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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16
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Neel S, Tauman A. Can Successful Implementation of the Common Canister Program Deliver Cost Containment and Improved Infection Control? Hosp Pharm 2012. [DOI: 10.1310/hpj4709-700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To review considerations for implementing the common canister program in hospitals, and to encourage a careful evaluation of a substantial financial and process improvement opportunity involving the common canister program. Background The common canister program has not received a comprehensive evaluation in the literature. It has not been compared to traditional inhaler administration, and the potential infectious risk of the traditional patient-specific inhaler administration process has not been considered. Ten microbiologic studies examining infection risk have been performed using a common canister protocol; no studies have been published with individual inhaler administration without a spacer. The results in all 10 of the common canister microbiologic studies indicated that this program was safe for patients when a multidisciplinary approach was followed and was accompanied by hospitalwide education. Conclusion Because of the opportunity to reduce inhaler expenditures by 50% and the theoretical concerns of contamination from the traditional inhaler process, this program should be evaluated. Best practice requires a relative assessment of all inhaler administration models to determine the safest and most efficacious practice. It may be surprising to learn how an inhaler, after touching a patient's mouth during the individual inhaler administration process, is handled, transported, and stored by staff, and the various contaminated surfaces the inhaler contacts in the retrieval, administration, and return to storage process.
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Affiliation(s)
- Scott Neel
- Implementation Manager, VHA Performance Services, Charlotte, North Carolina
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Lubret M, Bervar JF, Thumerelle C, Deschildre A, Tillie-Leblond I. [Asthma: treatment of exacerbations]. Rev Mal Respir 2012; 29:245-53. [PMID: 22405117 DOI: 10.1016/j.rmr.2011.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 04/12/2011] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Exacerbations remain, in both adults and children, a common reason for emergency consultation. The management of the asthmatic patient with an acute exacerbation is well defined. BACKGROUND The initial evaluation, based on the background risk factors and the clinical examination, will determine the choice of treatment and management. Treatment is based on bronchodilators and corticosteroids in the majority of cases. VIEWPOINTS An episode of exacerbation may be the opportunity to establish contact with the patient (an educational approach) to improve the adherence to long-term treatment with inhaled corticosteroids, which remain the best way of preventing future exacerbations. CONCLUSION Early and appropriate management of exacerbations of asthma should reduce asthma morbidity and mortality. It could also reduce the socioeconomic costs of these episodes and the number and duration of hospital admissions.
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Affiliation(s)
- M Lubret
- Unité de pneumologie allergologie pédiatriques, hôpital Jeanne-de-Flandre, CHRU de Lille, Lille cedex, France
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18
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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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Abstract
The management of acute asthma exacerbations in children remains controversial and the latest guidelines (Expert Panel Report [EPR]-3 2007 and the Global Initiative of Asthma 2008) leave several questions unanswered. This review summarizes the most up-to-date information on the practical prevention and control of asthma attacks in children, and describes the 20-year experience of a major tertiary asthma clinic with the administration of inhaled corticosteroids in this setting. The following subjects are discussed: the knowledge and skills required by the parents regarding asthma and its treatment, how to prevent or minimize exacerbations in asthmatic children, the drugs used in the treatment of exacerbations and their order of administration, and the steps to follow after discharge from the emergency department or after a severe asthma exacerbation. The efficacy of inhaled corticosteroids in the management of acute asthma exacerbations in children, both at home and in the emergency department, is discussed in detail. The goal of asthma-management programs is to arm parents with the skills and knowledge to prevent, detect and successfully control most exacerbations of asthma in children at home.
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Affiliation(s)
- Benjamin Volovitz
- Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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20
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Clark NM, Houle C, Partridge MR, Leo HL, Paton JY. The puzzle of continued use of nebulized therapy by those with asthma. Chron Respir Dis 2010; 7:3-7. [PMID: 20103617 DOI: 10.1177/1479972309357496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Kovesi T, Schuh S, Spier S, Bérubé D, Carr S, Watson W, McIvor RA. Achieving control of asthma in preschoolers. CMAJ 2010; 182:E172-83. [PMID: 19933790 PMCID: PMC2831671 DOI: 10.1503/cmaj.071638] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Thomas Kovesi
- Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
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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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24
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Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med 2008; 40:247-55. [PMID: 19081697 DOI: 10.1016/j.jemermed.2008.06.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 05/30/2008] [Accepted: 06/22/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice. OBJECTIVES We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population. METHODS This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test. RESULTS Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03-$10.28) vs. $18.26 ($9.88-$22.45) in the spacer and nebulizer groups, respectively (p < 0.001). CONCLUSION There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.
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Affiliation(s)
- Michael J Welch
- From the Allergy and Asthma Medical Group and Research Center, San Diego, California 92123, USA.
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26
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Comparison of single 2000-microg dose treatment vs. sequential repeated-dose 500-microg treatments with nebulized budesonide in acute asthma exacerbations. Ann Allergy Asthma Immunol 2008; 100:370-6. [PMID: 18450124 DOI: 10.1016/s1081-1206(10)60601-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND High repeated doses of inhaled corticosteroids (ICSs) are recognized as having a more rapid improvement of outcomes than a single dose of ICS in severe acute asthma. However, to our knowledge, there has been no direct comparison of the early effects of single or repeated administration of the same total dosage of ICS in children with moderate to severe exacerbations of asthma. OBJECTIVE To compare the efficacy of a single dose of 2000 microg of nebulized budesonide with 4 repeated doses of 500 microg of nebulized budesonide in 40 children with an acute asthma exacerbation. METHODS Randomized, double-blind, parallel study that compared the efficacy of 2000 microg of nebulized budesonide, administered in a single dose, with repeated doses (4 doses of 500 microg each) during the first 90 minutes in 40 children (mean [SD] age, 10.7 [2.4] years) with an acute asthma exacerbation that required treatment with an oral corticosteroid. Forced expiratory volume in 1 second, asthma attack score, and oxygen saturation were evaluated at 20, 40, 60, 90, 120, 180, and 240 minutes after initial treatment. Oral corticosteroids were given to all patients at 90 minutes. RESULTS There were no significant differences in forced expiratory volume in 1 second (P = .54) at any times between the groups. Also, asthma scores and oxygen saturation were not different in either group within 90 minutes (P = .51 and P = .64, respectively) and thereafter (P = .35 and P = .87, respectively). CONCLUSION The use of a single dose of nebulized budesonide is as effective as repeated administration of the same total dosage during the first 90 minutes before giving oral corticosteroids in children with moderate to severe exacerbations of asthma.
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Marguet C. [Management of acute asthma in infants and children: recommendations from the French Pediatric Society of Pneumology and Allergy]. Rev Mal Respir 2007; 24:427-39. [PMID: 17468701 DOI: 10.1016/s0761-8425(07)91567-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- C Marguet
- Unité de pneumologie allergologie pédiatrique, Départment de Pédiatrie, Hôpital Charles Nicolle, Rouen Cedex.
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Hurley KF, Sargeant J, Duffy J, Sketris I, Sinclair D, Ducharme J. Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma. Ann Emerg Med 2007; 51:70-7. [PMID: 17559971 DOI: 10.1016/j.annemergmed.2007.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Revised: 03/29/2007] [Accepted: 04/06/2007] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change. METHODS This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes. RESULTS At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED. CONCLUSION Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.
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Affiliation(s)
- Katrina F Hurley
- Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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Sannier N, Timsit S, Cojocaru B, Leis A, Wille C, Garel D, Bocquet N, Chéron G. Traitement aux urgences des crises d’asthme par nébulisations versus chambres d’inhalation. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.allerg.2005.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Heltzer M, Spergel JM. Asthma. COMPREHENSIVE PEDIATRIC HOSPITAL MEDICINE 2007. [PMCID: PMC7152009 DOI: 10.1016/b978-032303004-5.50079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Butz AM, Tsoukleris MG, Donithan M, Hsu VD, Zuckerman I, Mudd KE, Thompson RE, Rand C, Bollinger ME. Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma. ACTA ACUST UNITED AC 2006; 160:622-8. [PMID: 16754825 PMCID: PMC2269706 DOI: 10.1001/archpedi.160.6.622] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine the effectiveness of a home-based asthma education intervention in increasing appropriate nebulizer use and reducing symptom frequency, emergency department (ED) visits, and hospitalizations over 12 months. DESIGN A randomized clinical trial. Settings Pediatric primary care, pulmonary/allergy, and ED practices associated with the University of Maryland Medical System and The Johns Hopkins Hospital, Baltimore. PARTICIPANTS Children with persistent asthma, aged 2 to 9 years, with regular nebulizer use and an ED visit or hospitalization within the past 12 months. Children were randomized into the intervention (n = 110) or control (n = 111) group. Follow-up data were available for 95 intervention and 86 control children. INTERVENTION Home-based asthma education, including symptom recognition, home treatment of acute symptoms, appropriate asthma medication, and nebulizer practice. MAIN OUTCOME MEASURES Estimates of mean differences in asthma symptom frequency, number of ED visits and hospitalizations and appropriate quick relief, controller medication, and nebulizer practice over 12 months. RESULTS Of the 221 children, 181 (81.9%) completed the study. There were no significant differences in home nebulizer practice, asthma morbidity, ED visits, or hospitalizations between groups (P range, .11-.79). Although most children received appropriate nonurgent asthma care (mean, 2 visits per 6 months), more than one third of all children received at least 6 quick-relief medication prescriptions during 12 months, with no difference by group. CONCLUSIONS A nebulizer education intervention had no effect on asthma severity or health care use. Of concern is the high quick-relief and low controller medication use in young children with asthma seen nearly every 3 months for nonurgent care.
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Affiliation(s)
- Arlene M Butz
- Division of General Pediatrics, Department of Pulmonary and Critical Care, The Johns Hopkins University Medical Institutions, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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Saeki Adachi Y, Itazawa T, Nakabayashi M, Fuchizawa T, Okabe Y, Ito Y, Adachi Y, Murakami G, Miyawaki T. Safety and usefulness of a novel eMotion electric mesh nebulizer in children with asthma. Allergol Int 2006; 55:167-71. [PMID: 17075253 DOI: 10.2332/allergolint.55.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Accepted: 12/01/2005] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND A new electronic mesh nebulizer, eMotion is known to have higher performance compared to conventional nebulizers. However, there are some concerns about whether too much delivered dose might cause side effects with higher frequency. METHODS To evaluate the safety and usefulness of the nebulizer, we measured changes in heart rates and lung functions of 73 asthmatic children when they inhaled 1 microg/kg of procaterol with eMotion or a conventional nebulizer, Junior BOY. RESULTS In 34 children with mild asthma exacerbation, physical findings, lung function and transcutaneous oxygen saturation levels were improved after inhalation using both nebulizers. No adverse effects including significant increase of heart rate were found. Improvements in the rates of the parameters were comparable. When response to beta2-agonist inhalation was checked in 39 children in stable condition, similar degrees of improvement in lung function were observed, and heart rates did not change after inhalation with either nebulizers. CONCLUSIONS Safety and efficacy was comparable between eMotion and a conventional nebulizer when it was used to administer beta2-agonists in asthmatic children. However, from the fact that eMotion needs only 3-4 minutes to inhale 2 mL solution, eMotion could be more useful for most children who usually do not prefer longer inhalation time with conventional compressor nebulizers.
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Affiliation(s)
- Yoko Saeki Adachi
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Sugiahi, Toyama, Japan
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Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2006:CD000052. [PMID: 16625527 DOI: 10.1002/14651858.cd000052.pub2] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In acute asthma inhaled beta2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting. OBJECTIVES To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma. SEARCH STRATEGY We last searched the Cochrane Airways Group trials register in January 2006 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2005). SELECTION CRITERIA Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation. DATA COLLECTION AND ANALYSIS Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI). MAIN RESULTS This review has been updated in January 2006 and four new trials have been added. 2066 children and 614 adults are now included in 25 trials from emergency room and community settings. In addition, six trials on in-patients with acute asthma (213 children and 28 adults) have been reviewed. Method of delivery of beta2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI 0.63 to 1.49). The relative risk for children was 0.65 (95% CI: 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of -0.47 hours (95% CI: -0.58 to -0.37). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -7.6% baseline (95% CI: -9.9 to -5.3% baseline). AUTHORS' CONCLUSIONS Metered-dose inhalers with spacer produced outcomes that were at least equivalent to nebuliser delivery. Spacers may have some advantages compared to nebulisers for children with acute asthma.
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Affiliation(s)
- C J Cates
- Bushey Health Centre, Manor View Practice, London Road, Bushey, Watford, Hertfordshire, UK, WD23 2NN.
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Sannier N, Timsit S, Cojocaru B, Leis A, Wille C, Garel D, Bocquet N, Chéron G. [Metered-dose inhaler with spacer vs nebulization for severe and potentially severe acute asthma treatment in the pediatric emergency department]. Arch Pediatr 2006; 13:238-44. [PMID: 16423517 DOI: 10.1016/j.arcped.2005.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Accepted: 12/17/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma. METHODS In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later. RESULTS Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P<0.02). The overall length of stay in the emergency department was significantly shorter (148+/-20 vs 108+/-13 min, P<10(-9)). CONCLUSIONS The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.
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Affiliation(s)
- N Sannier
- Université Paris-Descartes, Faculté de Médecine, APHP, Hôpital Necker-Enfants-malades, Département des Urgences Pédiatriques, 149, rue de Sèvres, 75743 Paris cedex 15, France
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Butz AM, Syron L, Johnson B, Spaulding J, Walker M, Bollinger ME. Home-based asthma self-management education for inner city children. Public Health Nurs 2005; 22:189-99. [PMID: 15982192 DOI: 10.1111/j.0737-1209.2005.220302.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Optimal home self-management in young children with asthma includes accurate symptom identification followed by timely and appropriate treatment. The objective of this study was to evaluate a home-based asthma educational intervention targeting symptom identification for parents of children with asthma. Two hundred twenty-one children with asthma were enrolled into an ongoing home-based clinical trial and randomized into either a standard asthma education (SAE) or a symptom/nebulizer education intervention (SNEI). Data included home visit records and parent's self-report on questionnaires. Symptom identification and self-management skills significantly improved from preintervention to postintervention for parents in both groups with the exception of checking medications for expiration dates and the frequency of cleaning nebulizer device and equipment. However, significantly more parents of children in the SNEI group reported treating cough symptoms as compared with the SAE group (p = 0.05). Of concern is that only 38% of all parents reported having an asthma action plan in the home. A targeted home-based asthma education intervention can be effective for improving symptom identification and appropriate use of medications in children with asthma. Home asthma educational programs should address accurate symptom identification and a demonstration of asthma medication delivery devices.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Chipps BE, Murphy KR. Assessment and treatment of acute asthma in children. J Pediatr 2005; 147:288-94. [PMID: 16182663 DOI: 10.1016/j.jpeds.2005.04.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 12/29/2004] [Accepted: 04/21/2005] [Indexed: 11/18/2022]
Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, California, USA.
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Hendeles L, Hatton RC, Coons TJ, Carlson L. Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber. Am J Health Syst Pharm 2005; 62:1053-61. [PMID: 15901590 DOI: 10.1093/ajhp/62.10.1053] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Evidence supporting the delivery of bronchodilators with a metered-dose inhaler and a valved holding chamber (MDI+VHC) in place of a small-volume nebulizer (SVN) is discussed, and the steps taken to accomplish such a conversion program at one institution are described. SUMMARY Double-blind, randomized studies in patients with acute exacerbations of asthma have demonstrated that higher doses of albuterol delivered by MDI+VHC (4-10 puffs per dose) are as effective as 2.5 mg of albuterol sulfate delivered by SVN. Three double-blind studies support the conclusion that the two methods are equivalent with respect to both efficacy and adverse effects in patients with chronic obstructive pulmonary disease. MDI+VHC offers practical advantages over SVN, including the capacity for home use by the patient, portability, less setup time, and no need for daily disinfection. Pharmacists and respiratory therapists obtained approval through the pharmacy and therapeutics committee for respiratory therapists to convert orders for bronchodilators delivered by SVN to administration by MDI+VHC. The conversion policy allows physicians to override it, but none have exercised this option. On intensive care units (ICUs), the policy resulted in a 53% increase in the use of MDI+VHC during the six-month period after it went into effect. Respiratory therapists have been less thorough in implementing the policy for non-ICU patients. CONCLUSION Delivery of bronchodilators by MDI+VHC is as effective as delivery by SVN but offers several advantages. A policy to switch patients from SVN to MDI+VHC for bronchodilator administration met with limited success.
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Affiliation(s)
- Leslie Hendeles
- Pharmacy and Pediatrics, University of Florida (UF), Gainesville, USA.
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Deerojanawong J, Manuyakorn W, Prapphal N, Harnruthakorn C, Sritippayawan S, Samransamruajkit R. Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing. Pediatr Pulmonol 2005; 39:466-72. [PMID: 15786440 DOI: 10.1002/ppul.20204] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The jet nebulizer is a common device used for administering aerosol medication in young children. However, compared to a metered dose inhaler-spacer (MDI-spacer), it takes more time and personnel. This study aimed to compare the efficacy of salbutamol aerosol therapy given via these two devices in young wheezing children. A prospective randomized, double-blind, placebo-controlled trial was performed in children up to 5 years old who had acute wheezing and were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital. Patients were randomly divided into two groups. The first group received 2 puffs of placebo via MDI-spacer, followed by 0.15 mg/kg salbutamol respiratory solution via jet nebulizer. The second group received 2 puffs (100 microg/puff) of salbutamol via MDI-spacer, followed by placebo via jet nebulizer. Clinical scores and tidal breathing pulmonary function test were evaluated before and after treatment. Pulmonary function parameters included those derived from flow volume loops (volume to peak tidal expiratory flow over total expiratory volume, V(PTEF)/V(E); time to peak tidal expiratory flow over total expiratory time, T(PTEF)/T(E); and ratio of tidal expiratory flow at 25% remaining expiration to peak expiratory flow, 25/PF), compliance (Crs), and resistance (Rrs) of the respiratory system. The efficacy of both methods was compared by using analysis of covariance. Forty-seven wheezing children were studied (24 received salbutamol via MDI-spacer, and 23 received it via jet nebulizer). There was no statistical difference between the two groups regarding clinical scores and all pulmonary function parameters. However, heart rate was significantly increased after treatment in the jet nebulizer group when compared to those in the MDI-spacer group (P = 0.004). In conclusion, the efficacy of salbutamol aerosol therapy via MDI-spacer compared to jet nebulizer in young wheezing children was not different in terms of clinical score and postbronchodilator pulmonary function parameters. However, salbutamol aerosol therapy via jet nebulizer significantly increased the heart rate when compared to the MDI-spacer.
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Affiliation(s)
- J Deerojanawong
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Leung K, Louca E, Coates AL. Comparison of Breath-Enhanced to Breath-Actuated Nebulizers for Rate, Consistency, and Efficiency. Chest 2004; 126:1619-27. [PMID: 15539736 DOI: 10.1378/chest.126.5.1619] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To evaluate differences between three new-generation nebulizers-Pari LC Star (Pari Respiratory Equipment; Mississauga, ON, Canada), AeroEclipse (Trudell Medical International, London, ON, Canada), and Halolite (Medic-Aid Limited, West Sussex, UK)-in terms of rate and amount of expected deposition as well as the consistency of the doses delivered. METHODS The in vitro performance characteristics were determined and then coupled to the respiratory pattern of seven patients with cystic fibrosis (age range, 4 to 18 years) in order to calculate expected deposition. The Pari LC Star and AeroEclipse were characterized while being driven by the Pari ProNeb Ultra compressor (Pari Respiratory Equipment) for home use, and by a 50-psi medical air hospital source. The Halolite has its own self-contained compressor. Algorithms for the rate of output for the inspiratory flow were developed for each device. Patient flow patterns were divided into 5-ms epochs, and the expected deposition for each epoch was calculated from the algorithms. Summed over a breath, this allowed the calculation of the estimated deposition for each patient's particular pattern of breathing. RESULTS The rate of deposition was highest for the Pari LC Star and lowest for the Halolite. Rate of deposition was independent of respiratory pattern for the Pari LC Star and AeroEclipse, but proportional to respiratory rate for the Halolite. The differences between the Pari LC Star and AeroEclipse were less when driven by the 50-psi source. The AeroEclipse had the least amount of drug wastage. As designed, the Halolite delivered a predetermined amount of drug very accurately, whereas expected deposition when run to dryness of the other two devices had significant variations. CONCLUSIONS To minimize treatment time, the Pari LC Star would be best. To minimize drug wastage, the AeroEclipse would be best. To accurately deliver a specific drug dose, the Halolite would be best.
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Affiliation(s)
- Kitty Leung
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada
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Benito-Fernández J, González-Balenciaga M, Capapé-Zache S, Vázquez-Ronco MA, Mintegi-Raso S. Salbutamol via metered-dose inhaler with spacer versus nebulization for acute treatment of pediatric asthma in the emergency department. Pediatr Emerg Care 2004; 20:656-9. [PMID: 15454738 DOI: 10.1097/01.pec.0000142948.73512.81] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the effectiveness of salbutamol delivered via a metered-dose inhaler with spacer versus a nebulizer for acute asthma treatment in the pediatric emergency department. METHODS All consecutive children younger than 14 years old who required treatment of acute asthma exacerbation in the emergency department during May 2002 (prospective cohort, n = 321) and May 2001(retrospective cohort, n = 259) were included. Inhaled salbutamol was administered by metered-dose inhaler with a spacer (and a face mask in children younger than 2 years old) in the prospective cohort and by nebulizer in the retrospective cohort. RESULTS There were no significant differences between the two cohorts in the mean (+/-SD) age (44.50 +/- 38.64 vs. 48.37 +/- 43.55 months) and asthma treatment, arterial oxygen saturation (96.34 +/- 2.12% vs. 96.19 +/- 6.32%), and heart rate (123.71 +/- 23.63 vs. 129.41 +/- 34.55 beats/min) before emergency department consultation. The number of doses of inhaled bronchodilators was also similar (1.42 +/- 1.01 vs. 1.45 +/- 0.98) as well as the number of children that required a stay in the observation unit, admission to the hospital, or returned for medical care. The overall mean length of stay in the emergency department was slightly shorter in the prospective cohort (82 +/- 48 vs. 89 +/- 52 minutes). CONCLUSIONS The administration of bronchodilators using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with acute asthma exacerbations in the emergency department.
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Affiliation(s)
- Javier Benito-Fernández
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital de Cruces, Barakaldo, Bizkaia, Spain.
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Abstract
All asthmatics regardless of their perceived severity, are at risk of exacerbation, particularly if they are suboptimally treated in the outpatient arena. Fortunately most patients recover after administration of bronchodilators and anti-inflammatory medications, but preventable deaths continue to occur and refractory cases result in hospitalization and need for mechanical ventilation. We begin this article by reviewing the pathophysiology of acute exacerbations to build a foundation for the assessment of clinical status and to provide the rationale for a carefully contemplated and evidence-based therapeutic approach. We end this article with an in-depth examination of the particular problems that are encountered during mechanical ventilation and offer a strategy that helps minimize complications. In the final analysis, however, the greatest gains in the field of acute asthma will come not from its treatment but from its prevention by enhanced educational and environmental efforts and by the delivery of optimal medications at home.
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Affiliation(s)
- Susan J Corbridge
- College of Nursing, University of Illinois at Chicago and University of Illinois at Chicago Medical Center, Chicago 60612, USA.
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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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&NA;. Metered-dose inhalers with spacer devices are the system of choice for delivering short-acting ??2-agonists to children with asthma. DRUGS & THERAPY PERSPECTIVES 2003. [DOI: 10.2165/00042310-200319100-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Habashy D, Lam LT, Browne GJ. The administration of beta2-agonists for paediatric asthma and its adverse reaction in Australian and New Zealand emergency departments: a cross-sectional survey. Eur J Emerg Med 2003; 10:219-24. [PMID: 12972899 DOI: 10.1097/00063110-200309000-00012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To determine the current use of beta2-agonists, in particular salbutamol, for the management of acute asthma in children in emergency departments throughout Australia and New Zealand. METHODS A cross-sectional survey using a questionnaire that sought to determine the current use of salbutamol and any adverse drug reactions in paediatric emergency departments. RESULTS Out of 37 hospitals eligible as paediatric emergency departments, 33 (89.1%) responded to the survey, 54.5% having guidelines for the management of acute asthma. Of the paediatric emergency departments surveyed, 45.5% used metered-dose inhaler spacer combination in the treatment of mild to moderate asthma. All paediatric emergency departments used nebulized salbutamol for acute severe asthma. In addition, 85% of paediatric emergency departments used continuous-infusion intravenous salbutamol in unresponsive patients, 63.6% administering a single-dose intravenous salbutamol bolus before commencing the infusion. District paediatric emergency departments were more likely to treat with continuous-infusion intravenous salbutamol outside of the intensive care unit. Clinical unresponsiveness to inhaled salbutamol and clinical improvement were the reported criteria in all paediatric emergency departments for the use and cessation of intravenous salbutamol. Adverse drug reactions were common: tremor (90%), hypokalaemia (45.5%) and supraventricular tachycardia (21%), particularly if continuous-infusion intravenous salbutamol administered. Eight deaths from asthma were reported, none being related to adverse drug reactions. CONCLUSION We report a wide variation of salbutamol use in paediatric emergency departments and a high prevalence of type A adverse drug reactions when continuous-infusion intravenous salbutamol therapy was administered. More evidence is needed on the clinical significance of the adverse effects reported in this study and optimal doses for the safe use of continuous-infusion intravenous salbutamol therapy in paediatric emergency departments.
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Affiliation(s)
- Doaa Habashy
- Department of Emergency Medicine, The Children's Hospital at Westmead, Royal Alexandra Hospital for Children, Locked Bag 4001, Westmead NSW 2145, Australia
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Abstract
Many different devices are available to aid inhalational drug delivery. Although each device is claimed to have advantages over its rivals, the evidence to support greater efficacy of a particular device is scanty. Most comparative studies are underpowered or flawed in their design. They may use inappropriate end-points, or involve healthy subjects, whose response may be very different from the patient with acute severe asthma. The dosage of drug used in a trial may be at the shallow part of the dose-response curve, masking differences in devices. Only in a few cases have clinical trials detected a significant difference between devices, and trials have rarely taken patient preference into account. The most efficacious device in practice is likely to be the one that the patient will use regularly and in accordance with a health care workers' recommendations.
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Affiliation(s)
- P W Barry
- Department of Child Health, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, P.O. Box 65, Leicester LE2 7LX, UK.
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Abstract
BACKGROUND In asthma exacerbations, higher doses of inhaled beta-agonists are used to overcome acute bronchoconstriction. Traditionally, wet nebulisation has been used, but metered-dose inhaler with a spacer device is an alternative delivery method. OBJECTIVE To compare the clinical outcomes in adults and children with acute asthma, presenting in emergency departments or in the community, who have been randomised to beta-agonists given by two different delivery. METHODS a metered-dose inhaler with spacer or a nebuliser. RESULTS A Cochrane review has found no important differences between the two delivery methods in adults. Children may suffer fewer side effects with spacer delivery. CONCLUSIONS Individual response to treatment cannot be predicted, but many studies overcame this problem by using frequent repeated doses of beta-agonists (one respule via nebuliser or four separate actuations of a metered-dose inhaler through a spacer) every 10-15 min, titrated against the clinical response of the patients. This approach is advocated in clinical practice.
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Affiliation(s)
- Christopher Cates
- Manor View Practice, Bushey Health Centre, London Road, Bushey, Hertfordshire WD23 2NN, UK.
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Abstract
Asthma is a chronic inflammatory illness with acute exacerbations, which often is encountered in the ED setting. Knowledge of the presentation and treatment of asthma is crucial for any physician treating patients with this disease. Beta-agonist, anticholinergic, and corticosteroid therapy continue to be the mainstay of emergency therapy despite advances in newer medications. Proper attention to long-term treatment of asthma and aggressive treatment of acute exacerbations should help reduce morbidity and mortality.
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Affiliation(s)
- Brian K Adams
- Department of Emergency Medicine, Case Western Reserve University School of Medicine and MetroHealth Medical Center, Room BG3-68, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA
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Drblik S, Lapierre G, Thivierge R, Turgeon J, Gaudreault P, Cummins-McManus B, Verdy I, Haddon J, Lee J, Spier S. Comparative efficacy of terbutaline sulphate delivered by Turbuhaler dry powder inhaler or pressurised metered dose inhaler with Nebuhaler spacer in children during an acute asthmatic episode. Arch Dis Child 2003; 88:319-23. [PMID: 12651757 PMCID: PMC1719510 DOI: 10.1136/adc.88.4.319] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To compare the efficacy of terbutaline sulphate delivered via Turbuhaler with a pressurised metered dose inhaler (pMDI) connected to Nebuhaler spacer in a population of asthmatic children presenting to emergency departments because of an acute episode of asthma. METHODS Randomised double blind, double dummy, parallel study of acute asthma in the emergency department. A total of 112 children (6-16 years), who had a diagnosis of asthma, a baseline FEV1 of 25-60% of predicted normal value (PNV), and the ability to perform spirometry were studied. Patients received two doses of 0.5 mg/10 kg (maximum 2.0 mg) of terbutaline sulphate at time 0 minutes and time 30 minutes. The two groups were also stratified into subgroups based on FEV1: 25-45% and 45.1-60% PNV. FEV1 before treatment and at two 15-minute intervals after each treatment was the main outcome measure. PIF, PEF, heart rate, SpO2, and tremor were also measured at these times. RESULTS Both the Turbuhaler and pMDI+Nebuhaler groups showed significant increases from baseline to final value in their FEV1 results, 49% and 50% change from baseline to t = 60 min, respectively (p < 0.001) using last value carried forward. No significant difference was found between the two groups for these results. Subanalysis of the stratified groups revealed similar results. In addition, no significant difference was found in the group and subgroup comparisons for heart rate, SpO2, and tremor. CONCLUSION Results show that Turbuhaler and pMDI+Nebuhaler are similar in terms of benefit and side effects in the treatment of acute moderate to severe asthma attacks in this study population.
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Affiliation(s)
- S Drblik
- Service of Pulmonology, Hôpital Ste-Justine, Université de Montréal, Québec, Canada
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