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

GEMA 5.3. Spanish Guideline on the Management of Asthma

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

Path towards efficient paediatric formulation development based on partnering with clinical pharmacologists and clinicians, a conect4children expert group white paper

Improved global access to novel age-appropriate formulations for paediatric subsets, either of new chemical entities or existing drugs, is a priority to ensure that medicines meet the needs of these patients. However, despite regulatory incentives, the introduction to the market of paediatric formulations still lags behind adult products. This is mainly caused by additional complexities associated with the development of acceptable age-appropriate paediatric medicines. This position paper recommends the use of a paediatric Quality Target Product Profile as an efficient tool to facilitate early planning and decision making across all teams involved in paediatric formulation development during the children-centric formulation design for new chemical entities, or to repurpose/reformulate off-patent drugs. Essential key attributes of a paediatric formulation are suggested and described. Moreover, greater collaboration between formulation experts and clinical colleagues, including healthcare professionals, is advocated to lead to safe and effective, age-appropriate medicinal products. Acceptability testing should be a secondary endpoint in paediatric clinical trials to ensure postmarketing adherence is not compromised by a lack of acceptability. Not knowing the indications and the related age groups and potential dosing regimens early enough is still a major hurdle for efficient paediatric formulation development; however, the proposed paediatric Quality Target Product Profile could be a valuable collaborative tool for planning and decision making to expedite paediatric product development, particularly for those with limited experience in developing a paediatric product.

Metered-dose inhalers versus nebulization for the delivery of albuterol for acute exacerbations of wheezing or asthma in children: A systematic review with meta-analysis

OBJECTIVES

The benefits of metered-dose inhalers with a spacer (MDI+S) have increasingly been recognized as an alternative method of albuterol administration for treating pediatric asthma exacerbations. The aim of this systematic review was to compare the response to albuterol delivered through nebulization (NEB) with albuterol delivered through MDI+S in pediatric patients with asthma exacerbations.

METHODS

We conducted an electronic search in MEDLINE/PubMed, EMBASE, Ovid, and ClinicalTrials. To be included in the review, a study had to a randomized clinical trial comparing albuterol delivered via NEB versus MDI+S; and had to report the rate of hospital admission (primary outcome), or any of the following secondary outcomes: oxygen arterial saturation, heart rate (HR), respiratory rate (RR), the pulmonary index score (PIS), adverse effects, and need for additional treatment.

RESULTS

Fifteen studies (n = 2057) met inclusion criteria. No significant differences were found between the two albuterol delivery methods in terms of hospital admission (relative risk, 0.89; 95% confidence interval [CI], 0.55-1.46; I²  = 32%; p = .65). There was a significant reduction in the PIS score (mean difference [MD], -0.63; 95% CI, -0.91 to -0.35; I²  = 0%; p < .00001), and a significantly smaller increase in HR (better; MD -6.47; 95% CI, -11.69 to -1.25; I²  = 0%; p = .02) when albuterol was delivered through MDI+S than when it was delivered through NEB.

CONCLUSIONS

This review, an update of a previously-published meta-analysis, showed a significant reduction in the PIS and a significantly smaller increase in HR when albuterol was delivered through MDI+S than when it was delivered through NEB.

Estimating the impact of self-management education, influenza vaccines, nebulizers, and spacers on health utilization and expenditures for Medicaid-enrolled children with asthma

INTRODUCTION

We quantify the effect of a set of interventions including asthma self-management education, influenza vaccination, spacers, and nebulizers on healthcare utilization and expenditures for Medicaid-enrolled children with asthma in New York and Michigan.

METHODS

We obtained patients' data from Medicaid Analytic eXtract files and evaluated patients with persistent asthma in 2010 and 2011. We used difference-in-difference regression to quantify the effect of the intervention on the probability of asthma-related healthcare utilization, asthma medication, and utilization costs. We estimated the average change in outcome measures from pre-intervention/intervention (2010) to post-intervention (2011) periods for the intervention group by comparing this with the average change in the control group over the same time horizon.

RESULTS

All of the interventions reduced both utilization and asthma medication costs. Asthma self-management education, nebulizer, and spacer interventions reduced the probability of emergency department (20.8-1.5%, 95%CI 19.7-21.9% vs. 0.5-2.5%, respectively) and inpatient (3.5-0.8%, 95%CI 2.1-4.9% vs. 0.4-1.2%, respectively) utilizations. Influenza vaccine decreased the probability of primary care physician (6-3.5%, 95%CI 4.4-7.6% vs. 1.5-5.5%, respectively) visit. The reductions varied by state and intervention.

CONCLUSIONS

Promoting asthma self-management education, influenza vaccinations, nebulizers, and spacers can decrease the frequency of healthcare utilization and asthma-related expenditures while improving medication adherence.

Special considerations for the management of COVID-19 pediatric patients in the operating room and pediatric intensive care unit in a tertiary hospital in Singapore

COVID-19 was first identified in Wuhan, China and is caused by the novel coronavirus SARS-CoV 2. It has now spread rapidly to over 190 countries and territories around the world and has been declared a global pandemic by the World Health Organization. The virus is spread through droplet transmission and currently has a mortality rate of over 4% globally. The pediatric population has been found to be less susceptible to the disease with the majority of children having milder symptoms and only one pediatric death being reported globally so far. Despite this, strategies need to be put in place to prevent further spread of the virus. We present a summary of the general measures implemented at a large adult and pediatric tertiary hospital in Singapore (National University Hospital) as well as the specific strategies in place for the operating room and pediatric intensive care unit.

Management of Asthma in the Preschool Child

The management of asthma in the preschool population is challenging because disease phenotypes are heterogeneous and evolving. Available therapies aimed at preventing persistent symptoms and recurrent exacerbations include inhaled corticosteroids and leukotriene receptor antagonists; episodic use of inhaled corticosteroids and azithromycin may result in a decrease in exacerbations among children with intermittent disease. This article reviews an approach using patient characteristics for selecting initial treatment approaches based on disease phenotype, such as symptom patterns or evidence of atopic markers. Evidence for and against the use of oral corticosteroids during acute episodes and barriers to adherence and effective treatment are discussed.

A Systematic Review of Pediatric and Adult In-Flight Medical Emergencies

In-flight medical emergencies (IMEs) are acute onboard events of illnesses or injuries with potential immediate risk to a passenger's short- or long-term health, or life. IMEs are significant events that are related to public safety concerns. With the increasing amount of annual air travel every year, it is expected that the number of encountered IMEs will continue to grow. Thus, it will be critical to develop and implement appropriate measures to manage IMEs with the best possible outcome. Despite the fact that most IMEs are self-limited with no serious adverse events, serious IME can lead to death, disability, or other unfavorable health outcomes, particularly as a result of suboptimal medical care. In this article, we systematically reviewed the published up-to-date evidence on the subject of in-flight emergencies with a specific focus on pediatric population.

Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics

BACKGROUND

Acute asthma attack is a frequent condition in children. It is one of the most common reasons for emergency department (ED) visit and hospitalization. Appropriate care is fundamental, considering both the high prevalence of asthma in children, and its life-threatening risks. Italian Society of Pediatrics recently issued a guideline on the management of acute asthma attack in children over age 2, in ambulatory and emergency department settings.

METHODS

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was adopted. A literature search was performed using the Cochrane Library and Medline/PubMed databases, retrieving studies in English or Italian and including children over age 2 year.

RESULTS

Inhaled ß2 agonists are the first line drugs for acute asthma attack in children. Ipratropium bromide should be added in moderate/severe attacks. Early use of systemic steroids is associated with reduced risk of ED visits and hospitalization. High doses of inhaled steroids should not replace systemic steroids. Aminophylline use should be avoided in mild/moderate attacks. Weak evidence supports its use in life-threatening attacks. Epinephrine should not be used in the treatment of acute asthma for its lower cost / benefit ratio, compared to β2 agonists. Intravenous magnesium solphate could be used in children with severe attacks and/or forced expiratory volume1 (FEV1) lower than 60% predicted, unresponsive to initial inhaled therapy. Heliox could be administered in life-threatening attacks. Leukotriene receptor antagonists are not recommended.

CONCLUSIONS

This Guideline is expected to be a useful resource in managing acute asthma attacks in children over age 2.