Asthma in Children - Research Paper Example

?RUNNING HEAD: Asthma in Children Asthma in Children: Use of Nebulizer versus Metered dose Inhalers Using Spacers for delivering Albuterol in Acute Asthma in Children Name of the student: Under the guidance of: University: APA Format Word Count: Date of submission: Use of Nebulizer versus Metered dose Inhalers Using Spacers for delivering Albuterol in Acute Asthma in Children Introduction Asthma is a condition in which there is reversible obstruction of the airways secondary to hyperreactivity of the bronchi and chronic inflammation. It is a common respiratory condition and affects population of all age groups irrespective of race and gender. It constitutes about 2 percent of emergency room visits (Smith and Goldman, 2012). If left unattended and in the presence of severe symptoms asthma can contribute to significant morbidity, mortality and economic costs. Children with acute exacerbation of asthma are frequently seen in out-patient settings and emergency rooms. They are administered bronchodilators like albuterol to cause relief of symptoms. Albuterol is administered either through metered dose inhalers-spacer or jet nebulizer. Metered dose-inhaler spacer is an efficient and useful method of delivering albuterol for bronchodilatation. It delivers the drug quickly and can cause effects in few seconds. Delivery of the drug can be optimized using suitable mask. On the other hand nebulization is also an effective tool to deliver the drug. It is however cumbersome and needs atleast 15 minutes for one dose administration. The most commonly used delivery systems for asthma are nebulizers, dry-powder inhalers and metered dose inhalers with or without spacers (Smith and Goldman, 2012). In children less than 5 years of age, it is not possible to generate adequate inspiratory inflow and hence, effective use of dry-powder inhaler devices is not possible. Whether to use metered dose inhalers or nebulizers in acute exacerbation of asthma in children is a much debated topic. The main advantage with nebulizer is that the drug can be delivered even without the cooperation of the child. However, during this mechanism, only less than 10 percent of the aerosolized drug reaches the lungs (Smith and Goldman, 2012). The remaining drug gets deposited in the nebulization system or on the face or is lost to the surrounding regions. On the other hand upto 40 percent of the drug can be deposited in the lungs with metered dose inhalers. In infants and young children, the main difficulty in using metered dose inhalers is lack of coordination in triggering and inhaling the drug (Smith and Goldman, 2012). To overcome these aspects, spacers and masks are used. Spacers are able to eliminate the need for coordination in metered dose inhalers. The spacers have a valve "with the particular advantage of allowing aerosol to move out of the chamber at inhalation but holding particles in the chamber during exhalation" (Smith and Goldman, 2012). In this research essay, whether nebulizer or metered dose inhaler with spacer is a suitable method for administering albuterol therapy in children will be discussed through review of suitable literature. The research is made through PICO format and the steps involved in arriving at the evidence will be discussed. PICO Format When clinical decisions are made based on appropriate scientific evidence, it is nown as evidence-based practice. According to McKibbon (1998), "Evidence-based practice (EBP) is an approach to health care wherein health professionals use the best evidence possible, i.e. the most appropriate information available, to make clinical decisions for individual patients. EBP values, enhances and builds on clinical expertise, knowledge of disease mechanisms, and pathophysiology. It involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences." The most critical exercise for evidence-based practice is literature review. This can be done by approapriate search strategy and by creating a proper question in the following mentioned PICO format. Literature search is done through electronic databases. Nursing intervention chosen for the research: Administration of albuterol Clinical Question: Whether nebulizer or metered dose inhaler through spacer is suitable for administration of albuterol therapy in children. PICO Population: Pediatric patients with acute exacerbation of asthma Nursng intervention: Administration of bronchodilator through metered dose inhaler using spacer Comparison: Administration of bronchodilator through jet nebuliser Outocme: Relief from wheezing Search process The commencement of search in electronic databases was based on the inclusion/exclusion criteria and knowledge of the hierarchies of evidence. Hierarchy provides a confidence measure to the end-user (Evans, 2003). According to Evans (2003), random control trials can be considered of good standard and they are in fact labeled as the gold standard of research for providing optimal research designs to answer pertinent questions. However, systemic reviews and meta-analysis have topped the hierarchy list. The databases used for search were PUBMED, Google Scholar and CINAHL. The MESH terms used in PUBMED were asthma (AND), albuterol nebulisation (AND), albuterol metered dose inhaler-spacer. The limits used were children and English. In Google Scholar database, the search terms used were asthma (AND), albuterol nebulisation (AND), albuterol metered dose inhaler-spacer. The search yielded 15 articles. In the CINAHL database, the search terms used were cancer asthma (AND), albuterol nebulisation (AND), albuterol metered dose inhaler-spacer. The search yielded 5 articles. It was noted that both search engines placed the results in a hierarchical order with the most relevant articles coming first or accorded higher star ratings. This search yielded valuable papers. Discussion Delgado et al (2003) conducted a study to ascertain whether administration of albuterol by metered-dose inhaler with spacer is similar to that by nebulizer in terms of efficacy and relief of symptoms in children less than 2 years. The study was a randomized clinical trial that was double-blind and also placebo-controlled. The participants were children between 2 to 24 months of age in a pediatric emergency department setting. Those enrolled in the nebulizer group received placebo MDI with a spacer followed by albuterol through nebulization. On the other hand, the spacer group received albuterol by MDI with a spacer followed by isotonic sodium chloride solution through nebulization. The treatments were administered every 20 minutes by a single investigator who was blinded to assignment of the groups. The main outcome measured in this study was rate of admissions. Other outcomes measured were oxygen saturation and pulmonary index score. From the results of the study, it was evident that individuals in the nebulizer group had significant higher mean values of initial pulmonary index when compared to those in the spacer group. When the pulmonary index scores were controlled, the results determined that children in the spacer group had lesser rates of admission. The researchers of the study concluded that "metered-dose inhalers with spacers may be as efficacious as nebulizers for the emergency department treatment of wheezing in children aged 2 years or younger." Deerojanawong et al (2005) conducted a study to compare the efficacy of salbutamol (albuterol) therapy administered via metered dose inhaler with spacer versus jet nebulizer. The study was a double-blind randomized, placebo-controlled trial. The participants were children less than five years of age and the setting was inpatient unit of department of Pediatrics. The nebulizer group first received 2 puffs of placebo through MDI-spacer followed by salbutamol nebulization. The spacer group received salbutamol through spacer followed by placebo through nebulizer. The main outcomes that were measured were pulmonary function tests and clinical parameters. Covariance analysis was employed to determine the efficacy of both methods. From the results of the study it was evident that in terms of pulmonary function parameters and clinical scores there was no difference between the study and the control groups. One significant aspect that was noted in the study was that increase in heart rate was noted with nebulization therapy when compared to MDI-spacer therapy. The authors declared that "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." Yasmin et al (2012) conducted a study to evaluate and also compare the efficacy between metered dose inhaler delivery of salbutamol versus delivery through nebulizer. The spacer used in this study was a home based spacer. This was a prospective study that was randomized. The participants were children between 2-12 years with acute exacerbation of asthma. The study group received three doses of salbutamol through MDI and home-made spacer and the control group received the doses through jet nebulizer. The main outcomes that were measured were heart rate, wheeze, respiratory rate and oxygen saturation. The results of the study concluded that MDI with home- made spacer was as efficacious as nebulizer therapy in the treatment of children with acute asthma. Conclusion Based on the research articles that were reviewed, it is clear that both metered dose inhaler with spacer and nebulizer are useful tools to deliver albuterol to lungs to cause bronchodilation in children with acute exacerbation of asthma. The efficacy is the same in both situations in terms of reversal of asthma, pulmonary indices and clinical scores. However, those administered metered dose inhalers are probably less likely to be hospitalized. Mild side effects like increased heart rate are more common in nebulization therapy. References Bisgaard, H., Szefler, S. (2007). Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol., 42(8), 723-8. Dolovich, M.B., Dhand, R. (2011). Aerosol drug delivery: developments in device design and clinical use. Lancet , 377(9770), 1032-45. Evans, D., 2003. Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12(1), 77 – 84. Deerojanawong J, Manuyakorn W, Prapphal N, Harnruthakorn C, Sritippayawan S, Samransamruajkit R. (2005). Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing. Pediatr Pulmonol., 39(5), 466-72. Delgado, A., Chou, K.J., Silver, E.J., Crain, E.F. (2003). Nebulizers vs metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a pediatric emergency department. Arch Pediatr Adolesc Med., 157(1), 76-80. McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association, 86 (3), 396-401. Smith, C., Goldman, R.D. (2012). Nebulizers versus pressurized metered-dose inhalers in preschool children with wheezing. Canadian Family Physician, 58 (5), 528-530. Yasmin, S., Mollah, A.H., Basak, R., Islam, K.T., Chowdhury, Y.S. (2012). Efficacy of salbutamol by nebulizer versus metered dose inhaler with home-made non-valved spacer in acute exacerbation of childhood asthma. Mymensingh Med J., 21(1), 66-71. Read More