In Asthmatic Children Under the Age of 5yrs Is Spacer Inhaler More Beneficial Than a Nebulizer - Essay Example

In Asthmatic Children Under The Age Of 5yrs Is Spacer Inhaler More Beneficial Than A Nebulizer? Written by Presented to [mentor’s ] In partial fulfilment of the requirements of [program name] [date] ABSTRACT Present clinical scenarios in paediatric pulmonology are questioning the efficacy of MDIs over nebulizers in the acute management of asthma among children below five years of age. Children of this age group present a significant challenge in the management due to difficulty in the diagnosis of asthma condition itself. Management of asthma in such children requires quick response, which can be delivered effectively through beta agonists. However, the use of MDIs and nebulizers both are to be analysed for their efficacy in achieving quicker response. The paper looks into the clinical researches and academic literature analysing the same concerns. Contents In Asthmatic Children Under The Age Of 5yrs Is Spacer Inhaler More 1 Beneficial Than A Nebulizer? 1 ABSTRACT 2 In Asthmatic Children Under The Age Of 5yrs Is Spacer Inhaler More 4 Beneficial Than A Nebulizer? 4 Introduction 4 Prevalence Of Asthma Among Children 7 Use Of Spacer Inhaler Among Children Less Than Five Years Of Age 9 Use Of Nubulizer Among Children Less Than Five Years Of Age 11 Comparison Studies To Understand Efficacy Of Both Options 12 Cost Benefit Analysis 13 Recommendations 14 Conclusions 15 REFERENCES 16 In Asthmatic Children Under The Age Of 5yrs Is Spacer Inhaler More Beneficial Than A Nebulizer? Introduction Asthma prevalence is increasing with corresponding increase in incidences of emergency department admissions. Pollution as well as changes in lifestyle has contributed significantly in increasing the prevalence of asthma (Dhuper et al, 2011). Certain demographic factors such as poor socioeconomic status, are also contributing to higher numbers of asthma prevalence among certain ethnic populations such as African American and Hispanic populations (Dhuper et al, 2011). Among children, asthma is found to be 10 to 15% prevalent and a major cause of admissions to the emergency departments with high morbidity and mortality rates (Kovesi et al, 2010). Management of younger children remains a challenge as there are lot of constraints on the test results. Children show less cooperation, are more anxious and are not in the development stage to understand instructions or abide by them (Kovesi et al, 2010). The similar reasons are the cause of difficulty in diagnosis of the condition. While wheezing is a very common phenomena present in children, not all wheezing can be categorized as asthma. This is because wheezing pattern of breathing is quite similar to noisy breathing, which is caused by nasal secretions in children which they haven’t learnt to swallow (Kovesi et al, 2010). Children also show different asthma presentations as compared to adults (Kovesi et al, 2010). Therefore, the diagnosis of asthma is based mainly on symptoms and treatment responses than testing methods such as pulmonary function tests. Bronchodilator therapy remains a mainstay in the management of asthma conditions in children. The bronchodilator therapy can be carried out either orally or through inhalation. Inhalation therapy is now the preferred method of treatment of asthma symptoms due to lesser systemic effects as compared to oral therapy. Inhalation therapy is also speedier in remission of asthma symptoms as compared to oral therapy (Delgado, Chou, Silver and Crain, 2003). In children, the most common presentation in the emergency department is the reactive airway diseases. These situations are best handled with Metered Dose Inhalers due to smaller time of administration compared to nebulizers (Delgado, Chou, Silver and Crain, 2003). This time duration is particularly important in the emergency departments as the nursing staff may be pressured for time and attending to other emergencies. MDIs have been found to have lesser side effects in tachycardia and vomiting. This can also indicate a lesser systematic effect of the salbutamol via MDIs as compared to nebulizers (Delgado, Chou, Silver and Crain, 2003). The treatment of asthma in emergency conditions is primarily carried out either through nebulizers or through space inhalers. Beta agonists remain first line treatments after steroids or in conjunction with steroids for rapid and acute relief of asthma symptoms (Smith and Goldman, 2012). Steroids are good adjuncts to beta agonists in achieving sustained relief from asthma symptoms. The steroids help in reducing the inflammatory reaction that is the preliminary cause of asthma. These however, show their effect after six hours or so, making them useful for sustained prevention and management for asthma but not for acute management (Greene, Amour, Koyfman and Foran, 2013). Beta agonists are given at 3 doses of 20 minutes apart and observed for response and improvement in condition. Corticosteroids are given in the oral form at the initial stages of the acute asthma attack (Kling, Goussard and Gie, 2011). Nebulization is usually carried out with albuterol through albuterol metered dose inhaler. This method has found more compliance among patients due to ease of use, and is able to provide the similar level of relief through beta agonist drugs (Dhuper et al, 2011). However, care should be taken in giving out this medication in particular patient history cases, as it can result in greater intensity of side effects. The side effects include tremor, anxiety and dysrhythmias respectively (Dhuper et al, 2011). For the reasons cited above, the nebulizers are found to be more suitable treatment option for children under the ages of five years as compared to adults and older children. The dose metered inhalers show a reduced rate of hospitalization and clinically improved the recovery (Guidelines in Focus, 2011). These factors become all the more important among children who are less than three years of age, who are likely to show anxiousness and fear when taken to the hospital (Guidelines in Focus, 2011). Proper technique of application of the nebulizers is important and there is need to ensure the staff and the child’s parents or care takers know the correct method of administration of nebulizer therapy (Guidelines in Focus, 2011). When response to these drugs fail or is extremely slow, a nebulised ipratropium bromide is given every 20 minutes for the first two hours and then every four hours as the condition stabilizes (Kling, Goussard and Gie, 2011). It has been found to be helpful when given in conjunction with beta agonists in moderate to severe asthma cases. Ipratropium is a muscarinic acetylcholine receptor inhibitor and helps in the relaxation of vagally mediated smooth muscle. It is less potent and achieves its full effect in 90 minutes compared to beta blockers, but helps in sustaining the effect beta blockers (Greene, Amour, Koyfman and Foran, 2013). In any case, whether the use of nebulizers or MDIs is undertaken, the technique is the most important component of successful case management (Buddiga and Kulkarni, 2011). The use of inappropriate technique will lead to insufficient dose administered to the child, which can complicate management, and give a false assumption to the clinician that the therapy is not responding. Therefore, when assessing the success of any inhalation therapy, the clinicians and caretakers must first assess the inhalation delivery method. Prevalence Of Asthma Among Children Children are very likely to demonstrate symptoms of asthma or asthma like symptoms in younger ages. Around one third of children demonstrate signs and symptoms of wheezing until the age of three years old (Smith and Goldman, 2012). This heterogenic reason of wheezing can lead to a difficulty of delivering full dosage of drug through inhalation. Children become easily distressed when faced with breathing difficulty and hospital environments (Smith and Goldman, 2012). In such cases, providing them the right amount of aerosol to help relieve symptoms has to be quick and effective (Mathew and Singh, 2008). Proper treatment of asthma among children of preschool age requires that they be diagnosed correctly. Prevalence of asthma and related symptoms and their association with atopy are significant concerns when diagnosing for asthma. For example, wheezing among children without asthma is a very common condition, and is easily confused as a symptom or presentation of asthma. However, certain clinical findings and signs can help reach the diagnosis more accurately. These include presence of wheezing on more than four occasions of which in included one episode of wheezing observed in the presence of physician. History involves asking for previous history of parental asthma, presence of any atopic dermatitis, allergy sensitization or combinations of these (Smith and Goldman, 2012). Children with viral infections can also demonstrate signs and symptoms of asthma (Smith and Goldman, 2012). The treatment of asthma and asthma like symptoms in children within five years of age include drug delivery through nebulizers, pressured metered-dose inhalers pMDIs with or without spacers or dry-powder inhalers respectively (Smith and Goldman, 2012). For the spacers to work effectively, at least three tidal breaths through the spacer should be carried out by the child. The nursing staff must assist the patient and also guide the parents or the caretakers about the correct method of delivery of the dose. Regardless of the kind of method or equipment used, the maintenance and cleaning of the equipment is essential in order to ensure proper delivery of the dose, proper function of the equipment and decrease any potential malfunction of the nebulizers (Tay, Needleman and Avner, 2009). The patients and the parents of the children must be educated to maintain good cleaning practices in case of nebulizers and MDIs (Tay, Needleman and Avner, 2009). The nursing staff must be trained in keeping the material and equipment clean. This will ensure that they will teach the parents and caretakers the right techniques and methods. Use Of Spacer Inhaler Among Children Less Than Five Years Of Age Space inhalers and pMDIs are an effective tool for delivering higher dosages of aerosol drugs among children. However, this method is technique sensitive, which may make it difficult for younger children to follow through (Smith and Goldman, 2012). This problem can be partially overcome by the use of masks. Many designs and modes of delivery are now available and it is primarily the discretion of the physician to recommend which design to use for the child. However, space inhaler pMDI is most effective in emergency situations due to its good dose delivery (Mathew and Singh, 2008; Bhalla et al, 2008). The MDIs show lesser side effects of tachycardia and hypoxia, particularly if a space mask is used (Kling, Goussard and Gie, 2011). Studies support that continuous or regular use of space inhalers led to a reduced frequency of hospital admissions in children using the equipment (Goussard and Gie, 2011). Symptom resolution is also reported to be quicker in the case of space inhalers than with nebulizers (Smith and Goldman, 2012). However, the good ability of the nursing staff to administer the doses may also be a reason why space inhalers gave effective outcomes. MDIs are primarily indicated in children displaying severe dyspnoea, which can be added on by the spacer to aid in inhalation effectively (Hagmolen, De Berg, Bindels, Aalderen and Palen, 2008). Children are very likely to show perform on their essential as well as non-essential actions when using the inhaler (Hagmolen, De Berg, Bindels, Aalderen and Palen, 2008). The MDIs work through dissolving or suspending corticosteroid under pressure. The valve system in the MDI helps in releasing a measured dose of both the drug and propellant. The force by the propellant helps in delivering the drug through the larynx when inspired (Bhalla et al, 2008). Due to its effectiveness, the metered dose inhaler or MDI is now used as a preventive method of delivering inhaled corticosteroid therapy. In many cases the MDI is now replacing the use of nebulizers, with researchers believing it to be superior in dosage delivery than the nebulizer (Bhalla et al, 2008). The forceful nature of drug delivery can lead to sore throat, cough and inflammation in the larynx. Alongside, when present conditions such as chronic cough are already present, the use of MDI can aggravate the symptoms (Fayaz, Sultan and Rai, 2009). In children this can result in lack of compliance due to their inability to proper manage the side effects of using MDI through gargles (Bhalla et al, 2008). These side effects cause morbidity and consequently lead to decreased patient compliance. In many cases, the therapy may fluctuate between use of MDIs and nebulizers. There are other technical aspects of the pharmacological formulation that can impact the drug delivery effectiveness (Bhalla et al, 2008). The formulation of the particles can range from 1 to 10 µm in diameter. However, clinical findings show that only particles ranging from 1 till 3 µm deposit in the airways. The larger particles therefore, either deposit in the mouth or in the airways, which can cause symptoms of irritation in the tissues (Bhalla et al, 2008). MDIs are contraindicated in certain situations although they are more likely to be related to adults and older children than among younger age groups (Buddiga and Kulkarni, 2011). These include diagnosed sensitivity to various propellants used in the propellants (Buddiga and Kulkarni, 2011). Also, the use of DPIs is not advocated among patients who cannot generate an adequate inspiratory flow rate. This can be extremely difficult to determine among children less than five years of age (Buddiga and Kulkarni, 2011). Use Of Nubulizer Among Children Less Than Five Years Of Age Nebulizers for a long time have remained one of the favoured methods to deliver salbutamol for relief of asthma (Fayaz, Sultan and Rai, 2009). There are however, drawbacks which can lead to a decrease in compliance among patients, particularly in children. Nebulizers may be uncomfortable to children, require a long time to administer the same amount of dose as compared to other forms of inhalers and require compressed air or O2 to generate the spray as a medium for delivery of the drug (Fayaz, Sultan and Rai, 2009). Factors that can influence the amount of drug that actually reaches the airways include the distance between the mask used and the face of the child, the tidal volume, the respiratory rate and quality of respiration (deep versus shallow) and the patient’s inhalation technique, which may be extremely difficult to modify in little children (Fayaz, Sultan and Rai, 2009). Nebulizers are a useful method of drug delivery in children who are not cooperative. However, the drug delivery is significantly less than that of pMDIs. Only 10% of aerosol drug reaches the affected lung tissues in the case of nebulizers (Smith and Goldman, 2012). Comparison Studies To Understand Efficacy Of Both Options Study by found spacer devices superior to conventional nebulizer on account of time that is reduced and the overall costs that are saved due to lesser effort by the respiratory therapist (Dhuper et al, 2011). A consideration to undertake when comparing the use of nebulizers versus MDIs lies in the response the child may show towards one type of equipment over the other. Children with time learn to use one kind of equipment better than the other. In such a situation, the efficacy of one method or equipment over other becomes comparative, and may not clearly demonstrate the efficacy, just the ease of handling (Fayaz, Sultan and Rai, 2009). Children from ages 2 years onwards may not be willing to sit still for 20 minutes for nebulizers in which cases the use of MDI may be preferred by the nursing staff. Another consideration can be the busy situation of the emergency room where the nursing staff may not be able to devote this long duration of time to one patient. In such cases, the MDI may be the preferred method of choice (Fayaz, Sultan and Rai, 2009). Cost Benefit Analysis So far the discussion and comparisons have been carried out between nebulizers and MDIs. Dry powder inhalers or DPI are also used in the management of acute asthma cases. These have been reported to be superior to MDI as they are “breathe actuated and do not contain propellants” (Direkwatanachai et al, 2011). However, their standardized use is still under review, the reason for which it is not being considered in this discussion. Any treatment given out to the patient incurs costs. These costs when accumulated can significantly influence the resultant budgetary outcomes and may impact on the overall health care resource division (Smith and Goldman, 2012). Therefore, each treatment needs to be analysed fully for the various costs that are involved in its provision. The labour costs are significantly influenced with the time spent on each patient (Dhuper et al, 2011). Different spacer devices may cost differently in each case. When considering the ease of use the kind of mode of delivery, the spacer use is better than MDI and inhalation (Mathew and Singh, 2008). This method has easier understanding of the process, which meant that patients with lower educational background could use it (Dhuper et al, 2011). The MDI spacers show potential benefits in reduced costs, being a more convenient method than nebulizers and carrying lesser risk of infections, which can exacerbate asthma cases (Mathew and Singh, 2008). Metered dose inhalers are also difficult to teach particularly to children less than five years of age, which along with lack of compliance can lead to failure of delivery of required dose to manage asthma both in acute as well as home settings (Direkwatanachai et al, 2011). However, Cochrane reviews contradict the superiority of MDIs citing through its set of clinical trials and researches the efficacy of both in treating acute cases of asthma among children (Mathew and Singh, 2008). The same set of studies found no differences in the duration of stay in the hospitals in either case. Nebulizers, as mentioned above, display a higher risk of side effects compared to the MDIs when medication delivery was concerned (Mathew and Singh, 2008). Recommendations The treatment of asthma through aerosol is extremely challenging in younger children due to compliance. The choice of the method therefore, will depend on factors such as the age of the child, cooperation level of the child, the characteristics of the delivery device and the ease and ability of the family member or parent to use the device for effective drug delivery (Yilmaz et al, 2009). Studies carried out on the use of type of aerosol disperser took into account the acute emergency settings. However, most of the management of asthma cases takes place at chronic levels at home (Yilmaz et al, 2009). Therefore the use of the type of equipment will largely depend on the compliance level among children, the ability to better utilize the device for accurate dose delivery and ensuring the device is readily understood and utilized by the patient according to their educational, socioeconomic and individual level respectively. In any kind of equipment use for managing asthma cases in children, an essential need is to periodically check and correct if needed the method of use of nebulizer. The doctors and the health care providers, who are given the task of teaching the patients or the parents of children about how to use the equipment, must be taught about the proper use of the inhalers themselves (Yilmaz et al, 2009). Conclusions The nebulizers may provide better relief of asthma symptoms on account of ease of use and handling both in acute and chronic conditions, as per the recommendations of many similar studies (Yilmaz et al, 2009). A proper methodology of application of the drug ensures almost equivalent results in terms of quality of asthma management. The use of spacer is being considered primarily on the efficacy of it being able to deliver optimum amount of dose in children through use of masks etc. However, compliance in such cases then becomes an issue with children less than five years of age (Yilmaz et al, 2009). However, the metered dose inhaler has become a treatment method for the asthma management in children less than five years of age (ElMallah and Hendeles, 2012). Although the dosage quantity delivery is the same as with nebulizers, the MDI delivery method is convenient, safer, faster and less expensive (ElMallah and Hendeles, 2012). REFERENCES Bhalla R K, Watson G, Taylor W, Jones A S and Roland N J, 2008. Prospective, Randomized Cross-Over Trial to Assess the Ability of a Dry Powder Inhaler to Reverse the Local Side Effects of Pressurized Metered-Dose Inhalers. Journal of Asthma, 45: 814-819, 2008, pp. 814-819. Buddiga P and Kulkarni R, 2011. Use of Metered Dose Inhalers, Spacers and Nebulizers. Medscape Reference. Last accessed on March 20th, 2013. Delgado A, Chou K J, Silver E J and 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. 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