In Asthmatic Children below 18 Years Is Spacer Inhaler More Beneficial Than a Nebulizer - Literature review Example

In Asthmatic Children Below 18 Years Is Spacer Inhaler More Beneficial Than A Nebulizer? Themes Asthma is found to be a common disease in most of thecountries across the world. Correspondingly, various treatment measures have been developed, such as spacer inhalers and nebulizers (Wang & Hong, 2011). However, debates in the medical field have often been identified as concentrated on the effects of these treatment methods on patients, especially children (Watson, 2012). As mentioned above, this study emphasizes on examining the benefits of a spacer inhaler as compared to a nebulizer for children. In order to determine the different effects and benefits of these two forms of asthmatic treatments, three themes have been selected for this study based on which the two treatment forms will be assessed and compared. These three themes as relapse rate, infection rate and admission rate. Theoretically, in this context, relapse rate can be defined as the frequency of suffering trauma because of asthmatic attacks among children. Infection rate, similarly, indicates the rate of children getting affected due to infection as a consequence of using a spacer inhaler or a nebulizer. The third theme, i.e. admission rate further exhibits the frequency of children getting admitted to healthcare units owing to acute asthmatic attacks. These themes have been selected on the grounds that with the benefits of a spacer inhaler or nebulizer, children are likely to experience varying admission rates, relapse rates and infection rates. In the recent times the propensity of many patients with acute asthma after Emergency Department (ED) discharge has contributed towards numerous clinical trials (Camargo, Rachelefsky & Schatz, 2009). At the same time, there has been constant threat of infection to patients with acute asthma. Accordingly, the use of nebulizers has often imposed significant source of cross-infection which requires regular maintenance. Consequently, in many studies, the use of Metered-Dose Inhalers (MDI) has been suggested in order to decrease the risks of cross-infection as a result of using asthmatic treatments. Undoubtedly, the management of acute asthma in children has imposed significant challenges for many pediatricians. Correspondingly, in the literature discussion section, the author has considerably attempted to represent these three themes in details in accordance with the use of Spacer inhaler and nebulizer. Literature Discussion Admission Rate According to Conway, Brungs, Deveto & Herzog (2008), asthma is one of the highly prevalent chronic childhood diseases which can be closely related with the main reasons for emergency visits and hospital admissions among children (Conway, Brungs, Deveto & Herzog, 2008). Similarly, Direkwatanachai, Teeratakulpisaran, Suntornlohanakul, Trakultivakorn, Ngamphaiboon, Wongpitoo & Vangveeravong (2011) also debated that asthma should be considered as a worldwide high burden disease owing to the fact that its occurrence among children has increased dramatically in the recent years. It has further been argued by various practitioners that despite the introduction of various international treatment procedures, asthma exacerbation remains as a major concern at the emergency ward of many hospitals. It has been affirmed that ‘short-acting Beta 2 agonist’ is the primary treatment for acute exacerbation for all age groups of asthma patients. It is in this context that nebulizers for acute asthma patients are often prescribed as standard treatment particularly in young children. However, it was argued that there persists a certain limitation of using nebulizers among children. For instance, it has often been argued that nebulizers are comparatively more inconvenient than spacers and also possess the limitations of high cost and complex implementation process which results in longer relief period to children with asthma. In contrast to the use of nebulizers, it was argued that the use of MDI with spacer have radical impacts on the decreasing admission rates in emergency room in the hospitals, especially among children. It has been further admitted that salbutamol administered via MDI with Volumetic spacer are able to provide effective relief of mild to moderate severity acute asthma exacerbation among children between 5 and 18 years of age. The study was conducted on 216 participants according which it was ascertained that only 1.9% of total children were hospitalized and 8.3% re-visited within the 3 days due to the asthma symptoms (Direkwatanachai, Teeratakulpisaran, Suntornlohanakul, Trakultivakorn, Ngamphaiboon, Wongpitoo & Vangveeravong, 2011). Yilmaz, Sogut, Kose, Sakinci, & Yuksel (2009) further argued that delivery of drugs into lungs via inhalation increases the efficiency of treatment and decreases the side effects mostly observed among asthmatic patients. Accordingly, it was admitted that bronchodilator treatment with the use of spacer in the emergency room has resulted in decreasing admission rates in comparison to the use of nebulizer. Accordingly, it was ascertained from the sample studied, which included 97 children within the age group of 36 months to 166 months, that the use of nebulizers and spacers concerning to the treatment of bronchodilator in ambulatory house condition often had similar effects on the duration of acute asthma (Yilmaz, Sogut, Kose, Sakinci, & Yuksel, 2009). Fayaz, Sultan & Rai (2009) postulated that significant number of population is affected by asthma in the recent day context. For long years nebulizers have been used as the treatment for asthma. However, dependence on the use of nebulizer has gradually decreased which has been replaced by the use of MDI with spacer, especially among children. It is in this context that the study conducted by Fayaz, Sultan & Rai (2009) ascertained in their investigation conducted on 54 cases of children with acute asthma belonging to the age group of 3-14 years that the use of MDI with spacer to hold equal efficiency in managing acute asthma among children as compared to nebulizers. However, a major limitation of using MDI spacer has been argued as its cost-intensive nature compared with the use of nebulizers. Contextually, it was admitted that factors such as efficacy, acceptability, ease of use and cost of treatment related with acute asthma is crucial for the effective health management of children with acute asthma. It was further argued in this context that children are unable to use the nebulizer properly at home in a self-administered manner. Additionally, some nebulizers are not equipped with O2 level controlling systems and at times, may lead to high or low flow of O2 during moderate or severe attacks. Thus, it was advocated that in order to reduce the admission rate of asthmatic children in emergency department of hospitals, MDI with spacer are much effective than nebulizers (Fayaz, Sultan & Rai, 2009). According to Doan, Shefrin & Johnson (2011), asthma is becoming an increasingly common disease among children which is widely apparent in emergency rooms of hospitals. In relation to this, it was ascertained that Beta 2 agonists, which are delivered either through wet nebulizers or MDIs, is observed to be a vital treatment for children with acute asthma exacerbations in emergency wards. However, when the two forms of asthmatic treatments are compared, it was identified that that MDIs provide superior effects than nebulizers in the treatment of acute asthma exacerbations wherein nebulizers were often found to lead to adverse clinical side effects (Doan, Shefrin & Johnson, 2011). On the contrary, Doan, Shefrin, & Johnson (2011) admitted that use of MDIs offer several benefits associated with decreasing risks for cross infection. The use of MDIs also offers better convenience in the use of children’s personal devices whether be nebulizers or spacers. At the same time, it was proclaimed that one major barrier for using MDIs in asthmatic treatments is related with its cost factor. Nonetheless, it was proclaimed that use of MDIs with spacers to deliver bronchodilators in children with moderate asthma exacerbations often contributes towards decreasing admission rates in emergency departments of hospitals in comparison to the use of nebulizers. It was further observed from the study of sample participants which included children aged between 2-18 years and suffering with acute asthma exacerbation that although the cost of nebulizer drugs and devices are less expensive than MDIs with spacers, the use of MDIs with spacers result in shorter length of stay in emergency departments of hospitals than the use of nebulizers. This results in reduction of costs in relation to the use of MDIs spacers (Doan, Shefrin, & Johnson, 2011). Relapse Rate Krishnan, Nowak, Davis & Schatz (2009) stated that airway contagion from respiratory infections or contact to allergens and irritants, or the combination of these two risk factors contributes towards increased airflow impediment and asthmatic symptoms. It has been admitted that anti-inflammatory therapy in consistent to systematic Corticosteroids (CSs), is often used by medical professionals as a primary tool for the management of acute asthma particularly for those in emergency department. It is in this context that the increasing relapse rate among patient with asthma after discharge from emergency room has lead towards many clinical trials and evaluations of alternate anti-inflammatory treatment strategies including the use of Intramuscular Corticosteroids (IMCs) and inhaled CSs. At the same time, it has been argued that in the ambulatory and emergency room settings, the primary goal of the treatment is to normalize the severe hypoxemia as well as to reduce the risk of relapse of the asthmatic patients. In this context, examinations have revealed that use of MDI with spacer is as effective as nebulizers in reducing the relapse rate among children with asthma. It was admitted in this regard that failure to use spacer may have the potential to cause relapse in the children with acute asthma exacerbation. It was identified that ICS treatment have the potential to reduce acute asthma relapse rates after discharge from emergency department by about 50% (Krishnan, Nowak, Davis & Schatz, 2009). Focused on a similar context, Cronin, Kennedy, McCoy, Fhailí, Crispino-O’Connell, Hayden, Wakai, Walsh & O’Sullivan (2012) conducted a study on a sample population of children aged between 2 to 16 years presenting in emergency department of OLCHC, Dublin. On the basis of the findings derived, it was ascertained that MDIs with spacer are effective in delivering corticosteroids and offering effective relief in acute exacerbations that largely helps in reducing relapse rates as well as admission rates in emergency departments. Simultaneously, this procedure also reduces the need for Beta 2 agonist therapy. MDIs with spacers are also affirmed to reduce the risks arising from poor compliance of using of nebulizers and further help to overcome inconvenience. Correspondingly, it has been ascertained that appropriate management of ‘acute asthma exacerbation’ and proper awareness regarding the syndrome often leads towards reducing rate of relapses in children with acute asthmatic problems. Studies in this context reveals that lower relapse rate have been apparent to the use of MDIs with spacer than the use of nebulizers among cases involving children with ‘acute asthma exacerbation’. Accordingly, it was identified that in clinical practices, the dose of Beta 2 agonist delivered to children with acute exacerbation largely varies on the types of spacers and nebulizers used as well as on the characteristics of the individual patient’s airway during the attack or relapse (Cronin, Kennedy, McCoy, Fhailí, Crispino-O’Connell, Hayden, Wakai, Walsh & O’Sullivan, 2012). In this context, Subbarao, Mandhane & Sears (2009) stated that genetic predisposition evidently depicts gene-by-environment interaction as primarily responsible for international variations in the allergy and asthma prevalence rates. It was also admitted that environmental factors like infections and contact to endotoxins often act as risk factors for children, which may lead towards relapse of acute asthma in these populaces. It was further argued that better understanding of these risk factors may significantly help in reducing relapse rate among children with acute asthma. It was further ascertained from the study of the sample population of 5,000 children suffering from wheezing that such patients are most vulnerable to asthma at their younger age. It was observed that asthma in adults may actually persist from childhood that may have occurred as the relapse of childhood asthma. The repeated respiratory tract infection may also have the potential to cause relapse risks in children with asthma (Subbarao, Mandhane, & Sears 2009). Infection Rate When comparing the infection rates among children using spacers and nebulizers, Goh, Tang, Ling, Hoe, Chong, Moh & Huak (2011) revealed that use of MDI with spacer provides an efficient management of acute asthma in children consisting in both the emergency departments as well as inpatient settings. It has been admitted in this regard that delivering Beta agonist via MDIs with spacer is much safer and reduces any possibility of infection in children with acute asthma exacerbations. At the same time, it has been argued that the use of MDIs with spacer in place of nebulizer reduces the possibility of spreading infections to other patients as well as to health staffs attending them. It has been ascertained that in order to facilitate enhanced safety and treatment for children with asthma it is essential that children with asthma are supported with hospital administration for facilitating them with the best practices. Accordingly, it was ascertained that large number of patients with acute asthma considered the use of spacer better, safer and convenient as compared to nebulizers, especially for children. Accordingly, the study that was conducted on the sample population of 19,951 children aged 18 years or younger revealed that use of MDIs with spacers have the potential to reduce infections in children as well as it facilitates in reducing spread of infections to other patients, health staffs, as well as family members during asthmatic attacks (Goh, Tang, Ling, Hoe, Chong, Moh & Huak, 2011). Khoo, Tan, Said & Lim (2009) argued that MDIs inhaler with spacer uses lower dose of bronchodilator, requires lesser equipments as well as it involves lesser and simpler steps in drug preparation than the use of nebulizer therapy which adds convenience for children. It was admitted that use of MDIs with spacers are widely acceptable and preferable during the relapse of an airborne infection in children with acute asthma. Contextually, it has often been observed that the use of nebulizers in hospitals is primarily associated with relatively high risks of transmission of acute airflow obstruction. Additionally, the limitations and risks of using nebulizer have immensely challenged its use against MDIs with spacers in the treatment of acute airflow obstruction when treating asthmatic patients. Nonetheless, it has been admitted that MDI with spacers are usually preferable for short-term treatment of acute airflow obstruction while nebulizers are considered as useful for long-term relief in asthmatic patients including all age groups. Nonetheless, the study consisted of 50 patients with acute asthma exacerbation wherein 46 patients (92%) were able to use MDI with spacer in the appropriate manner. Evidently, it was identified that the use of spacer in children has been examined to yield significant benefits over the use of nebulizers in emergency departments. It is worth mentioning in this context that MDIs with spacers must be used by one patient with acute asthma as multiple uses of MDIs may contribute towards the spread of infections (Khoo, Tan, Said & Lim, 2009). Cates, Crilly & Rowe (2009) further stated that number of physicians engaged in treating asthma patients have been encountered with acute exacerbations of asthma in hospitals as well as in primary care. Contextually, it was ascertained from the studied sample which included adults as well as children (but not infants) suffering from acute asthma admitted in the hospital emergency department that the use of nebulizers act as a potential source of cross-infection in asthma treatments. Simultaneously, the study revealed that the use of nebulizer device in delivering Beta 2 agonist has certain side effects. It is in this context that the use of nebulizers has been examined to result in causing mouth infections which may be accompanied with severe pain in children. At the same time, it has been recognized that MDI inhalers with spacers minimizes the difficulty among the acute asthma patients to coordinate. Additionally it was ascertained that the use of MDIs with spacers also lead towards increasing pulmonary drug disposition and reduces impaction in the oropharynx as well as any fatal effects related with corticosteroid therapy including irritations and candidiasis. However, the study found that despite its efficiency in overcoming many of the side-effects associated with the use of nebulizer, some patients, especially children, often are reluctant to use spacers due to its size and regular maintenance, i.e. on the grounds of convenience (Cates, Crilly & Rowe, 2009; Muchao & Filho, 2010). Conclusion Asthma is medically referred as a life threatening chronic disease among children affecting 300 million populaces across the world (Pakhale, Mulpuru & Boyd, 2011). Over the years, there has been significant development and advancement in the international treatment of the acute asthma exacerbation among children. Despite the advancement in the treatment of asthma, it remains as a matter of concern for emergency department of hospitals as to which treatment procedure shall be safer and effective when comparing the use of spacers and nebulizers. Accordingly, it has been observed that medical practitioners often prescribe Beta 2 agonist as the primary treatment for patients with asthma. At the same time it was ascertained that CSs enables great deal of effective treatment to children with acute asthma exacerbation. This Beta 2 agonist and CSs are delivered either via spacer or nebulizer. It in this context that the use of nebulizer is often argued to be inconvenient and time consuming for children suffering from asthma. On the other hand, it has been ascertained that use of MDIs with spacers is quite expensive than the use of nebulizers but are more efficient in reducing admission rates among children suffering from acute asthma problems. Accordingly, when assessing the difference of these two treatment methods on the basis of relapse rate, it has been identified that risks of relapse rate in children with acute asthma exacerbation tends to increase with the contact to allergens, irritants and any other respiratory infections. Thus, in order to reduce the relapse rate it is crucial that children are kept away from the factors causing allergens and irritants. Contextually, it has been identified that use of spacer in emergency room is often preferable as it reduces the relapse rate in the children with acute asthma exacerbation. At the same time, it has been identified that use of spacer reduces the possibility of infections in the emergency rooms. Contradictorily, it has been ascertained that the use of nebulizers is often associated with infectious diseases affecting the patients as well as the engaged medical practitioners and other participants in the surrounding when being treated. Thus, it can be unarguably stated that in asthmatic Children below 18 years the use spacer inhaler is more beneficial than the use of nebulizers. Recommendations The chronic and life threatening effects of asthma among children has apparently become a major concern in the medical field wherein practitioners have to witness various challenges in dealing with the issue (Rai, Patil, Vardhan, Marwah, Pethe & Pandey, 2007). Accordingly, effective management of asthma requires that efficient partnership is created between patient with asthma and the health care providers. It is crucial that hospital administration facilitates patient with asthma to acquire substantial knowledge, skills and confidence to manage the disease during the case of emergency being adequately aware of the risk potentials and efficiency needs. It is also important that hospital administration provides the parents of children suffering from asthma with adequate understanding about the use of devices such as spacer inhalers or nebulizers. It is necessary that children with asthma are provided with efficient and convenient device that they can use easily during the relapse time, as studies reviewed in the above sections apparently revealed that the effectiveness of treatment procedure depends largely on the way of usage and user conveniences (Lalloo, Ainslie, Wong, Abdool-Gaffar, Irusen, Mash, Feldman, O’Brien & Jack, 2007). In this context, practitioners have often been observed to have firmly suggested that parents of children suffering from asthma should duly consult with physicians or asthma educators for ensuring effective management of the prescribed treatment procedures and their children’s health. It is crucial that parents must be able to identify the signs as well as symptoms of asthma in their children which is again subjected to adequate understanding regarding the appropriate and timely usage of nebulizer therapy and spacer (Schatz, Kazzi, Brenner, Camargo, Corbridge, Krishnan, Nowak & Rachelefsky, 2009). At the same time, patient with severe asthma should also be taught with cleaning and maintenance of spacer this shall facilitate in reducing the possibility of any infections among children. It has been ascertained that effectiveness of drug delivery through spacer devices largely relies on the patient’s inhalation technique. Accordingly, the improper use of spacer or nebulizer may result in reduction in drug delivery to the lungs thus, it is crucial that proper inhalation technique is taught to the children to make sure that drug is delivered to lungs through cleaned spacer and thereby confirm its efficiency (Holt & Gregory, 2012). However, it is worth mentioning that even tough using spacer is quite costly and expensive for children with asthma, it is found to be much convenient in using as compared to nebulizers which again increases its efficiencies in the treatment procedure. References Camargo, C. A., Rachelefsky, G. & Schatz, M. (2009). Managing asthma exacerbations in the emergency department. Proceedings of the American Thoracic Society 6 (4), pp. 357-366. Cates, C. J., Crilly, J. A. & Rowe, B. H. (2009). Holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma (review). The Cochrane Collaboration (1), pp. 1-97. Cronin, J., Kennedy, U., McCoy, S., Fhailí, S. N., Crispino-O’Connell, G. C., Hayden, J., Wakai, A., Walsh, S. & O’Sullivan, R. (2012). Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial. Trials 13 (141), pp. 2-11. Conway, E., Brungs, S., Deveto, L. & Herzog, D. (2008). Consistent approach to asthma education reduces hospital re-admission rates. Resp Care 53 (11), p. 1. Doan, Q., Shefrin, A. & Johnson, D. (2011). Cost-effectiveness of metered-dose inhalers for asthma exacerbations in the pediatric emergency department. Pediatrics 127 (5), pp. 1105-1111. Direkwatanachai, C., Teeratakulpisaran, J., Suntornlohanakul, S., Trakultivakorn, M., Ngamphaiboon, J., Wongpitoo, N. & Vangveeravong, M. (2011). Comparison of salbutamol efficacy in children- via the metered-dose inhaler (MDI) with Volumatic spacer and via the dry powder inhaler, Easyhaler, with the nebulizer - in mild to moderate asthma exacerbation: amulticenter, randomized study. Asian Pac J Allergy Immunol 29, pp. 25-33. Fayaz, M., Sultan, A. & Rai, M. E. (2009). Comparison between efficacy of mdi+spacer and nebuliser in the management of acute asthma in children. J Ayub Med Coll 21 (1), pp. 32-34. Goh, A. E. N.,Tang, J. P. L., Ling, H., Hoe, T. O., Chong, N. K., Moh, C. O. & Huak, C. Y. (2011). Efficacy of metered-dose inhalers for children with acute asthma exacerbations. Pediatric Pulmonology 46, pp. 421-427. Holt, T. O. & Gregory, K. L. (2012). Medication administration/aerosol therapy. Journal of Asthma & Allergy Educators 3 (6), pp. 293-294. Krishnan, J. A., Nowak, R., Davis, S. Q. & Schatz, M. (2009). Anti-inflammatory treatment after discharge home from the emergency department in adults with acute asthma. Proc Am Thorac Soc 6, pp. 380-385. Khoo, M. S.,Tan, L. K., Said, N. & Lim, T. K. (2009). Metered-dose inhaler with spacer instead of nebulizer during the outbreak of severe acute respiratory syndrome in Singapore. Respiratory Care 54 (7), pp. 855-860. Lalloo, U., Ainslie, G., Wong, M., Abdool-Gaffar, S., Irusen, E., Mash, R., Feldman, C., O’Brien, J. & Jack, C. (2007). Guidelines for the management of chronic asthma in adolescents and adults. SA Fam Pract 49 (5), pp. 19-31. Muchao, F. P. & Filho, L. V. R. S. (2010). Advances in inhalation therapy in pediatrics. Jornal de Pediatria 86 (5), pp. 367-376. Pakhale, S., Mulpuru, S. & Boyd, M. (2011). Optimal management of severe/refractory asthma. Clinical Medicine Insights Circulatory, Respiratory and pulmonary medicine 5, pp. 37-47. Rai,S. P., Patil, A. P., Vardhan, V., Marwah, V., Pethe, M., & Pandey, I. M., (2007). Best treatment guidelines for bronchial asthma. MJAFI, 63 (3), pp. 264-268. Subbarao, P., Mandhane, P. J. & Sears, M. R. (2009). Asthma: epidemiology, etiology and risk factors. Canadian Medical Association 181 (9). Schatz, M., Kazzi, A. A. N., Brenner, B., Camargo, C. A., Corbridge, T., Krishnan, J. A., Nowak, R. & Rachelefsky, G. (2009). Introduction. Proceedings of the American Thoracic Society 6, pp. 353-393. Wang, X. & Hong, J. (2011). Management of severe asthma exacerbation in children. World J Pediatr 7 (4), pp. 293-301. Watson, P. (2012). Inhaler spacer devices to treat asthma in children. Journal of Asthma 108 (46). Yilmaz, O., Sogut, A., Kose, U., Sakinci, O. & Yuksel, H. (2009). Influence of Ambulatory Inhaled Treatment with Different Devices on the Duration of Acute Asthma Findings in Children. Journal of Asthma 46, pp. 191-193. Appendix Article Review Template Author(s) Title and Year of Publication Aim/Purpose Sample Methodology Results Implications:Nursing practice, Education and Research Grading 1-10 Direkwatanachai, C., Teeratakulpisaran, J., Suntornlohanakul, S., Trakultivakorn, M., Ngamphaiboon, J., Wongpitoo, N. & Vangveeravong, M. Comparison of salbutamol efficacy in children via the MDI with Volumatic® spacer and via the dry powder inhaler, Easyhaler®, with the nebulizer in mild to moderate asthma exacerbation: a multicenter, randomized study. Asian Pac J Allergy Immunol (2011). To determine the efficacy of salbutamol administered via the MDI with Volumatic spacer and the Easyhaler (DPI) compared to nebulization in mild to moderate asthma exacerbations in children. [5] Children between 5 and 18 years of age who presented at an emergency or outpatient department were assigned as sample for the study. [4] Sequential Assessments [3] This study showed that salbutamol administered via pMDI with Volumatic® spacer or DPI (Easyhaler®), as compared to administration by nebulization, provided effective relief of mild to moderate severity acute asthma exacerbation in children between 5 and 18 years of age. [7] Salbutamol delivered via Easyhaler® caused significantly less tachycardia at 40 and 60 min of dosing than the other 2 groups while the children in the nebulizer group had higher incidence of hypertension after 60 min of treatment. [6] 5 Yilmaz, O., Sogut, A., Kose, U., Sakinci, O. & Yuksel, H. Influence of Ambulatory Inhaled Treatment with Different Devices on the Duration of Acute Asthma Findings in Children. Journal of Asthma (2009). The aim of this study was to assess the influence of using nebulizer or spacer on the duration of acute findings where ambulatory bronchodilator treatment is continued in home settings. [7] The study included a total of 97 children aged between 36 and 166 months (mean 79.2±2.9) followed up in the Pediatric Allergy Department with the diagnosis of asthma. None of the children had additional diseases that could influence the duration of acute asthma findings. [6] Observational study. [4] The results of our study indicated that use of nebulizers and spacers for bronchodilator treatment in ambulatory house conditions had similar effect on the duration of acute asthma findings. [8] The outcome measure used in the study was persistence of clinical acute asthma findings. This has been reported to be a useful short-term monitoring parameter along with assessment of health related quality of life (HRQoL) and school absenteeism. [6] 6 Fayaz, M., Sultan, A. & Rai, M. E. Comparison Between Efficacy Of Mdi+Spacer And Nebuliser In The Management Of Acute Asthma In Children J Ayub Med Coll Abbottabad (2009). To determine differences in management of acute asthma in children in hospital settings, different medical and nursing professionals and then to standardize one management plan to treat acute asthmatic children. [5] Asthmatic children of 3-14 years were selected. [6] Retrospective review of case notes. [5] The result of this study revealed that MDI+spacer is as effective as nebulizer in the management of acute asthma in children.[7] Rees and Price18 stated nebulizers are expensive, time consuming and inconvenient. They are often used incorrectly at home and a child should not be discharged from hospital until he/she is taking the treatment that he/she will be taking at home. [8] 6 Doan, Q., Shefrin, A. & Johnson, D. Cost-effectiveness of Metered-Dose Inhalers for Asthma Exacerbations in the Pediatric Emergency Department. Pediatrics (2011). To compare the incremental cost and effects (averted admission) of using a metered-dose inhaler (MDI) against wet nebulization to deliver bronchodilators for the treatment of mild to moderately severe asthma in pediatric emergency departments (EDs). [5] The sample for this study included children aged 2 to 18 years, with an acute asthma exacerbation coming to the ED for treatment, excluding children with severe respiratory distress requiring ICU admission or chronic cardiorespiratory illnesses (other than asthma).[7] Decision model. [7] The result depicted that using MDIs with spacers in place of nebulizers to deliver bronchodilators (either albuterol alone or both albuterol and ipratropium bromide) to children with mild-to moderate asthma exacerbations would, in most cases, result in both cost savings and a reduction in hospitalizations. [6] Use of MDIs with spacers in place of wet nebulizers to deliver albuterol to treat children with mild-to-moderate asthma exacerbations in the ED could yield significant cost savings for hospitals and, by extension, to both the health care system and families of children with asthma. [8] 7 Goh, A. E. N., Tang, J. P. L., Ling, H., Hoe, T. O., Chong, N. K., Moh, C. O. & Huak, C. Y. Efficacy of Metered-Dose Inhalers for Children With Acute Asthma Exacerbations Pediatric Pulmonology (2011). The purpose of this study was to review the efficacy of our evidence-based asthma pathway, which uses MDI with spacer instead of a nebulizer to administer beta agonists, in the management of acute asthma exacerbations in children in both the emergency room and inpatient settings. [6] A total of 19,951 children (infants to older children) aged 18 years and younger who attended the emergency room for asthma exacerbations.[7] Case with historical control. [3] The result postulated results show that implementation of the standardized asthma pathway in the emergency room, using MDIs with spacer for the administration of beta-agonists instead of nebulizers, did not lead to a significant increase in the number of asthma admissions. [6] The using an MDI with spacer as part of an evidence-based asthma pathway can be used for the management of acute asthma in children in both the emergency room and inpatient settings. It is a safer and more cost-effective method for delivering inhaled beta-agonist to children with acute asthma exacerbations. [5] 5 Cates, C. J., Crilly, J. A. & Rowe, B. H. Holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma (Review) The Cochrane Collaboration (2009). To assess the effects of holding chambers (spacers) compared to nebulizers for the delivery of ß2-agonists for acute asthma. [5] Adults and children (but not infants) with acute asthma presenting for medical assistance in the community setting or hospital emergency department. [6] Randomization: no details. [2] FEV-1 and FVC, pulse, blood pressure, respiratory rate, side effects. Assessed at -11 minutes (before) and 10, 30, 60, 90, 120, 180 (after) inhalation from the MDI and spacer. Maximum change in FEV-1 and FVC from baseline. [5] Hospital admission rates did not differ significantly on the basis of delivery method in adults (RR: 0.97; 95% CI: 0.63 to 1.49) or in children (RR: 0.72; 95%CI: 0.47 to 1.09); Figure 3.No significant heterogeneity was observed. [6] 5 Krishnan, J. A., Nowak, R., Davis, S. Q. & Schatz, M. Anti-inflammatory Treatment after Discharge Home from the Emergency Department in Adults with Acute Asthma Proc Am Thorac Soc (2009) The objective of this systematic review is to synthesize the results of randomized clinical trials in adults with acute asthma, comparing alternative outpatient anti-inflammatory treatment strategies to reduce the risk of relapse after discharge home from the ED. [4] Adults with acute asthma were ascertained as sample. [3] Randomized Clinical Trials [4] The main findings of this systematic review of clinical trials in adults with acute asthma after ED discharge are as follows: (1) IMCS regimens appear to be as effective as OCS regimens in preventing relapse (total n = 5599 participants); (2) in patients with mild-to-moderate acute asthma, ICS and OCS regimens are similarly effective in preventing relapse (total n = 5269 participants); (3) there was a non significant trend suggesting that combination therapy with ICSs and OCSs might be more effective than an OCS alone in preventing relapse (total n = 5912 participants); and (4) additional studies are needed to examine the safety and efficacy of initiating macrolide antibiotics (in the absence of infection) and leukotriene modifiers after an episode of acute asthma. [6] ICS treatment (compared with no ICS treatment) might reduce acute asthma relapse rates after ED discharge by about 50% (20, 25–26). Many RCTs show that ICSs reduce exacerbations in patients with persistent asthma. [5] 4 Cronin, J., Kennedy, U., McCoy, S., Fhailí, S. N, Crispino-O’Connell, G., Hayden, J., Wakai, A., Walsh, S. & O’Sullivan, R. Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial Trials (2012). The aim of the study was to test hypothesis whether a single dose of oral dexamethasone 0.3 mg/kg (max. 12 mg) is non-inferior to prednisolone 1 mg/kg/day (max. 40 mg) for three days in the treatment of exacerbations of asthma in children, as measured by the Pediatric Respiratory Assessment [5] Children aged 2 to 16 years who present to the ED of OLCHC, Dublin 12, Ireland [3]. A randomized, open-label, active control clinical trial.[5] Dexamethasone has also been shown to be significantly more palatable than prednisolone to children presenting to the ED with exacerbations of asthma [6] This clinical trial may provide evidence that a shorter steroid course using dexamethasone can be used in the treatment of acute pediatric asthma, thus eliminating the issue of compliance to treatment [7] 5 Subbarao, P., Mandhane, P. J. & Sears, M. R. Asthma: epidemiology, etiology and risk factors Canadian Medical Association (2009). The objective of this study was to examine risk factors for the development of allergy and asthma in early childhood. [5] Sample selected for this study included 5000 pregnant women. [6] Systematic review [3] The influence of some environmental risk factors such as allergens may be modified by sex. In one study of adults, 18% of women with asthma, but only 2.3% of men with asthma, had normal results on common tests related to at (negative skin prick tests, immunoglobulin E < 100 IU/mL and eosinophilia < 5%),  which suggested different disease mechanisms between the sexes. [6] Reduction in risk, and perhaps even true primary prevention of asthma, remains elusive but is a key goal of asthma management. [5] 5 Khoo, S. M., Tan, L. K., Said, N. & Lim, T. K. Metered-Dose Inhaler With Spacer Instead of Nebulizer During the Outbreak of Severe Acute Respiratory Syndrome in Singapore Respiratory Care (2009). The objective of this study was to identify patients’ and nurses’ abilities and perspectives on MDI with spacer for the treatment of acute airway obstruction during such an outbreak. [4] 50 consecutive MDI-with spacer treatments administered in the respiratory wards of the National University Hospital of Singapore. [5] Interview [4] This study demonstrated that the use of MDI with spacer for treatment of acute air flow obstruction in an in-patient population during an outbreak of airborne infection is acceptable and preferred by a majority of patients. [7] MDI with spacer is acceptable as a short-term substitute for nebulizer during an outbreak, but its long-term implementation in regular care may be impeded by nursing opinions. [6] 5 Read More