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PubMedDate not supplied

Updating asthma management: the process of change.

A strategic approach to changing clinical practice that is managed by a multidisciplinary team is an effective way of implementing new treatment methods or approaches to patient care. The Royal Children's Hospital, Melbourne, Australia, a tertiary pediatric hospital, instituted new Asthma Delivery Device Guidelines in recognition of current evidence that described the benefits of treating acute pediatric asthma with pressurized metered dose inhalers and spacer devices. The working group that coordinated the project attributes the successful change in practice to a multifaceted, multidisciplinary approach, a significant planning stage, initial and ongoing intensive staff and patient/parent education, and accessibility of information.

Asthma↗
PubMed2001

Multidisciplinary education and management program for children with asthma.

A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.

Anti-Asthmatic Agents↗
PubMed2005

Global Initiative for Chronic Obstructive Lung Disease strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: an Asia-Pacific perspective.

Chronic obstructive pulmonary disease (COPD) is a major public health problem and its prevalence and mortality are increasing throughout the world, including the Asia-Pacific region. To arrest these worldwide trends, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Expert Panel's global strategy for the diagnosis, management, and prevention of COPD was published in 2001. Based on recently published clinical trials, the GOLD statement was updated in 2003. The Asia-Pacific COPD Roundtable Group, a taskforce of expert respirologists from the Asia-Pacific region, has recently formulated a consensus statement on implementation of the GOLD strategy for COPD in the Asia-Pacific region. The key issues identified by the COPD Roundtable Group for comment are: (i) where there is no access to spirometry, diagnosis of COPD could be suspected on the basis of history, symptoms and physical signs; (ii) inhaled bronchodilators are the preferred regular treatment for COPD in the region, but oral bronchodilators may be considered if the cost of inhaled bronchodilators is a barrier to treatment; (iii) the use of a Metered Dose Inhaler with spacer in place of a nebulizer is recommended in the treatment of acute airflow obstruction in patients with COPD; (iv) influenza vaccination is recommended for all patients with COPD in communities where there is a high likelihood of Severe Acute Respiratory Syndrome; and (v) simplified pulmonary rehabilitation programmes should be established in areas where comprehensive programmes are unavailable. Physical exercise training and education on smoking cessation should be core elements of any rehabilitation program. In summary, the COPD Roundtable Group supports implementation of the GOLD strategy for the diagnosis, management and prevention of COPD in the Asia-Pacific region, subject to the additions and modifications to the guidelines suggested above.

Asia↗
PubMed1993

Comparison of the efficacy and safety of inhaled fluticasone propionate 200 micrograms/day with inhaled beclomethasone dipropionate 400 micrograms/day in mild and moderate asthma.

This study was designed to compare the efficacy and safety of a new inhaled corticosteroid, fluticasone propionate at a total daily dose of 200 micrograms, with beclomethasone dipropionate 400 micrograms/day in childhood asthma. A total of 398 asthmatic children (aged 4-19 years) were randomised to receive either fluticasone propionate 200 micrograms daily or beclomethasone dipropionate 400 micrograms daily for six weeks inhaled via a spacer device from a metered dose inhaler. During the study the patients recorded morning and evening peak expiratory flow rate (PEFR), symptom scores, and use of beta 2 agonist rescue medication. In addition, clinic visit PEFR and forced expiratory volume in one second were measured. Safety was assessed by recording all adverse events and by performing routine biochemistry and haematology screens including plasma cortisol concentration before and after treatment. For the purposes of analysis the diary card data were grouped into three periods: week 3 (days 15-21), week 6 (days 36-42), and weeks 1-6 (days 1-42). The results showed no significant difference between treatments on most efficacy parameters. However, there were significant differences in changes from baseline in favour of fluticasone propionate for % predicted morning PEFR both at week 3 (fluticasone propionate 6.1%, beclomethasone dipropionate 3.9%) and at week 6 (fluticasone propionate 8.3%, beclomethasone dipropionate 5. 9%) and % predicted evening PEFR at week 6 (fluticasone propionate 7.3%, beclomethasone dipropionate 4.9% and over weeks 1-6 (fluticasone propionate 5.5%, beclomethasone dipropionate 3.6%. Comparison between groups showed that the group receiving fluticasone propionate had a lower % of days with symptom-free exercise at week 6 (fluticasone propionate 87%, beclomethasone dipropionate 81%) and % days without rescue medication at week 6 (fluticasone propionate 87%, beclomethasone dipropionate 80%) and over weeks 1-6 (fluticasone propionate 80%, beclomethasone dipropionate 73%). Except for a higher incidence of sore throat in the fluticasone propionate group, the two treatments did not differ with regard to safety. There was no evidence of adrenal suppression with either treatment. In conclusion, fluticasone propionate 200 microgram daily ws at least as effective and as well tolerated as beclomethasone dipropionate 400 microgram daily in childhood asthma.

Administration, Inhalation↗
PubMed1991

Effect of terbutaline on mucociliary clearance in asthmatic and healthy subjects after inhalation from a pressurised inhaler and a dry powder inhaler.

BACKGROUND: beta Agonists have been shown to increase mucociliary clearance in some studies but not all. Whether the formulation of beta agonists affects mucociliary clearance is not known but may be important as the use of dry powder inhalers increases. METHODS: The effect of different methods of administration of inhaled terbutaline on mucociliary clearance and forced expiratory volume in one second (FEV1) was assessed in 10 patients with asthma and 10 healthy subjects. Terbutaline (1 mg) was administered through a metered dose inhaler with a spacer (Nebuhaler) or a dry powder inhaler (Turbuhaler), or both treatments were given, in a four way double blind, double dummy trial. Mucociliary clearance was measured by bronchoscintigraphy. RESULTS: Clearance of radioactivity from the lobar bronchi increased in the asthmatic patients by a median of 32% after terbutaline was given by metered dose inhaler and 55% after a combined dose of 2 mg from both inhalers (1 mg from each) compared with placebo but by only 9% after 1 mg of terbutaline was given by a dry powder inhaler. In the healthy subjects mucociliary clearance increased by 51% when terbutaline was given by a dry powder inhaler, by 66% when given by a metered dose inhaler, and by 66% when given by both inhalers combined. The effect of terbutaline on FEV1 was the same with each of the inhalers. CONCLUSION: Despite similar changes in FEV1 with the two formulations terbutaline increased mucociliary clearance significantly in asthmatic and healthy subjects when inhaled from a metered dose inhaler whereas when it was inhaled from a dry powder inhaler its effect was significant only in healthy subjects. The reason for the difference in asthmatic subjects is unclear, but may be associated with differences in the deposition of terbutaline.

Administration, Inhalation↗
PubMedDate not supplied

Terbutaline aerosol from a metered dose inhaler with a 750-ml spacer or as a nebulized solution. Comparison of two delivery systems for bronchodilator aerosol.

The clinical effect of 1.0 mg terbutaline given as a pressurized aerosol with a 750-ml spacer was compared with that of 4.0 mg terbutaline given as a nebulized solution (Pari Inhalier Boy). No differences were found in the parameters measured--forced vital capacity, 1 s forced expiratory volume, forced mid-expiratory flow, and oscillatory resistance. The results indicate that the same clinical response to a given dose of a pressurized aerosol supplied with a 750-ml spacer has the same effect as a fourfold dose via a nebulizer. It is concluded that the more practical 750-ml spacer should be tried when contemplating nebulization therapy.

Adult↗
PubMedDate not supplied

A prospective evaluation of the 1-hour decision point for admission versus discharge in acute asthma.

Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV(1) alone as an outcome predictor yielded suboptimal performance. FEV(1) at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better (P =.0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV(1) reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.

Academic Medical Centers↗
PubMed2006

A controlled trial of a school-based intervention to improve asthma management.

The present study investigated schools as an appropriate context for an intervention designed to produce clinical and psychological benefits for children with asthma. A total of 193 out of 219 (88.1%) children with asthma (aged 7-9 yrs) from 23 out of 24 (95.8%) schools completed the study. Intervention schools received a staff asthma-training session, advice on asthma policy, an emergency beta2-agonist inhaler with spacer and whole-class asthma workshops. Nonintervention schools received no asthma-related input. Intervention children required less general practitioner-prescribed preventer medication despite no differences in symptom control compared with the nonintervention asthmatic group. Increased peer knowledge of asthma may have mediated improved active quality of life in the intervention group, together with increased self-esteem in young females. Those females not receiving the intervention, but identified as being asthmatic within the classroom, and thus possibly stigmatised, reported decreased self-esteem. Lower self-esteem in young males was associated with pet ownership. No change was found in staff knowledge, the establishment of asthma policies or school absences which were low even before intervention. In conclusion, a whole-school intervention can improve the health of children with asthma when followed with support for all children but effects are likely to be modified by sex and the home environment.

Asthma↗
PubMedDate not supplied

Steroid-induced acute psychosis in a child with asthma: report of one case.

A 5-year-old girl was admitted due to severe asthmatic attack. She was treated with methylprednisolone (40 mg i.v. q6h), aminophylline (loading with 5 mg/kg and maintained with 0.6 mg/kg/hr i.v. drip), nebulized terbutaline sulphate (5 mg q6h), oral procaterol 12.5 micrograms bid, along with oxygen therapy. Acute psychotic reaction with visual hallucination, delusion, panic reaction and myoclonic movement of hands developed on day 3 of admission. The patient had no previous history of psychiatric problems. The theophylline level was 9.89 micrograms/ml at the moment of psychotic reaction. After the dose of methylprednisolone was reduced from 40 mg to 20 mg i.v. q6h and shifted to other anti-asthma treatment by procaterol metered dose inhaler via spacer, the psychotic reaction disappeared a few hours later. The psychotic reaction was thought to be due to steroid therapy since no other causes could explain the psychotic reaction.

Anti-Asthmatic Agents↗
PubMed1995

The effects on prescribing patterns and costs of having a special interest in asthma.

To define the characteristics of general practices with a special clinical interest in asthma and to estimate the resulting extra prescribing costs, we sent a postal questionnaire to all English practices containing members of the General Practitioners in Asthma Group. Item and cost comparisons for 24 PACT (prescribing analysis and cost) aggregates were made between practices who had operated an agreed, written management plan for asthma before 1 April 1990 and all other practices in their respective Family Health Services Authorities. One hundred and sixty-three practices with GPIAG members responded (70%), of which 26 filled the management plan requirement. These 26 practices showed evidence of significantly better asthma care provision than the remainder of the sample. Their prescribing costs were significantly higher for respiratory drugs (median 37% higher) but lower in other drug categories. For respiratory drugs, costs were significantly higher for inhaled adrenoceptor stimulants, steroid inhalers, large spacers, and peak flow meters, but lower for cough medicines and systemic nasal decongestants: the number of items prescribed showed similar patterns. The prescribing costs of practices claiming a special interest in asthma are likely to show higher respiratory drug costs, but overall prescribing costs showed no increase in the practices studied.

Anti-Asthmatic Agents↗
PubMed1998

[Effect of salmeterol in obstructive sleep apnea syndrome].

The effect of inhaled long-acting beta 2-agonists on obstructive sleep apnoea syndrome (OSAS) is unknown, though from the pharmacological point of view both therapeutic and adverse effects might be discussed. The purpose of this study was to obtain data on the efficacy and safety of Salmeterol in patients with OSAS. In a randomised, double-blind, placebo-controlled, crossover study effects of Salmeterol were investigated in 20 patients with OSAS: 4 female, 16 male; age 53.0 +/- 7.8 years, body mass index (BMI) 28.0 +/- 3.0 kg.m-2; apnoea hypopnoea index (AHI) 35.6 +/- 17.8 h-1. Patients with asthma, chronic obstructive pulmonary disease (COPD), and left heart failure were excluded. Placebo or verum (50 micrograms Salmeterol) were administered at 7 p.m. by metered dose inhaler and spacer device. All patients underwent full polysomnography during baseline, placebo, and verum night. Statistical analysis was performed by Student's t-test (p < 0.05). Between placebo and verum there were no differences in total sleep time, sleep stages, apnoea index (AI), AHI, and nadir SaO2. There was, however, a significant deterioration of mean SaO2 (placebo 93.1 +/- 2.0 vs Salmeterol 92.5 +/- 2.2%) and of relative time spent with SaO2 < or = 90% (placebo 13.1 +/- 14.5 vs Salmeterol 19.5 +/- 20.8%), as well as a significant increase in heart rate (placebo 63.1 +/- 9.2 vs Salmeterol 65.6 +/- 9.3 h-1). Thus, in patients with OSAS Salmeterol had no adverse effect on quality of sleep, AI or AHI. The slight increase in heart rate and the deterioration of oxygen saturation are clinically irrelevant. The latter might be due to ventilation-perfusion-mismatch. This study demonstrates that Salmeterol has no influence on obstructive sleep apnoea and hypopnoea, but on the other hand provides an acceptable safety profile in OSAS. This might be of special importance in patients suffering from both OSAS and obstructive airway disease.

Adrenergic beta-Agonists↗
PubMedDate not supplied

Budesonide inhalation powder: a review of its pharmacologic properties and role in the treatment of asthma.

Budesonide inhalation powder, available as Pulmicort Turbuhaler, is a corticosteroid with a high ratio of local to systemic effects that is administered to treat persistent asthma. The Turbuhaler achieves lung deposition approximately twice that of a metered-dose inhaler (MDI) with or without a spacer device. Budesonide inhalation powder has clinical efficacy equivalent to that of fluticasone and beclomethasone, but it has lower systemic bioavailability and fewer systemic side effects. As with other inhaled corticosteroids, dysphonia and oral candidiasis are the most frequent adverse effects, and systemic effects are infrequent. The initial starting dosage is 200 microg (1 puff) twice/day and may be increased to 800 microg twice/day in adults or 400 microg twice/day in children. Patients prefer the Turbuhaler to the MDI, Diskhaler, and Rotahaler because it is easier to use and more convenient to carry.

Administration, Inhalation↗
PubMed1985

Treatment of acute bronchoconstriction in children with use of a tube spacer aerosol and a dry powder inhaler.

In a double blind cross-over study 24 children suffering from acute bronchoconstriction were treated with either placebo, or terbutaline delivered by a pressurized aerosol with a tube spacer (TS), or salbutamol from a dry powder inhaler (Rotahaler = RO). Both active treatments resulted in a significant increase in FEV1 as compared with placebo (P less than 0.001). Furthermore, TS treatment resulted in significantly greater improvement in FEV1 than treatment with the RO (P less than 0.05). Under the conditions of marked airways obstruction problems with correct handling of the RO (loading and breaking the capsule) were prevalent and many children were unable to empty the RO capsule. These difficulties seemed to account for the smaller bronchodilation after RO treatment and were not seen under quiet circumstances. It is recommended that inhalation therapy in children is supervised by an adult during periods of marked airways disease.

Adolescent↗