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PubMed2003

[Pharmacoeconomic study of antibiotic therapy for exacerbations of chronic bronchitis and chronic obstructive pulmonary disease in Latin America].

Chronic obstructive pulmonary disease (COPD) and chronic bronchitis are highly prevalent diseases. Studies designed to analyze the economic impact of these diseases in Latin American countries have not previously been published. In the present study we analyzed the direct health care costs of treating patients with exacerbations of chronic bronchitis and COPD in Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela, applying the real cost of drugs and medical acts in those 7 countries to the pattern of treatment and outcomes obtained from a study carried out in primary care settings in Spain. The mean direct health care cost ranged from US $98 in Colombia to $329 in Argentina. Most of the cost was related to failure of therapy, which accounted for 52% of the total cost of exacerbation, with the lowest rate in Colombia at 28.6% and the highest in Ecuador at 59.3% The cost of antibiotic therapy represented 19% of the total cost; the rest was owing to other drugs or medical visits. Exacerbations generate significant costs for health care systems. There are considerable variations related mainly to differences between systems. Antibiotic therapy represents a small part of the overall cost. The use of more effective antibiotics, if they can reduce failure rates, may be a cost-effective strategy.

Acute Disease↗
PubMed2001

Acute exacerbation of chronic maxillary sinusitis during therapy with nafarelin nasal spray.

OBJECTIVE: To describe a case of acute exacerbation of chronic bilateral maxillary sinusitis during therapy with nafarelin nasal spray for chronic pelvic pain and suspected adenomyosis uteri in a patient of 34 years. DESIGN: Case report. INTERVENTIONS: In the follicular stage of the cycle a diagnostic laparoscopy was carried out because of unexplained pelvic pain for 2 years with biopsy of the pelvic peritoneum and of the uterine fundus was done, revealing no pathology. One and a half years ago the patient already had a diagnostic laparoscopy for the same reason without pathological findings. Vaginal ultrasound showed minor signs of adenomyosis uteri (irregular structure of the myometrium with small cysts). One week after the operation, a therapy with nafarelin nasal spray was initiated in order to induce a hypoestrogenic state. Fourteen days later the therapy had to be stopped because of acute exacerbation of chronic maxillary sinusitis and Caldwell Luc operation and turbinoplastic was performed. OUTCOME: Resolution of the acute maxillary sinusitis after operative intervention and termination of the above-mentioned medication, resolution of pelvic pain after therapy with leuprolide after 4 weeks. CONCLUSIONS: To our knowledge, this is the first report of an acute exacerbation of a chronic maxillary sinusitis during the administration of nafarelin nasal spray. Gynecologists prescribing nasal sprays should ask their patients about symptoms of chronic sinusitis. Patients with a history of sinusitis should visit an ear, nose and throat (ENT) specialist before initiating therapy with nasal sprays; alternatively, drugs with a different formulation should be used for down-regulation of the ovarian function in order to avoid this complication.

Administration, Intranasal↗
PubMed2001

Infectious etiologies in acute exacerbation of COPD.

Acute exacerbation (AE) is a frequent episode during the prolonged chronic course of chronic obstructive pulmonary disease (COPD), which entails significant morbidity and mortality. The purpose of this study was to determine the frequency distribution of infectious etiologies in these episodes. Two hundred forty hospitalizations for AECOPD were included in a prospective, purely serologically based study. Paired sera were obtained for each of the hospitalizations and were tested using immunofluorescence or EIA methods to identify 13 different pathogens. Only significant changes in antibody titers were considered diagnostic. The mean age ( +/- SD) of the patients was 66.8 +/- 9.0 years and 179 (84%) were males. In 175 (72.9%) hospitalizations at least one infectious etiology was identified. In 117 (48.8%) hospitalizations at least one of 7 viral etiologies was identified. In 72 (30.0%) hospitalizations at least one of the following atypical bacteria was identified: Legionella spp. in 40 (16.7%), Mycoplasma pneumoniae in 34 (14.2%), and Coxiella burnetii in a single hospitalization. In 58 (24.2%) hospitalizations at least one classic bacterial etiology was found: Streptococcus pneumoniae in 48 (20.0%), Hemophilus influenzae in 10 (4.2%) and Moraxella catarrhalis in 9 (3.8%). More than one etiology was found in 72 (30.0%) hospitalizations. There were no significant differences in the etiologic distribution when the patients were classified by severity of airway obstruction or the clinical type of the exacerbation. We conclude that in most cases of hospitalization due to AECOPD the infectious etiology is viral or atypical bacteria and is classic bacteria in only a minority of cases. More than one etiologic cause can be identified in a third of the cases. The frequency distribution of the etiologies is not associated with the severity of airway obstruction or the clinical type of the exacerbation. The results of our study suggest that atypical bacteria should be covered in antibiotic regimens recommended for AECOPD. This issue should be addressed in future studies.

Adult↗
PubMed1996

Early corticosteroid use in acute exacerbations of chronic airflow obstruction.

To determine the benefit of early steroid use in acute exacerbations of chronic airflow obstruction in the ED, 113 patients with an average age of 66 years, acute or chronic dyspnea, an FEV1 of < 60% and FEV1/FVC ratio of < 60% were included in a randomized, double-blinded, interventional clinical trial. All patients received the same bronchodilator treatment. At 6 hours the steroid- treated group showed a 21.71 L/min improvement in PEFR (P < .05) and 0.14 L improvement in FEV1 (P < .05), while the nonsteroid group showed insignificant improvements of 5.52 L/min and 0.02 L, respectively. Of those patients receiving steroids, 22 achieved > 40% improvements in PEFR by 6 hours and 17 achieved similar results in FEV1, whereas of those not receiving steroids, 13 and 8, respectively, achieved improvements. Within 24 hours of observation in the ED, 16 patients receiving steroids were discharged and none relapsed within 2 weeks. Of those not receiving steroids, only 10 were discharged and 3 returned with exacerbations. Although early response to steroids in chronic airflow obstruction is variable, the overall medical and cost benefits justify their early use in acute exacerbations.

Adult↗
PubMed2004

[The "COPD emergency 2003" study: a description of the hospital management of exacerbations of COPD].

CURRENT SITUATION: Despite its impact on public health and numerous recommendations COPD remains under-diagnosed and its care pathways are not well known. Exacerbations are common presentations of the illness and contribute greatly to its impact on the health of the individual and the community. Despite this the methods of their management in hospital have not been precisely described. The purpose of the prospective study "COPD emergency 2003" is to describe these different aspects of the management of COPD and to study their determining factors. MATERIALS AND METHODS: It is a prospective, multicentre observational study of all the exacerbations of COPD managed as emergencies in public and private hospitals during a two-month period. Enrolment takes place between October 2003 and January 2004. The analysis will begin when the last patient has been discharged from hospital. EXPECTED RESULTS: The data obtained will allow identification of those aspects of the management of COPD and its exacerbations that are heterogeneous or in conflict with the current guidelines as well as the patient care pathways. In the future this study should help target the approaches aimed at improving the outcomes of patients suffering from COPD.

Adult↗
PubMed2004

[ANTEAB: a study of early antibiotic therapy in intensive care management of acute exacerbations of chronic obstructive lung disease].

INTRODUCTION: Intensive Care Unit (ICU) admission for acute exacerbation of chronic obstructive lung disease (COLD) is a major cause of morbidity and mortality in such patients. Although bacterial and/or viral infections are considered as the major precipitating factor, the antibiotic strategy in this setting is unclear. The potential benefit of routine antibiotic therapy in the absence of evidence of overt infection remains controversial, and has not been adequately studied in patients admitted to the ICU. To assess the benefit (or lack thereof) of routine early systemic antibiotic therapy in patients with COLD admitted to the ICU. METHODS: This is a multicenter, randomized, double-blind controlled trial, comparing amoxicillin-clavulanic acid administered for 7 days to a placebo. Patients included are those with documented or suspected COLD, exclusive of other bronchial or lung disease, and admitted for acute exacerbation, in the absence of overt sepsis or broncho-pneumonia, and having no other organ failure. Patients recently hospitalized, having received antibiotics for > 24 h, or on long-term steroids will not be included. Co-interventions (bronchodilators, steroids) are controlled for. Patients will be administered the antibiotic or placebo within 24 hours of admission. EXPECTED RESULTS: A 20% reduction of the duration of clinical symptoms of exacerbation is expected. To this end, 520 patients are planned to be included in 15 centers in a 2-year period. Secondary end-points are the incidence of documented infection (lower respiratory tract or other sites), antibiotic use, the proportion of patients having infection with resistant bacteria, the incidence of endotracheal intubation, the duration of stay and mortality in the ICU and the hospital.

Acute Disease↗
PubMed1997

Tardive dyskinesia exacerbated after ingestion of phenylalanine by schizophrenic patients.

Despite continued research, the influences that promote or exacerbate tardive dyskinesia (TD) symptoms remain incompletely understood. Recent findings (Gardos et al. 1992; Richardson et al. 1989) suggest that ingestion of the dietary constituent, phenylalanine, might exacerbate TD symptoms, but a double-blind, placebo-controlled challenge had not previously been conducted in schizophrenic patients. On two different mornings, in counterbalanced order, 18 male schizophrenic patients with TD were challenged with either 100 mg/kg phenylalanine or placebo. Effects on abnormal involuntary movements, recall memory, and plasma phenylalanine were measured 90 minutes post-challenge. The results supported the hypothesis in that involuntary movements increased to a statistically and clinically meaningful degree after the phenylalanine challenge, but not after placebo. No effects on memory were detected. Significant order effects characterized the plasma findings but not the behavioral data. Results indicate that a dietary constituent, the amino acid phenylalanine, can potentially exacerbate tardive dyskinesia symptoms in schizophrenic patients. The influence of phenylalanine and other ingested substances on clinical symptomatology warrants further investigation.

Adult↗
PubMed1997

Ketamine-induced exacerbation of psychotic symptoms and cognitive impairment in neuroleptic-free schizophrenics.

The N-methyl-d-aspartate (NMDA) receptor has been implicated in the pathophysiology of schizophrenia. We administered subanesthetic doses of the NMDA receptor antagonist ketamine in a double-blind, placebo-controlled design to 13 neuroleptic-free schizophrenic patients to investigate if schizophrenics will experience an exacerbation of psychotic symptoms and cognitive impairments with ketamine. We also examined whether schizophrenics experienced quantitative or qualitative differences in ketamine response in comparison to normal controls. Schizophrenics experienced a brief-ketamine-induced exacerbation of positive and negative symptoms with further decrements in recall and recognition memory. They also displayed greater ketamine-induced impairments in free recall than normals. Qualitative differences included auditory hallucinations and paranoia in patients but not in normals. These data indicate that ketamine is associated with exacerbation of core psychotic and cognitive symptoms in schizophrenia. Moreover, ketamine may differentially affect cognition in schizophrenics in comparison to normal controls.

Adult↗
PubMed2001

The place of antibiotic therapy in the management of chronic acute exacerbations of chronic bronchitis.

In the USA, more than 16 million adults are affected by chronic obstructive pulmonary disease, and chronic bronchitis has been estimated to affect up to 13 million individuals or approximately 4-6% of adults. Chronic bronchitis is an increasing cause of significant morbidity and mortality. During acute exacerbations of chronic bronchitis, subjects experience a worsening of bronchitic symptoms, with an increase from baseline in one or more or the following; dyspnoea, cough and/or sputum volume, purulence or viscosity. The severity of an exacerbation can be graded by how many of these symptoms are present. Antibiotic therapy should be initiated based on patient history and severity of the exacerbation.

Acute Disease↗
PubMed2002

Haemophilus influenzae in acute exacerbations of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a common progressive respiratory disease that is associated with infective exacerbations that lead to worsening of symptoms. Many organisms are thought to trigger infective exacerbations, but Haemophilus influenzae is the most commonly isolated bacterium. The role of H. influenzae in infective exacerbations remains uncertain, mainly because the organism chronically colonises patients whose clinical condition is stable. H. influenzae may also comprise part of the normal nasopharyngeal flora in man, making the interpretation of positive cultures difficult in some cases.

Acute Disease↗
PubMed2002

Use of antibiotics in patients admitted to the hospital due to acute exacerbation of chronic obstructive pulmonary disease (COPD).

BACKGROUND: The purpose of this study was to assess to what extent symptoms and signs of bacterial infection are present and evaluated in patients admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) in relation to initiation of antibiotic treatment. METHODS: All adult patients (>18 years of age) discharged from a department of internal medicine in Copenhagen in 1997 with a diagnosis of exacerbation of COPD were included in our study and their reports were retrospectively reviewed. Gender, age, number of admissions and length of hospital stay, use of antibiotics and steroids prior to admission, temperature, white blood cell (WBC) count, results of lung auscultation and X-ray examination of the thorax at admittance, and growth of sputum culture and antibiotic treatment in the hospital were all registered. RESULTS: A total of 400 admissions took place. In 104 of them, chest X-ray was compatible with pneumonia, and 99 cases were treated with antibiotics. In 44% of the remaining 296 cases, antibiotics were given. It was found that 25-45% of the patients with very little evidence of infection-i.e. the absence of, or only the presence of, one of the following indicators of infection: fever (temperature>37.5 degrees C), a raised WBC count (>9 billion/l), or crepitation at lung auscultation-were given antibiotics. In cases presenting with two or three of these indicators, 50-75% were given antibiotics. In 85% of the cases, penicillin or a macrolide was the initial antibiotic of choice. The median hospital stay was 6 days for the entire group of patients. CONCLUSION: These data suggest that, in patients with acute exacerbation of COPD, a relatively high number of patients with only weak symptoms or signs of bacterial infection are treated with antibiotics.

Journal Article↗
PubMed2006

Failure to maintain an aspirin-desensitized state in a patient with aspirin-exacerbated respiratory disease.

BACKGROUND: Aspirin desensitization is a useful therapy in patients with aspirin-exacerbated respiratory disease. OBJECTIVE: To describe the clinical course of a man with aspirin-exacerbated respiratory disease who was unable to be desensitized to oral aspirin. METHODS: A standard aspirin desensitization protocol was used to achieve a maximum dose of 650 mg of oral aspirin. The patient initially tolerated this dose of aspirin. RESULTS: Within days of desensitization, the patient began to react to 650 mg of aspirin. Monitored challenge with this dose of aspirin led to marked decrease in forced expiratory volume in 1 second and pronounced nasal and ocular symptoms. CONCLUSIONS: We present a patient with classic aspirin-exacerbated respiratory disease, who despite undergoing a standard aspirin desensitization protocol was unable to maintain his desensitized state.

Administration, Oral↗
PubMed2006

Effect of clarithromycin on cytokines and chemokines in children with an acute exacerbation of recurrent wheezing: a double-blind, randomized, placebo-controlled trial.

BACKGROUND: Clarithromycin is postulated to possess immunomodulatory properties in addition to its antimicrobial activity. OBJECTIVE: To evaluate the effect of clarithromycin on serum and nasopharyngeal cytokine and chemokine concentrations in children with an acute exacerbation of recurrent wheezing. METHODS: Children with a history of recurrent wheezing or asthma and who presented with an acute exacerbation of wheezing were enrolled in a double-blind, randomized trial of clarithromycin vs placebo. Concentrations of tumor necrosis factor alpha (TNF-alpha), interferon-gamma (IFN-gamma), interleukin-1beta (IL-1beta), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating factor, RANTES, eotaxin, macrophage inflammatory protein 1alpha, macrophage inflammatory protein 1beta, and monocyte chemoattractant protein 1 were measured in serum and/or nasopharyngeal aspirates before, during, and after therapy. Mycoplasma pneumoniae and Chlamydophila pneumoniae infection were evaluated for by polymerase chain reaction and serologic testing. RESULTS: Nasopharyngeal concentrations of TNF-alpha, IL-1beta, and IL-10 were significantly and persistently lower in children treated with clarithromycin compared with placebo. There tended to be a greater effect of clarithromycin on nasopharyngeal cytokine concentrations in patients with evidence of M. pneumoniae or C. pneumoniae infection. No significant differences were detected in serum cytokines for children treated with clarithromycin compared with placebo. CONCLUSION: Clarithromycin therapy reduces mucosal TNF-alpha, IL-1beta, and IL-10 concentrations in children with an acute exacerbation of recurrent wheezing.

Acute Disease↗
PubMed2005

Asthma-related exacerbations, therapy switching, and therapy discontinuation: a comparison of 3 commonly used controller regimens.

BACKGROUND: Asthma control is the goal of therapeutic interventions. In observational studies, the use of short-acting beta-agonists (SABAs) is a surrogate for symptoms and emergency department or hospital events for exacerbations. OBJECTIVE: To compare asthma exacerbations, medication switch, and use of SABAs among 3 treatment cohorts: fluticasone propionate and salmeterol as a single inhaler (FSC), fluticasone and salmeterol as separate inhalers (FP + SAL), and fluticasone propionate alone (FP). METHODS: Administrative claims data from approximately 10 million individuals from April 2000 to December 2002 were examined. Patients 15 years or older with claims for asthma, SABAs, and study medications were included in the study. Asthma-related medical and pharmacy claims were evaluated. Multivariate regression techniques were used to model the outcomes of interest, controlling for patient characteristics. RESULTS: The odds of a hospitalization or emergency department event were significantly lower for the patients receiving FSC (n=1013) compared with those receiving FP (n=1130) (odds ratio, 0.75; 95% confidence interval, 0.61-0.93) and those receiving FP + SAL (n=271) (odds ratio, 0.69; 95% confidence interval, 0.51-0.95). Patients receiving FSC also had a significantly lower risk of switch or discontinuation of index medication and lower rates of postindex SABA use. CONCLUSION: In this analysis, patients receiving FSC had lower rates of asthma-related symptoms and exacerbations as measured by SABA refills and hospitalization, respectively, when compared with patients receiving either FP or FP + SAL. This observational examination of medical and pharmacy claims data adds to the clinical reports that demonstrate the increased effectiveness of FSC when compared with FP or FP + SAL.

Administration, Inhalation↗
PubMed2006

Comparison of nebulized ipratropium bromide with salbutamol vs salbutamol alone in acute asthma exacerbation in children.

BACKGROUND: Despite multiple doses of beta2-agonists in the treatment of acute asthma exacerbation, significant residual airways obstruction often remains. OBJECTIVE: To determine whether the addition of inhaled ipratropium bromide to salbutamol provides improvement in lung function and clinical asthma symptoms in young children with acute asthma exacerbation. METHODS: This study was a prospective, double-blind randomized control trial of children aged 3 to 15 years who presented with an acute asthma exacerbation at the emergency department or outpatient clinic of Thammasat University Hospital, Pathumthani, Thailand, between September 2001 and February 2003. Subjects were randomized to receive 3 doses of nebulized salbutamol mixed with isotonic sodium chloride solution (control) or ipratropium bromide (treatment) every 20 minutes. Additional doses of salbutamol were given every 30 minutes as needed. Asthma outcome measures were evaluated 40, 70, 100, and 120 minutes after baseline. Primary outcomes were the differences in percent change in asthma clinical score and percent change in peak expiratory flow rate (PEFR) from baseline. Secondary outcomes included change in percent predicted PEFR. RESULTS: Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group. CONCLUSION: Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies.

Administration, Inhalation↗
PubMed2000

Leukotriene receptor antagonists may prevent NSAID-induced exacerbations in patients with chronic urticaria.

BACKGROUND: About 30% of patients with chronic urticaria experience flares of hives and/or angioedema after ingesting either aspirin or nonsteroidal anti-inflammatory drugs. In such patients, cross-reactivity to all NSAIDs seems to occur suggesting a mechanism dependent on cyclooxygenase inhibition. OBJECTIVE: To evaluate the preventive effect of leukotriene receptor antagonists on urticaria exacerbations induced by NSAIDs in a patient with chronic urticaria. METHODS: A 59-year-old woman with a 2-year history of recurrent urticaria exacerbated by different NSAIDs including aspirin 500 mg (2 episodes), piroxicam 20 mg, and nimesulide 100 mg (1 episode each) was studied. Acetaminophen 375 mg and floctafenine 50 mg induced a marked flare of urticaria/angioedema in a single-blind, placebo-controlled challenge. RESULTS: The patient was totally urticaria free during a 3-week course of montelukast 10 mg once a day. After montelukast withdrawal, a gradual relapse of urticaria/angioedema occurred along with a further acute urticaria/angioedema episode after a single piroxicam, 20-mg tablet. Zafirlukast 20 mg twice daily was started. After some days the patient was urticaria-free again, and after 3 weeks she tolerated a 6-day course of injective piroxicam (20 mg once a day) without any problem. To date the patient is still urticaria-free. CONCLUSION: Leukotriene receptor antagonists may prevent the severe urticaria/angioedema exacerbations which follow the use of NSAIDs in some patients with chronic urticaria.

Angioedema↗
PubMed1999

Comparison of exhaled nitric oxide to spirometry during emergency treatment of asthma exacerbations with glucocorticoids in children.

BACKGROUND: Asthma is characterized as a chronic inflammatory process; however, there is no easily measured marker for airway inflammation. Such a marker, particularly in children, would be very helpful in the management of asthma even in the acute setting. OBJECTIVE: The purposes of this study were to determine whether asthmatic children have (1) elevation of exhaled breath nitric oxide (ENO) during acute exacerbations when presenting to the emergency room, (2) reduction of ENO following glucocorticoid treatment, or (3) improvement in spirometry and clinical examination accompanying reduction of ENO levels. METHODS: Peak ENO levels were measured by chemiluminescence during exhalation into the NO analyzer. Ten asthmatic children (mean age 10 years) who presented to the Pediatric Special Care Unit at National Jewish Medical and Research Center in acute respiratory distress with an asthma exacerbation were studied. The subjects were recruited, after informed consent was obtained from the parent, on the basis of specific inclusion/exclusion criteria. Measurements of ENO in parts per billion (ppb) and spirometry, including percentiles of forced expiratory volume in one second (FEV1%) and peak expiratory flow (PEF%), were performed before and after at least 5 days of glucocorticoid therapy. RESULTS: The mean ENO level in the asthmatic children prior to glucocorticoid treatment was 48 +/- 8ppb, and after glucocorticoid treatment the ENO level was 17 +/- 1ppb; (P < .002). Prior to glucocorticoid treatment, the mean FEV1% value was 68 +/- 3% compared with the postglucocorticoid treatment FEV1% value of 100 +/- 5%; (P < .0001). Prior to glucocorticoid treatment, the mean PEF% value was 81 +/- 7%, compared with the postglucocorticoid treatment PEF% value of 105 +/- 6%; (P < .02). CONCLUSIONS: The mean peak ENO level after glucocorticoid therapy was significantly less than that measured before treatment in children with acute asthma exacerbations. Concomitant with the decrease in ENO levels, there was improvement in the spirometry values and physical examination in the asthmatic children; thus, ENO is a sensitive marker for response to anti-inflammatory treatment in children.

Anti-Asthmatic Agents↗
PubMed1998

Efficacy of aminophylline in the treatment of acute asthma exacerbation in children.

BACKGROUND: The role of aminophylline (ethylene diamine salt of theophylline) in the treatment of acute exacerbation of asthma has not been well established in children. OBJECTIVE: The aim of the study was to determine the additional therapeutic benefit of intravenous aminophylline in the treatment of children hospitalized for acute asthmatic exacerbation and treated with inhaled bronchodilators and glucocorticoid therapy. METHODS: Thirty-eight children aged from 2 to 16 years (mean age 5.64 +/- 3.31), admitted for acute exacerbation of asthma, participated in a prospective, randomized, double-blind, placebo-controlled study. All the subjects received methylprednisolone, administered intravenously, and nebulized salbutamol. The treatment group received intravenous aminophylline therapy and the placebo group received 0.9% saline solution for 24 hours. RESULTS: The number of salbutamol nebulizations needed and the clinical asthma scoring were recorded both at onset and at the end of 24 hours. There was no significant difference in either the mean number of nebulizations or the clinical asthma scores between the two groups (P = .7843, P = .8452). CONCLUSION: Intravenous aminophylline (ethylene diamine salt of theophylline) demonstrated no additional beneficial effect to the combination of beta adrenergic agonists and glucocorticoid treatment in acute asthma attack in children.

Acute Disease↗