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Pharmacological management of children's asthma in general practice: findings from a community-based cross-sectional survey in Auckland, New Zealand.

Pharmacological management of children's asthma in general practice: findings from a community-based cross-sectional survey in Auckland, New Zealand.

N Z Med J. 2011;124(1346):44-56

Authors: Crengle S, Robinson E, Grant C, Arroll B

Abstract
AIM: To describe the pharmacological management of children's asthma and to assess whether there were ethnic differences in pharmacological management.
METHODS: A community-based, cross-sectional, interviewer administered face-to-face survey. The sample (n=583) included the caregivers of 221 Maori, 173 Pacific, and 189 European/other children. Data collected included sociodemographic information, and medications received and medication delivery devices used in the 12 months prior to interview. Descriptive and logistic regression analyses to investigate ethnic differences in pharmacologic management were undertaken.
RESULTS: Spacer devices were used by 80% of children under 7 years of age and 34% of children 7 years or over. No ethnic differences in the use of these devices were observed. Maori (58%) and Pacific (65%) were significantly (p<0.0001) more likely to have been given a nebuliser (European/other 34%). Most (96%) children received inhaled beta-agonists and there were no ethnic differences for these medications. Overall, 69% of children had received inhaled corticosteroids (ICS) and there were no significant ethnic differences in receipt of these medications. However, only 68-78% of children in the moderate, severe, and very severe morbidity groups reported inhaled corticosteroids use in the previous 12 months, suggesting that this group is being under-treated. Morbidity stratified analyses suggested that Maori and Pacific children who had experienced severe morbidity in the previous 12 months were less likely to have received ICS.
CONCLUSIONS: Some aspects of the pharmacological management of asthma are more consistent with recommendations in evidence-based guidelines than previously reported in NZ. The proportion of children with asthma who were receiving beta agonists and ICS were higher than that previously reported in NZ and the reported use of anticholinergics was low. However, other findings show there is still room for further improvements to be made, particularly with respect to the use of inhaled corticosteroids among children who experience significant morbidity, the use of nebulisers, and the use of spacer devices. The implementation of clinical quality assurance activities that support primary health organisations and providers to monitor and improve the delivery of evidence-based asthma care could further improve asthma outcomes.

PMID: 22143852 [PubMed - in process]

Trends in Preventive Asthma Medication Use Among Children and Adolescents, 1988-2008.

Trends in Preventive Asthma Medication Use Among Children and Adolescents, 1988-2008.

Pediatrics. 2011 Dec 5;

Authors: Kit BK, Simon AE, Ogden CL, Akinbami LJ

Abstract
OBJECTIVE:To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008.METHODS:We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988-1994, 1999-2002, and 2005-2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines.RESULTS:Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988-1994 to 34.9% (SE: 3.3) in 2005-2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005-2008 compared with 1988-1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5-4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4-0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4-0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did.CONCLUSIONS:Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.

PMID: 22144697 [PubMed - as supplied by publisher]

Relation of bronchial and alveolar nitric oxide to exercise-induced bronchoconstriction in atopic children and adolescents.

Relation of bronchial and alveolar nitric oxide to exercise-induced bronchoconstriction in atopic children and adolescents.

Pediatr Allergy Immunol. 2011 Dec 7;

Authors: Linkosalo L, Lehtimäki L, Holm K, Kaila M, Moilanen E

Abstract
To cite this article: Linkosalo L, Lehtimäki L, Holm K, Kaila M, Moilanen E. Relation of bronchial and alveolar nitric oxide to exercise-induced bronchoconstriction in atopic children and adolescents. Pediatr Allergy Immunol 2011; Doi: 10.1111/j.1399-3038.2011.01223.x ABSTRACT: Background and objective:  Exercise challenge test is widely used in diagnostics and follow-up of childhood asthma, but the method is complex, time consuming, and expensive. In this study, we aimed to find out whether flow-independent nitric oxide (NO) parameters (bronchial NO flux [J'aw(NO) ] and alveolar NO concentration [CA(NO) ]) predict exercise-induced bronchoconstriction (EIB) in atopic children and adolescents with asthma-like symptoms. Also, the respective NO parameters corrected for axial backward diffusion (J'aw(NO) [TMAD] and CA(NO) [TMAD]) were calculated and included in the analysis. Methods:  Thirty patients (6-19 yr old) with confirmed atopy (positive skin prick tests or allergen-specific IgE) and asthma-like respiratory symptoms were included in the study. Before the current investigations, none of the patients had been diagnosed to have asthma and none were on inhaled corticosteroids. Exhaled NO was measured at multiple exhalation flow rates, and exercise challenge test was carried out. Bronchial NO flux and alveolar NO concentration were calculated according to the linear method with and without correction for axial backward diffusion. Sixty-six healthy school children served as controls. Results:  The patients were divided into two groups according to EIB. Patients with EIB (EIB+ group, n = 18) had enhanced bronchial NO output as compared to patients without EIB (EIB- group, n = 12); but the EIB- group did not differ from healthy controls. EIB+ group had also higher alveolar NO concentration than EIB- group and healthy controls, but EIB- group did not differ from healthy controls. When bronchial NO flux and alveolar NO concentration were corrected for axial diffusion, J'aw(NO) (TMAD) had equal difference as J'aw(NO) between the groups as expected. However, only EIB+ had higher CA(NO) (TMAD) than healthy controls, and the patient groups did not differ from each other. In patients, bronchial NO output correlated with the magnitude of exercise-induced change in PEF (r(s) = -0.388, p = 0.034), FEV(1) (r(s) = -0.395, p = 0.031), and FEF(50%) (r(s) = -0.431, p = 0.020), i.e., the higher the bronchial NO output, the larger the decrease in PEF/FEV(1) /FEF(50%) . Alveolar NO concentrations correlated with the change in FEV(1) (r(s) = -0.439, p = 0.015), FEF(50%) (r(s) = -0.454, p = 0.013), FEF(75%) (r(s) = -0.447, p = 0.017), and FVC (r(s)  = -0.375, p = 0.045). For J'aw(NO) (TMAD), the correlations and p-values were equal to those of J'aw(NO) , but, interestingly, CA(NO) (TMAD) had no significant correlations with any of the exercise-induced changes in lung function. Conclusion:  The results showed that in atopic children and adolescents, increased bronchial NO output as well as J'aw(NO) (TMAD) were associated with EIB, while alveolar NO concentration (but not CA(NO) [TMAD]) correlated with the degree of obstruction in smaller airways induced by exercise challenge.

PMID: 22145648 [PubMed - as supplied by publisher]

Particulate Matter Concentrations in Residences: An Intervention Study Evaluating Stand-Alone Filters and Air Conditioners.

This study, a randomized controlled trial, evaluated the effectiveness of free-standing air filters and window air conditioners (ACs) in 126 low income households of children with asthma. Households were randomized into a control group, a group receiving a free-standing HEPA filter placed in the child's sleeping area, and a group receiving the filter and a window-mounted AC.

IAQ was monitored for week-long periods over three to four seasons. High concentrations of particulate matter (PM) and carbon dioxide were frequently seen. When IAQ was monitored, filters reduced PM levels in the child's bedroom by an average of 50%. Filter use varied greatly among households and declined over time, e.g., during weeks when pollutants were monitored, filter use was initially high, averaging 84 ± 27%, but dropped to 63 ± 33% in subsequent seasons. In months when households were not visited, use averaged only 34 ± 30%. Filter effectiveness did not vary in homes with central or room ACs.

The study shows that measurements over multiple seasons are needed to characterize air quality and filter performance. The effectiveness of interventions using free-standing air filters depends on occupant behavior, and strategies to ensure filter use should be an integral part of interventions.

Helium-oxygen therapy for infants with bronchiolitis: a randomized controlled trial.

OBJECTIVE: To compare nebulized racemic epinephrine delivered by 70% helium and 30% oxygen or 100% oxygen followed by helium-oxygen inhalation therapy via high-flow nasal cannula (HFNC) vs oxygen inhalation via HFNC in the treatment of bronchiolitis.

DESIGN: Prospective, randomized, controlled, single-blind trial.

SETTING: This study was conducted from October 1, 2004, through May 31, 2008, in the emergency department of an urban, tertiary care children's hospital. Patients  Infants aged 2 to 12 months with a Modified Wood's Clinical Asthma Score (M-WCAS) of 3 or higher.

INTERVENTIONS: Patients initially received nebulized albuterol treatment driven by 100% oxygen. Patients were randomized to the helium-oxygen or oxygen group and received nebulized racemic epinephrine via a face mask. After nebulization, humidified helium-oxygen or oxygen was delivered by HFNC. After 60 minutes of inhalation therapy, patients with an M-WCAS of 2 or higher received a second delivery of nebulized racemic epinephrine followed by helium-oxygen or oxygen delivered by HFNC. Main Outcome Measure  Degree of improvement of M-WCAS for 240 minutes or until emergency department discharge.

RESULTS: Of 69 infants enrolled, 34 were randomized to the helium-oxygen group and 35 to the oxygen group. The mean change in M-WCAS from baseline to 240 minutes or emergency department discharge was 1.84 for the helium-oxygen group compared with 0.31 for the oxygen group (P < .001). The mean M-WCAS was significantly improved for the helium-oxygen group compared with the oxygen group at 60 minutes (P = .005), 120 minutes (P < .001), 180 minutes (P < .001), and 240 minutes (P < .001).

CONCLUSION: Nebulized racemic epinephrine delivered by helium-oxygen followed by helium-oxygen inhalation therapy delivered by HFNC was associated with a greater degree of clinical improvement compared with that delivered by oxygen among infants with bronchiolitis.

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