Krystal Jerry, PGY 3 Saima Khan, PGY 3 Emily Klepper, PGY 3 Jimisha Patel, PGY 3 Kevin Gipson, PGY 2

Brief review of Asthma epidemiology Discuss management of asthma at CHNOLA Compare relative effectiveness of MDIs vs

Nebs in treating acute asthma Discuss provider and parent attitudes toward

asthma management at CHNOLA Present a new protocol for asthma

management

Asthma is airway inflammation characterized by airflow obstruction and bronchial hyper-responsiveness that lead to symptoms such as coughing, difficulty breathing and wheezing

It is one of the most common chronic childhood diseases

Asthma is a significant health problem worldwide

causing substantial burden and morbidity

1980 to 2009: Prevalence of Asthma increased ◦ 10% of children ages 5-17yo had asthma ◦ Lifetime prevalence is 13%

2003: 12.8 million days of missed school attributed to asthma

2004: In the United States, 198,000 visits or 3% of

all pediatric hospitalizations were for Asthma

Acute Asthma ◦ Short acting beta agonist (SABAs) Relax airway smooth muscle Bronchodilation within minutes of administration Peak effect 15-30 min and wears off 4-6 hrs ◦ Systemic Steroids Improve airway response to SABAs, improve lung

function, and decrease risk of relapse Onset 4-6 hrs Oral is just as effective and IV administration

Advantages Disadvantages •Pt coordination not required •Effective with tidal breathing •Can be used with Oxygen •Can deliver combination therapies

•Lack of portability •Lengthy treatment time •Contamination possible •Not all meds avail in solution form, some suspensions do not aerosolize well

•Performance variability •Deliver at best 10% of meds to lung •Greater facial and OP deposition of med and systemic absorption and side effects

Advantages Disadvantages •Portable and compact

•Treatment time is short

•No drug prep required

•No contamination of contents

•Dose-dose reproducibility high

•Reduced pharyngeal deposition

•Reduced need for coordination

•Device actuation required

•Upper limit to unit dose content

•Remaining doses difficult to determine

•Potential for abuse

•Not all meds available

•Inhalation can be more complex for some patients

•Integral actuator devices may alter aerosol properties compared to native actuator

Anonymous questionnaires ◦ Sent to PCP offices ◦ Residents ◦ Respiratory Therapist

Number of Responses ◦ Attending Physicians (10) ◦ Residents (16) ◦ Respiratory Therapists (9)

Attendings, residents, and RTs all preferred nebulized treatments for the management of inpatient asthma exacerbations

There was no consensus between attendings, residents, and RTs regarding the appropriate age for use of MDIs

What age is appropriate for initiation of MDI with mask and/or spacer?

Attendings Residents RTs Most common response

>5yo >2yo “Any age”

Compare response to inhaled albuterol after administration by neb vs. MDI in children with acute asthma ◦ Research Article A: Efficacy of albuterol administered by nebulizer versus

spacer device in children with acute asthma, The Journal of Pediatrics, Vol. 123 Issue 2, August 1993, pp 313-317

◦ Research Article B: Costs and effectiveness of spacer versus nebulizer in

young children with moderate and severe acute asthma, The Journal of Pediatrics, Vol. 136 Issue 4, April 2000, pp428-421.

Double blinded study 33 Patients (6-14yo) with FEV 20-70% of

predicted value Treatment ◦ MDI/spacer or neb ◦ Albuterol via one route, placebo for other

Dosages: ◦ Neb (5mg/ml): 0.15mg/kg to max of 5mg ◦ MDI (100mgc/puff): Less than 25kg = 6 puffs 25-35 = 8 puffs Greater than 35 = 10 puffs

Outcomes measured at 10, 20, 40 min after treatment ◦ Respiratory

rate ◦ Heart rate ◦ FEV1 ◦ Clinical score

Score 0 Score 1 Heart rate <120 >/=120 Respiratory rate

<2 SD for age >/= 2 SD for age

Pulses paradoxus

<15 >/= 15

Dyspnea Absent or mild

Moderate or severe

Accessory muscle use

Absent or minimal

Moderate or severe

Wheezing Absent or expiratory only or both

Throughout expiration or expiratory and inspiratory

No difference in efficacy between MDI/spacer and nebulizer Lung function and clinical symptoms were similar for each

delivery system

Only significance was increased HR with neb

**Both MDI with spacers and nebs are equally effective at delivering Albuterol to children with acute asthma**

A randomized double blind placebo controlled study

60 pts aged 1-4yo with moderate to severe asthma

Treatment ◦ MDI/Spacer or neb (30 pts to each group) ◦ Albuterol via one route, placebo for other

Doses ◦ MDI/Spacer: 600mcg Albuterol (6 puffs) then

placebo neb ◦ Neb: 6 puffs by placebo MDI then 2.5mg by neb

over 10min

Assessed at baseline, 20 min, 60 min Side effects of hyperactivity (parental

evaluation) and tremor also assessed Patients were admitted if ongoing hypoxia or

wheezing present 60 min after final study treatment

1. Greater reduction in wheezing after first treatment in MDI/spacer group compared to neb (p=0.03)

2. Higher increase in heart rate after first treatment in neb group compared to MDI/spacer (p<0.01)

3. Continued to have higher heart rate throughout study period (p=0.03)

4. No other differences were seen between groups after first treatment!

5. Median number of treatments required -4 in MDI/spacer -4.5 in neb

Mean total cost in NZ$ (p=0.03) ◦ MDI/Spacer $825.00 ◦ Neb $1,282.00

Time required to deliver each treatment ◦ 1.5 min MDI/spacer ◦ 10 min neb

86% of children and 85% of parents preferred MDI/spacer

MDI/spacer is as effective as nebulizer in treating moderate to severe asthma

MDI/spacer has fewer side effects compared to a nebulizer

MDI/Spacer is more cost efficient than nebulizer use

Nebulizer

•Continuous Neb:$1093 • Initial Neb: $188 •Each Subsequent Neb:

$146 •Vial for neb treatment:

$4.20 for a box of 30 2.5mg vials

MDI

•MDI: $52.50 •RT administered MDI:

$89.50

The barrier to use of an MDI with Mask/spacer is due to lack of education among our patient population and physicians ◦ Cost effective ◦ Time effective ◦ Better deposition to lungs ◦ Portable

Allows patients and parents to be more comfortable with MDI usage ◦ Increase MDI usage inpatient ◦ Discharge patients on MDI with spacer and mask

Template of Asthma Orders - Currently under

review by Respiratory Therapists

MDI Dosage Cards

-Distributed in Oct 2013

108 pre-intervention charts

Pocket cards distributed in

October 2013

107 post-intervention charts

0%10%20%30%40%50%60%70%80%90%

100%

Inpatient Use ofMDIs

Correct Dosingof MDIs

Discharge toHome with MDI

Pre-Intervention

Post-Intervention

p=0.0031 p=<0.0001 p=0.4415

We demonstrate a clear change in provider practices after peer-to-peer education on the efficacy of MDI.

Use of MDI in the inpatient setting increases

patient confidence in the delivery method, improves patient adherence and quality of life, and reduces cost.

Review included 1,897 children and 729 adults in 39 trials

This study focused on the ER, with the majority of the trials conducted in

the emergency room setting

The method of delivery of beta -agonist did not show a significant difference in hospital admission rates. ◦ In adults, the risk ratio (RR) of admission for spacer

versus nebulizer was 0.94 (95% CI 0.61 to 1.43) ◦ The risk ratio for children was 0.71 (95% CI 0.47 to

1.08, moderate quality evidence)

In children, length of stay in the emergency department was significantly shorter when the spacer was used ◦ 103 minutes vs 70 minutes

Length of stay in the emergency department for adults was similar for the two delivery methods.

Pulse rate was lower for spacer in children ◦ mean difference -5% baseline (95% CI -8% to -2%,

moderate quality evidence)

Risk of developing tremor was also lower ◦ RR 0.64; 95% CI 0.44 to 0.95, moderate quality

evidence

Ongoing Chart review ◦ Inpatient MDI usage ◦ Discharge on MDI ◦ Emphasize optimal dosing

Teaching session with Respiratory Therapists and Residents ◦ Proper use of MDI with spacer and mask

Reintroduce our Asthma Orders to administration Bring Cochrane Review findings to ER Parent surveys

Future Goals

Any Questions?

1. Practical Management of Asthma, Pediatrics in Review, Vol. 30 No. 10, October 1, 2009 pp. 375 -385

2. Asthma Epidemiology, Pathophysiology and Initial Evaluation, Pediatrics in Review, Vol. 30 No. 9, September 1, 2009 pp. 331 -336

3. CDC - Asthma - A Presentation on Asthma Management and Prevention http://www.cdc.gov/asthma/speakit/default.htm

4. Efficacy of albuterol administered by nebulizer versus spacer device in children with acute asthma, The Journal of Pediatrics Vol. 123 Issue 2, August 1993, pp 313-317

5. Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma, The Journal of Pediatrics, Vol. 136 Issue 4, April 2000, pp428-421.

6. Cates CJ, Welsh EJ, Rowe BH. Holidng chamers vs nebulizers for beta-agonist treatment of acute asthma. Cochrane Colaboration. 2013.