Metered-dose inhaler with spacer vs nebulization for severe and potentially severe acute asthma treatment in the pediatric emergency department]

OBJECTIVE: To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma. METHODS: In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later. RESULTS: Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P<0.02). The overall length of stay in the emergency department was significantly shorter (148+/-20 vs 108+/-13 min, P<10(-9)). CONCLUSIONS: The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.     

Use of a tube spacer to improve the efficacy of a metered-dose inhaler in asthmatic children

Many children with asthma do not use the standard metered-dose inhaler (MDI) skillfully. To improve drug delivery, correct problems of hand-lung incoordination, and reduce local side effects, a number of spacer devices have been developed. We evaluated one such device, a tube spacer (Aerochamber), in 16 asthmatic children (5 to 12 years). On four separate days and in a randomized, double-blind, placebo-controlled manner, they received either metaproterenol sulfate by MDI aerosol (130 micrograms) or placebo with and without the tube spacer. To maximize techniques, at each visit the children had proper instructions, including viewing a videotape. Spirometry was performed at baseline and 5, 15, and 30 minutes, and hourly for six hours, and the patient was monitored. Analysis of the entire group (forced expiratory volume at 1 s and midmaximal expiratory volume) revealed no difference between metaproterenol administered with or without the tube spacer, and both were significantly different than placebo through two hours. Six children had longer and three had better bronchodilatation with the MDI plus tube spacer than with the MDI alone. Side effects and vital signs did not differ between treatments. Under the circumstances of our study, the tube spacer device might enhance the use of the MDI in children who are not properly taught and/or who forget or cannot perform proper technique.     

Efficacy of fluticasone metered-dose inhaler and dry powder inhaler for pediatric asthma.

BACKGROUND: For the treatment of bronchial asthma, two types of fluticasone inhaler devices are available, namely, metered-dose inhaler with spacer (MDI-S) and the dry powder inhaler (DPI). The former is recommended for young children with a low peak inspiratory flow (PIF) and the latter for adolescents and adults. But the difference in the therapeutic efficacy between them has been studied only rarely in adolescent patients. METHODS: In the present study, 21 post-elementary school-age patients with moderate persistent bronchial asthma (age 8-15 years, 10.3 +/- 2.1 years), who all had a sufficient PIF of 114 +/- 29 L/min, were examined in order to compare the two types of fluticasone inhalers. Eleven of 21 patients inhaled 200 microg/day Flutide using the MDI-S twice daily for 1 month in the first month, and the same dose using the DPI for the next month. The other 10 patients inhaled the opposite regimens. At the end of the each treatment, spirometry was examined. RESULTS: Measurements done before therapy and then at the end of MDI-S and DPI therapy, respectively, were as follows: forced expiratory volume in 1 s (FEV(1.0)), 72.4 +/- 18.2%, 91.5 +/- 18.2% and 84.1 +/- 16.3% (MDI-S vs DPI, P > 0.040); maximal mid-expiratory flow (MMEF), 62.0 +/- 23.6%, 88.7 +/- 26.5%, 79.3 +/- 33.4% (P > 0.044) and the peak expiratory flow (PEF) was 73.9 +/- 25.0%, 95.6 +/- 32.8%, and 90.5 +/- 29.5%, respectively (n.s.). MDI-S was thus found to be more effective in terms of %FEV(1.0) and in %MMEF. CONCLUSIONS: High therapeutic efficacy was obtained with the use of the MDI-S in fluticasone inhalation for post-elementary school-age patients with sufficient inspiration ability.     

Metered-dose inhaler: the emergency department orphan.

OBJECTIVE: Physicians providing emergency department care to children primarily use nebulizers for the delivery of bronchodilators and these physicians have misconceptions regarding the advantages and disadvantages of using metered-dose inhalers (MDIs) with a spacer (MDI + S) for acute asthma exacerbations. DESIGN: Self-administered mail survey. SETTING: Emergency department. PARTICIPANTS: Emergency medicine section members of the American Academy of Pediatrics and Canadian Pediatric Society. INTERVENTIONS: Bronchodilator delivery methods in acute pediatric asthma. MAIN OUTCOME MEASURES: The 2 principal outcomes for bivariate analysis were self-reported nebulizer use in all patients and MDI + S use in patients with mild acute asthma. RESULTS: Of eligible physicians, 333 (51%) of 567 responded. The majority were dual trained in pediatrics and pediatric emergency medicine (72%) and practiced full time (83%) in an urban (83%) pediatric emergency department (80%). The most commonly cited advantages of MDIs were their cost (33%) and speed of use (28%). The most commonly cited disadvantages were patient or parent dissatisfaction (24%) and relative ease of nebulizer use (23%). Only 10% to 21% of participants used MDIs in the emergency department and reserved this delivery method for children with mild asthma exacerbations. There were no significant associations between selected respondent demographic variables and the use of MDIs. CONCLUSIONS: Misconceptions regarding the efficacy and safety of MDI + S for the treatment of acute asthma exacerbations exist but are limited to a minority of surveyed emergency medicine physicians caring for children. Nebulizers remain the preferred method of routine bronchodilator delivery by physicians providing care to pediatric asthmatics in the emergency department.     

Professional liability in a pediatric emergency department

The risk of professional liability resulting from care given in the pediatric emergency department is a growing concern. This retrospective study examined the patients, diagnoses, and outcome of all threatened and actual claims that originated in the emergency department of a pediatric teaching hospital from 1977 through 1988. Twenty-five cases were identified by the hospital risk manager from approximately 320,000 visits (8.0 cases/100,000 visits); 22 charts were available for review. Ages of the patients ranged from 2 weeks to 13 years (mean 2.9 years, median 3.0 years). The patients' payment status was private insurance (n = 10), state public aid (n = 5), and no third-party payment source was listed for 7 children. Ten patients (46%) visited the emergency department between midnight and 8:00 AM, when an attending physician was not present. Return visits within 2 weeks for the same complaint occurred in 10 cases. The majority of the patients were discharged home (n = 18), and all of them had appropriate, adequately documented discharge instructions. The final diagnoses fell into four general categories: minor trauma/abuse (n = 7), neoplasms/chronic illnesses (n = 7), infectious diseases (n = 6), and appendicitis (n = 2). Review of the charts before knowledge of the legal outcome raised quality-of-care issues in 41% of the cases (n = 9).(ABSTRACT TRUNCATED AT 250 WORDS)     

Medication errors in a pediatric emergency department

OBJECTIVE: To initiate investigation into the medication errors that occur in a pediatric emergency department. These errors have the potential for significant morbidity and mortality, as well as costly litigation. METHODS: We conducted a retrospective chart review of all medication and intravenous fluid errors identified in a pediatric emergency department through incident reports filed over a 5-year period. An attempt was made to determine who was involved with the errors and what caused the errors. The patient outcomes were noted and classified according to clinical significance using previously published criteria. RESULTS: Thirty-three incident reports involving medication or intravenous fluid errors were analyzed. Most errors occurred on the evening and night shifts. Nurses were involved in 39% of reported errors; the nurse and emergency physician were jointly involved in 36%. The most common error was an incorrect dose of medication (35%) or incorrect medication given (30%). In one third of the cases, the family was not made aware of the error. In 12%, patients required additional treatment, and one was admitted to the hospital because of the error. There were no deaths. CONCLUSION: Incorrect recording of patient weights leading to an incorrect medication dose and failure to note drug allergy are common causes for medication errors in the pediatric emergency department. Incorrect drugs and i.v. fluids are given because of similar names and packaging. Many of the errors in the ED seem to be preventable.     

Delirium in the pediatric emergency department

Clinical presentations in the pediatric emergency department (ED) are frequently complicated by acute changes in mental status consistent with delirium. These patients may be considered management problems because of persistent oppositional and aggressive behavior, or may be depressed because of a flat, anhedonic, or unresponsive appearance. As a consequence of the delirium, their management is complicated by an inability to cooperate or participate in their own care. The subjective experience for the patient is also distressing because they frequently recognize the deterioration in their own behavior and cognitive skills. These patients can be effectively diagnosed in the ED, and appropriate treatment recommended and initiated.     

Simulation in the pediatric emergency department

Simulation provides a means to educate, monitor, evaluate, and potentially document the competency of emergency physicians. The evolution of high-fidelity simulators has led to a surge of enhanced medical applications that fit nicely into the core of emergency medicine training. Simulation can facilitate training in resuscitation, procedures, CRM, and mass casualty management. Although improved outcomes from simulation are not well established, there is a general consensus regarding the added value over current training. And finally, simulation provides the ability to construct training to match the current educational efforts related to individual physicians or system-level improvements in communication and patient safety.     

规范儿科急诊预检与分诊

分析儿科急诊预检分诊的国内外现状,阐述急诊预检分诊的目的及正确实施预检分诊在急诊医疗服务中的重要性,提出对儿科急诊预检分诊的建议和设想.     

Preliminary experience with 2-octylcyanoacrylate in a pediatric emergency department

OBJECTIVE: Documentation of use of octylcyanoacrylate adhesives in a pediatric emergency department with reference to patient selection, complications, and parent satisfaction. DESIGN: Retrospective and concurrent chart review of the first 100 patients on which 2-octylcyanoacrylate (2-OCA, Dermabonda) was used in a pediatric emergency department. Additional telephone follow-up was performed for each patient. RESULTS: The average patient age was 4.7 years, average laceration size 1.2 cm. Sixteen percent of wounds were repaired with 2-OCA. Three immediate complications involved a minor dehiscence and two eyelid adhesions. Two wound infections and a patient with hematoma and keloid formation were identified as later complications. The vast majority of parents preferred tissue adhesive repair to sutures. Time in department was reduced from 106 minutes to 69 minutes on average (P < 0.0001, CI 26-52). CONCLUSIONS: Octylcyanoacrylate adhesives performed well in the daily practice of a pediatric emergency department, and were used for a significant percentage of laceration closures. Convenience, average infection rates, and good parental satisfaction make tissue adhesives a valuable addition to our wound closure techniques. Certain pitfalls occurring during early experience with these adhesives can be recognized and avoided.     

Interfacing with police in the pediatric emergency department.

In summary, ED staff and local police departments should make a concerted effort to work together. The ED director should develop management protocols in conjunction with local police chiefs to plan strategies in advance. It is helpful to provide "orientation sessions," so that each group of professionals knows what to expect of the other. It may also be helpful to arrange tours of the ED so that police know where to go when they are called to the ED. All of these efforts should foster better care of children in the ED and will reduce tensions between the dedicated groups who work with such children.