Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis.

Nebulized ipratropium bromide is though to be synergistic with albuterol in therapy for acute childhood asthma. Because the efficacy of ipratropium in bronchiolitis is uncertain and some infants with bronchiolitis do not respond to nebulized albuterol alone, the following study was undertaken. In this double-blind, placebo-controlled trial, 69 infants between 6 weeks and 24 months of age who exhibited the first episode of acute bronchiolitis were randomly assigned to receive either nebulized albuterol (0.15 mg/kg per dose) and ipratropium bromide (250 micrograms per dose) (group A, n = 36) or nebulized albuterol and normal saline (placebo) (group B, n = 33) for two doses, 1 hour apart. The two groups were comparable at baseline. Both therapies resulted in clinically significant improvement. However, the addition of ipratropium resulted in no additional benefit with respect to decrease in the respiratory rate (mean decreases 10.6/min vs decreases 8.6/min, P = .86), accessory muscle score (range 0 through 3) (decreases 0.92 vs decreases 0.82, z = -0.44), wheeze score (range 0 through 3) (decreases 0.94 vs 0.85, z = -0.20), oxygen saturation (increases 0.25% vs increases -0.33%, P = .86), or hospitalization rate (17 vs 10). The number of "nonresponders" and "clear responders" was also very similar in both groups. No toxicity was noted. The increase in heart rate was mild and similar in both groups (increases 6.7 vs increases 11.1). The power of the study to detect a difference between the two treatment groups in the respiratory rate change > or = 8/min is greater than 90%.(ABSTRACT TRUNCATED AT 250 WORDS)     

High-versus low-dose, frequently administered, nebulized albuterol in children with severe, acute asthma

Thirty-two 5- to 17-year-old children who had severe, acute asthma were randomly assigned to receive either high doses (0.15 mg/kg of body weight per dose) or low doses (0.05 mg/kg of body weight per dose) of nebulized albuterol every 20 minutes for six doses. Compared with the low-dose regimen, the high-dose regimen resulted in significantly greater improvement in forced expiratory volume in 1 second, forced vital capacity, and wheeze score and a lower hospitalization rate. The changes in heart rate, respiratory rate, blood pressure, white blood cell count, and serum potassium concentration did not differ significantly between the groups. The incidence of side effects, which included tremor, hyperactivity, and vomiting, was not significantly different in the two populations. Serum albuterol levels varied widely, but there was no correlation between the levels and the increase in heart rate or other side effects. high-dose, frequently administered, nebulized albuterol appears both safe and effective in treating severe, acute asthma in children.     

Addition of ipratropium to nebulized albuterol in children with acute asthma presenting to a pediatric office

A prospective, randomized, double-blind study was conducted to determine whether there was any benefit to the addition of ipratropium to a single nebulized albuterol treatment in infants and children with mild to moderate acute asthma presenting to a pediatric office. There were no significant differences between the albuterol group and the combined albuterol-ipratropium group in the relief of the respiratory distress, disposition of the patients from the office, or in the incidence of relapse. The addition of ipratropium to nebulized albuterol is of no added benefit in the treatment of infants and children with mild-to-moderate acute asthma presenting to a pediatric office.     

Controlled trial of nebulized albuterol in children younger than 2 years of age with acute asthma.

To determine the response to nebulized beta 2 agonist, 28 children younger than 2 years of age who visited the emergency department during an episode of acute asthma were studied. Each subject had a previous history of recurrent wheezing episodes. They were randomly assigned to receive two administrations of either nebulized albuterol (0.15 mg/kg per dose) or placebo (normal saline) with oxygen, 1 hour apart. After two nebulizations, the albuterol-treated patients had a greater improvement in clinical status (respiratory rate, degree of wheezing and accessory muscle use, total clinical score, and arterial oxygen saturation) than the placebo group. None of the patients in the albuterol group experienced a decrease of arterial oxygen saturation of greater than or equal to 2%. It is concluded that a trial of nebulized beta 2 agonists is warranted in the treatment of acute asthma in infants and young children.     

Randomized trial of the addition of ipratropium bromide to albuterol and corticosteroid therapy in children hospitalized because of an acute asthma exacerbation.

OBJECTIVE: To determine whether the addition of inhaled ipratropium bromide to inhaled albuterol and systemic corticosteroid therapy was more efficacious than inhaled albuterol and systemic corticosteroids alone in the inpatient treatment of acute asthma exacerbations in children. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: Pediatric inpatient unit of a tertiary urban hospital. PARTICIPANTS: Eighty children (aged 1-18 years) hospitalized because of an acute asthma exacerbation. INTERVENTION: Children were randomized to receive either nebulized ipratropium bromide, 250 microg, or nebulized isotonic sodium chloride solution, 1 mL. All children received albuterol and systemic corticosteroids. MAIN OUTCOME MEASURES: The primary outcome variable was a validated clinical asthma score, measured at baseline and every 6 hours for 36 hours. Secondary outcome measures included the forced expiratory volume in 1 second, the oxygen saturation, the number of doses of inhaled study drug, the time to an inhaled drug-dosing interval of 4 hours, and the length of the hospital stay. RESULTS: There were no differences between groups on baseline characteristics. The intention-to-treat analysis, using repeated-measures analysis of variance, showed no significant (P =.07) difference between the groups in the clinical asthma score over time. There were also no significant differences between groups on secondary outcomes. CONCLUSION: The addition of nebulized ipratropium bromide to nebulized beta(2)-agonist and corticosteroid therapy in the treatment of children hospitalized because of asthma (following intensive emergency department treatment) confers no extra benefit.     

Standard dose of inhaled albuterol significantly increases QT dispersion compared to low dose of albuterol plus ipratropium bromide therapy in moderate to severe acute asthma attacks in children

BACKGROUND: Beta-2 agonist therapy has previously shown to increase the QT dispersion (QTd) in asthmatic patients and increased QTd has been well documented in association with cardiac arrhythmias and sudden death. However, the data concerning the effect of low doses of beta-2 agonist therapy in combination with the anticholinergic agents to potentiate bronchodilatation on QTd in asthmatic children are limited. The objectives of this study was to investigate the changes on QTd during both the standard dose of nebulized albuterol therapy and low dose nebulized albuterol plus inhaled ipratropium therapyn to assess the potential arrhythmogenic risk of these two treatment strategies in children with acute asthmatic attacks. METHODS: Forty-three children with the diagnosis of moderate to severe acute asthma were enrolled in the study. Standard dose of nebulized albuterol therapy (0.15 mg/kg) were administered to 20 patients (group 1) and low dose of nebulized albuterol (0.075 mg/kg) plus nebulized ipratropium bromide therapy (250 microg/dose) were given to the remaining 23 patients (group 2). Respiratory distress score, peak expiratory flow rate, arterial blood pressure, O2 saturation, serum potassium and urea nitrogen levels were studied and QT interval parameters were measured from the standard 12-lead electrocardiograms at baseline and after treatment. RESULTS: Significant improvement was achieved in respiratory distress score and peak expiratory flow rate after three dose inhalation. No significant difference was observed between the pre and post-treatment values of serum potassium, blood urea nitrogen, O2 saturation and arterial blood pressure values. The evaluation of the corrected QTd (QTcd) showed that while there was no statistical difference in the pre and post-treatment values in group 2 (30.4+/-3.1 msn vs 32.1+/-3.9 msn), QTcd was found to be significantly increased in group 1 after treatment (29.0+/-3 msn vs 40.6+/-5.1 msn, P<0.0001). CONCLUSION: The data of the present study suggest that the increase of the QTd is more prominent with the use of a standard dose of albuterol compared to low dose albuterol plus ipratropium therapy. Therefore, it may be concluded that a low dose of albuterol plus ipratropium bromide therapy may be preferred to avoid rhythm disturbances in asthmatic children.     

Comparison of racemic albuterol and levalbuterol for treatment of acute asthma

OBJECTIVE: To determine whether levalbuterol resulted in fewer hospital admissions than racemic albuterol when used for treatment of acute asthma.Study design A randomized, double-blind, controlled trial was conducted in the emergency department (ED) and inpatient asthma care unit of an urban tertiary children's hospital. Children age 1 to 18 years (n=482) provided a total of 547 enrollments. Patients received a nebulized solution of either 2.5 mg racemic albuterol or 1.25 mg levalbuterol every 20 minutes (maximum six doses). Patients admitted to the asthma care unit were treated in a standardized fashion by using the same blinded drug assigned in the ED. Hospitalization rate was the primary outcome. RESULTS: Hospitalization rate was significantly lower in the levalbuterol group (36%) than in the racemic albuterol group (45 %, P=.02). The adjusted relative risk of admission in the racemic group compared with the levalbuterol group was 1.25 (95% confidence interval, 1.01-1.57). Hospital length of stay was not significantly shorter in the levalbuterol group (levalbuterol, 44.9 hours; racemic albuterol, 50.3 hours; P=.63). No significant adverse events occurred in either group. CONCLUSIONS: Substituting levalbuterol for racemic albuterol in the ED management of acute asthma significantly reduced the number of hospitalizations.     

Hypokalaemia following nebulized salbutamol in children with acute attack of bronchial asthma

Objective : To determine whether use of nebulized salbutamol therapy for treatment of an acute attack of asthma in children is associated with hypokalaemia and if so what is its frequency, severity and effect on recovery.
Methodology : Forty-six children, aged 10 months to 12 years (mean 7.9±1.5 years) with acute attack of bronchial asthma, treated initially with three doses of nebulized salbutamol 0.15-0.3mg/kg, every 30 min participated in the study. Blood for serum potassium was obtained at the beginning and after three doses of nebulized salbutamol therapy, before administering other drugs.
Results : The mean±SD serum potassium level decreased marginally from 3.9±0.5mEq/L to 3.7±0.5mEq/L ( P <0.05). A decrease in serum potassium concentration was noted in 26 (56.5%) and hypokalaemia (serum potassium <3.5 mg/L) in 17 (39%) patients. It was more frequent in patients who had received oral salbutamol for the preceding 7 days. The average time taken for recovery was longer in patients who had hypokalaemia than those who had normal serum potassium concentration (8.6±2.7 h vs 6.5±2.7 h; P <0.005).
Conclusions : Hypokalaemia may occur in about one-third of patients treated with three doses of nebulized salbutamol therapy, especially those on prior oral salbutamol therapy. The monitoring of serum potassium concentration may be warranted in such patients.     

A randomized,controlled trial of the effectiveness of nebulized therapy with epinephrine compared with albuterol and saline in infants hospitalized for acute viral bronchiolitis

OBJECTIVE: In previously well infants hospitalized with acute viral bronchiolitis, the effectiveness of repeated nebulized therapy with epinephrine (EPI) was compared with treatment with albuterol (ALB) or saline placebo (PLAC). STUDY DESIGN: In this randomized, double-blind, parallel-group, controlled trial, infants received study nebulizations every 1 to 6 hours and were assessed twice daily by the research team. The primary outcome was length of hospital stay (LOS). Secondary outcomes included the time from admission until the infant had normal hydration, oxygenation, and minimal respiratory distress. RESULTS: A total of 149 infants were randomized; 50 were allocated to receive racemic EPI, 51 were given ALB, and 48 received PLAC. Baseline characteristics and pre-enrollment symptoms, signs, and therapy were similar between groups. There were no group differences in the primary outcome measure, mean LOS (hours)(+/- SD): EPI = 59.8 (62), ALB = 61.4 (54), and PLAC = 63.3 (47); P =.95 by intent-to-treat analysis. Group differences were not statistically significant in any of the secondary outcomes. CONCLUSIONS: There were no group differences in the effectiveness of therapy for infants hospitalized with bronchiolitis. Based on these results, we do not recommend routine use of either nebulized EPI or ALB in this patient group.     

布地奈德雾化吸入治疗儿童哮喘急性发作的疗效观察

目的　观察布地奈德混悬液治疗儿童哮喘急性发作的疗效。方法　通过随机分组 ,70例患儿分为三组 ,观察组 30例 ,给予雾化吸入布地奈德混悬液加全乐宁、爱全乐 ;对照Ⅰ组 2 0例 ,给予静滴地塞米松 ,雾化吸入全乐宁、爱全乐 ;对照Ⅱ组 2 0例 ,给予单纯静滴地塞米松。观察用药前、用药后患儿症状体征 (呼吸困难、咳嗽、喘息、喘鸣音 )改善情况及消失天数。结果　观察组治疗后 1h各症状体征评分的改善分数为 :呼吸困难 1 1、咳嗽1 1、喘息 1 4、喘鸣音 1 4分 ;对照Ⅰ组分别为 0 9、0 7、1 0、0 9分 ;观察组各症状体征改善分数明显优于对照Ⅰ组 (P <0 0 5 )。各组症状体征消失天数 :观察组分别为呼吸困难 1 9、咳嗽 4 1、喘息 3 0、喘鸣 3 6d ,对照Ⅰ组分别为 3 9、8 0、5 8、8 0d ,对照Ⅱ组分别为 4 1、8 9、6 6、7 1d ,观察组较两个对照组病程明显缩短 (P <0 0 5 )。结论　对哮喘急性发作患儿 ,在雾化吸入支气管扩张剂的同时 ,加用布地奈德混悬液雾化吸入 ,对改善症状和缩短病程明显优于加用静滴地塞米松及单纯静滴地塞米松 ,疗效显著     

Effect of injected long-acting epinephrine in addition to aerosolized albuterol in the treatment of acute asthma in children

The additional effect, if any, of subcutaneous, long-acting epinephrine (Sus-Phrine) to aerosolized albuterol for acute pediatric asthma was studied. Over an eight-month period, patients were enrolled in a prospective, randomized, controlled trial. All patients were recruited and studied in a pediatric emergency department. Forty-three children between the ages of three and 12 years, with a mean age of 8.9 years, presenting with acute asthma were enrolled. Group 1 received Sus-Phrine, 0.005 ml per kg before albuterol aerosols, as appropriate. Group 2 only received albuterol aerosols. There was no significant difference in the extent of improvement between the two groups at either 20 minutes or two hours for clinical score, peak flow, or respiratory rate. Subcutaneous, long-acting epinephrine provides no additional benefit to a beta-2 agonist by nebulization for children with acute asthma.     

Treatment of asthma crises in children with nebulized salbutamol

Thirty-two children were treated with nebulized salbutamol for acute asthma. Seventy-five per cent of the treatments were efficient, either after a first nebulization at 0.15 mg/kg (47% = group I), or after a second nebulization 45 min later, at 0.05 mg/kg (27% = group II). Twenty-five per cent of the treatments (group III) were inefficient or only partly efficient. The clinical tolerance was good except in two children. Group I and II presented differences only for the auscultation score. Children from group I and II were older and had less severe asthma than those from group III. On the basis of this study, nebulized salbutamol appears to be an affective and safe treatment for acute asthma. The repeated administration of low doses, shortly after the first nebulization increases the quality of the response.     

A single dose of nebulized budesonide decreases exhaled nitric oxide in children with acute asthma

This study was conducted to investigate whether a single dose of nebulized budesonide effectively decreased airway inflammation as demonstrated by exhaled nitric oxide (eNO) levels. A single dose of nebulized budesonide, but not nebulized terbutaline, rapidly decreased eNO levels in 6 hours. The decrease in eNO levels induced by nebulized budesonide was correlated to an increase in peak expiratory flow rate.     

The effect of nebulized budesonide treatment in children with mild to moderate exacerbations of asthma

Background: The role of inhaled corticosteroids in the treatment of acute asthma remains a controversial subject. Objective and methods: A randomized, double-blind, placebo-controlled parallel-group clinical trial on the effect of a 5-d course of nebulized budesonide treatment in children with mild to moderate exacerbation of asthma was performed. The need for systemic corticosteroid intervention was evaluated as the primary outcome measure. Results: Sixty-seven children aged 6 to 15 y were enrolled. During the emergency department phase, they received three nebulizations of either budesonide(1 mg/dose) or placebo, and then in the home phase of the study, they continued their study medications twice a day for another 4 d. Though the level of improvement in the emergency department phase was similar between the groups given either budesonide or placebo treatments (6.8±1.9% vs 4.0±1.5%, p=0.30, respectively), nebulized budesonide caused a trend towards a benefit in terms of the need for systemic corticosteroid intervention (2/33 vs 7/34, p=0.07), but not in secondary outcome measures.

Conclusion: Though we show a tendency towards a benefit with nebulized budesonide in children with mild to moderate exacerbations in terms of prevention of progression of the illness, the documented benefit is small and includes, at least, consideration for clinical significance, cost-effectiveness, impracticality and safety.     

Adverse asthma outcomes among children hospitalized with asthma in California

OBJECTIVE: To use administrative data to determine whether adverse asthma outcomes for pediatric asthma hospitalizations are related to specific clinical and nonclinical patient characteristics. DESIGN: Cross-sectional study. SETTING: All pediatric (0 to 17 years of age) asthma-related hospital discharges, 1986 to 1993, in California. PATIENTS: A total of 113 974 eligible patients with asthma-related discharges. MAIN OUTCOME MEASURE: Adverse asthma outcomes (intubation, cardiopulmonary arrest, and death). RESULTS: Adverse asthma outcomes occurred in 0.48% of subjects. The frequency of adverse asthma outcomes increased during the 1990s compared with 1986. After controlling for differences in gender, age, specific comorbid conditions, year, race, and insurance type, adverse asthma outcomes were more likely to occur in the 5- to 11-year-old group (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.13-1.69) and in the 12- to 17-year-old group (OR: 4.48; CI: 3.20-6.21) compared with those children in the 0 to 4-year-old age group. Asian Pacific-American children were more likely (OR: 1.59; CI: 1.24-2.59) than were white children to experience an adverse asthma outcome. Children who had a secondary diagnoses of pneumonia (OR: 1.54; CI: 1. 19-2.00) also were more likely to experience an adverse asthma outcome. The odds of an adverse outcome increased progressively after 1986, becoming significant after 1989. Gender and insurance type were not associated with increased odds of experiencing an adverse asthma outcome. CONCLUSIONS: Adverse asthma outcomes among hospitalized children are increasing in the 1990s and are associated with specific clinical and nonclinical patient characteristics.     

小儿重症哮喘的机械通气治疗

病情极危重的哮喘常被称为“致死型哮喘”或“危及生命的哮喘”,表现为严重的低氧血症、呼吸性酸中毒、呼吸肌疲劳、肺性脑病等。这些症状可危及生命且药物治疗通常不能缓解。1961年Leonhardt首先用机械通气治疗危重型哮喘,现已成为治疗这类疾病的重要手段。哮喘的机械通气治疗