Severe allergy: an audit and service review.

BACKGROUND: In 2002, a paediatric respiratory service in South Wales carried out a study to identify children in local schools who had a diagnosis of severe allergy, requiring them to carry an epipen. This investigation was carried out as a result of three schools seeking advice. Three children were identified as suffering from severe allergy; one child from each of the three schools. It was evident that sufficient education and support was not available for these children, their families and school staff regarding allergy management. This led to further investigation to see if there were others experiencing similar problems. METHOD: To identify school-aged children with a diagnosis of severe allergy, a survey took place of the three schools mentioned above plus a further 111 schools. Sixteen additional children were noted to be carrying epipens in 16 separate schools. An audit pro forma was devised and used to collect relevant data to establish previous allergy management and current allergy status. The 16 children and their families were invited to an assessment clinic where they were interviewed by a respiratory nurse specialist. RESULTS: There were deficiencies in allergy management relating to: assessment, diagnosis, medication provision, education, support and ongoing follow up. These deficiencies highlighted the need for the development of a paediatric allergy service and a multi professional collaborative approach to care. CONCLUSION: The findings from the five phases of this study have influenced the development of an allergy clinic. This has led to collaborative working between healthcare professionals, school staff, children, and their families. The findings have promoted practice in terms of conducting thorough nursing and medical assessment, appropriate diagnosis, education and ongoing support for children and their families.

A confidential inquiry into asthma deaths in Wales.

BACKGROUND: Death from asthma is regarded as preventable in principle, especially under the age of 65 years. METHODS: In 1994 a confidential inquiry was set up to investigate deaths attributable to asthma in residents of Wales under the age of 65 years. During the period of the inquiry 92 cases were notified as being ascribed to asthma, or (in 1996) having a mention of asthma on the death certificate. Of these, 80 were investigated further with the help of general practitioners, hospital notes, and relatives. The details were then considered by a small panel of doctors who endeavoured to identify factors that may have contributed to the deaths. RESULTS: Asthma was considered to be the underlying cause of 52 deaths. Although disease severity was usually a major factor, some aspect of the patient's behaviour or circumstances seemed to have contributed to 31 deaths, while in 15 cases there was probably a deficiency in medical care. CONCLUSIONS: Some preventable asthma deaths still occur, particularly in relation to inadequate treatment. Factors associated with patients' behaviour and circumstances are more difficult to tackle but, if doctors are aware of high risk patients, increased vigilance may prevent some deaths.

Nebulised ipratropium bromide and sodium cromoglycate in the first two years of life.

In a double blind crossover trial, we compared sodium cromoglycate, ipratropium bromide, and water in 23 asthmatic children less than 2 years old (mean age 11.8 months). Each child received nebulised solutions containing 20 mg of sodium cromoglycate, 250 micrograms of ipratropium bromide, or 2 ml water three times a day for three two month periods. Daily symptom scores did not show significant differences between the treatments but parental preferences indicated that both sodium cromoglycate and ipratropium bromide were superior to placebo. Sodium cromoglycate was prophylactic and was more likely to help the older patients. Ipratropium bromide produced an immediate clinical benefit and the response was not age dependent. We were unable to pick responders from non-responders on the basis of lung function tests performed on a routine outpatient basis. Both ipratropium bromide and sodium cromoglycate help some but not all asthmatic children aged less than 2 years.

Respiratory problems 2 years after acute bronchiolitis in infancy.

We assessed the clinical progress of 55 children 2 years after admission to hospital with acute bronchiolitis and performed lung function tests on 40. During the 2 year follow up period 75% of the children had wheezed, 36% had 2 or more lower respiratory symptoms lasting more than 2 weeks, 33% had more than 100 days of lower respiratory symptoms, and 13% were readmitted to hospital with acute respiratory disease. In addition 60% of the children were hyperinflated on lung function tests. Many of the children with hyperinflation at the 2 year assessment had not been hyperinflated 1 year earlier, suggesting variable airways obstruction. Reversibility of airways obstruction was also assessed by response to nebulised salbutamol. Nine children had a fall greater than 15% in airways resistance after salbutamol and these children had the highest baseline airways resistances. Airways resistance was higher in the children with a family history of atopy.

Bronchodilator effect of two inhaled H1-receptor antagonists, clemastine and chlorpheniramine, in wheezy school-children.

Chlorpheniramine, clemastine and a placebo have been compared for their ability to relieve bronchoconstriction in 14 childhood asthmatics between the ages of 6 and 14 years. Each attended on three separate occasions, inhaling a 2 ml solution containing either 4 mg of chlorpheniramine, 1 mg of clemastine or placebo under double-blind conditions. Lung function was assessed before and at intervals for 30 minutes after the inhalation by peak expiratory flow and spirometry. Each child then inhaled 5 mg of salbutamol in 2 ml of water and the lung function tests were repeated. A significant degree of bronchodilatation was seen 30 minutes after all three inhalations, but considerable coughing occurred after inhaling chlorpheniramine. Actual changes in raw data showed a significant improvement after clemastine between the 20 and 30 minute recordings and that at 30 minutes clemastine produced significantly greater bronchodilatation than placebo. Inhaled H1-receptor antagonists merit further investigation to delineate their role in childhood asthma.

Bronchodilator effects of the H1 receptor antagonist--clemastine.

We investigated the specific H1 receptor antagonist, clemastine, in 15 children with asthma. In the respiratory unit, clemastine was an effective bronchodilator but in a clinical trial we could not show any significant benefit compared with placebo.

Nebulised therapy in acute severe bronchiolitis in infancy.

We have measured total work of breathing before and after the inhalation of water, salbutamol, and ipratropium bromide, given as nebulised solutions, in 39 studies on 25 infants with acute, severe bronchiolitis. Twenty minutes after nebulised water, mean work of breathing per minute was increased by 4% and work per litre by 10% with 2 infants having significant improvement and 2 others showing deterioration. After salbutamol, mean work of breathing per minute showed a 22% increase and work per litre a 0.5% rise. The condition of only one child improved by greater than 25% after this drug. Ipratropium bromide led to significant improvement in 6 out of 15 studies and no corresponding deterioration. The group results showed a fall in work of breathing, 18% in work per minute and 16% in work per litre.

Lung function after acute bronchiolitis.

We performed 211 lung function measurements on 93 children in the first year after they had been admitted with acute bronchiolitis. During the convalescent phase of the illness, 77% of the infants were hyperinflated with a thoracic gas volume greater than 40 ml/kg and 3 months later 43% were hyperinflated. Twelve months after the initial illness, 17% still had lung function abnormalities and most of these children have had lower respiratory tract symptoms. For the group as a whole about 60% have had at least one episode of wheezing. Specific conductances were significantly lower in children from atopic families, indicating worse lung function, but the significance of this finding is unclear.

Causes and management of bronchiolitis with chronic obstructive features.

During the last 4 years we have seen 13 children with a severe bronchiolitis. The children have had prolonged respiratory illnesses waxing and waning over many months, often requiring oxygen therapy for long periods. The diagnosis is based on a clinical picture similar to acute bronchiolitis, but persisting for months, frequently associated with failure to thrive, coupled with lung function evidence of hyperinflation and airways obstruction but normal static compliance. Confusion with other chronic lung conditions can be clarified by straightforward observations and investigations. We believe that chronic bronchiolitis is fairly common and often misdiagnosed. The short- and medium-term prognosis appears good although small airways disease may persist into adult life.

Assessment of a new device for delivering aerosol drugs to asthmatic children.

A new device, known as the aero-chamber, for delivering aerosol drugs was compared with a standard aerosol inhaler in asthmatic children aged between 5 years 3 months and 13 years 10 months. The study was conducted under double-blind conditions using fenoterol, a beta 2 stimulant, as the active agent and a placebo. Response to treatment was assessed by measuring the peak expiratory flow rate before and after each inhaler. Seven of 10 children had greater mean improvements in peak expiratory flow rates when receiving the active drug from the aerochamber. The aerochamber offers a method for administering a whole range of canistered packaged drugs to children unable to use the standard inhalers.

Lung function abnormalities after acute bronchiolitis.

Measurements of thoracic gas volume, airways resistance, and total respiratory resistance were measured in a group of babies with acute severe bronchiolitis. Assessments were made at convalescence, three to four months later, and after 12 months. Clinical histories were also taken 12 months after the acute episode. Results at this time showed that 35% of the infants had coughing attacks, 50% episodes of wheezing, 50% had dry skin or eczema, and that over 75% had lung function abnormality.

Measurement of work of breathing in infancy.

Assessment of lung function in young children is extremely difficult unless sedation is given. If tidal exchange and intrathoracic pressure swings can be recorded, the severity of the respiratory problem can be measured by construction pressure-volume loops and calculating the work of breathing. The system we have used to measure tidal thoracic volumes is that of a soft, rubber, inflatable jacket with pressure-volume characteristics linear from inflation pressure of 2.5 to 7 cm H2O. Oesophageal (intrathoracic) pressures are measured using water-filled nasogastric tubes (FG6). Frequency responses showed that 63% rise times for the jacket and water-filled nasogastric tube assessed together to be 10.5 msec. Recordings were traced onto a computer digitizing tablet and print-outs were obtained with the following information: respiratory rate, tidal thoracic volume, minute thoracic volume, oesophageal pressure, resistive work per min, elastic work per min, and total work per min. Comparisons were made between volumes measured using the respiratory jacket (VJ) and by pneumotachograph and integrator (VInt) in six infants. Hysteresis arising from the jacket produces some change in resistive work of breathing, but the total work of breathing is only increased by a maximum of 10.5%. Studies on healthy newborn babies showed that the jacket system tends to underrecord the resistive work of breathing, but that total work of breathing values are very similar. Reproducibility of analysis showed the following coefficients of variation from the mean: tidal thoracic volume, 1.6%; minute thoracic volume, 1.7%; resistive work, 5%; elastic work, 2%; and total work, 2.5%. The extent of breath-to-breath variation is much larger. This system makes it possible to obtain serial measurements of work of breathing without the need for sedation in infants who may be acutely ill and in respiratory failure.