Efficacy of racemic albuterol versus levalbuterol used as a continuous nebulization for the treatment of acute asthma exacerbations: a randomized, double-blind, clinical trial.

OBJECTIVE: To compare racemic albuterol (RAC) with levalbuterol (LEV) in continuous form for the treatment of acute pediatric asthma exacerbations in the emergency department. STUDY DESIGN: Children between the ages of 6 and 17 inclusive were enrolled if they had a history of asthma, presented to the emergency department with an acute asthma exacerbation, and had an initial forced expiratory volume in 1 second (FEV1) <70% predicted. Patients were then randomized to receive either 7.5 mg of RAC or 3.75 mg of LEV over 1 hour, in addition to standard asthma therapies. Spirometry and asthma scoring were performed at the end of the first hour, and a second hour-long nebulization with the same drug was administered if deemed necessary. Spirometry and asthma scoring were again performed and the final disposition was recorded. As a second, optional part of the study, baseline serum albuterol levels were collected on some patients before treatment. RESULTS: A total of 99 patients completed the study (44 RAC and 55 LEV). Baseline characteristics were similar except that the RAC group had a higher baseline asthma score. Children in the RAC group had a greater improvement in their FEV1 (p = .043) as well as in their asthma scores (p = .01) after 1 hour of continuous treatment compared to the LEV group. The greater improvement in asthma scores was maintained after the second hour of continuous therapy in the RAC group (p = .008) but not for FEV1 measurements (p = .57). There were no differences between groups for changes in heart rate, respiratory rate, oxygen saturation, or rates of admission. CONCLUSIONS: At the doses used, RAC appears to be superior to LEV with respect to changes in FEV1 and asthma score. There was no significant difference between the drugs with respect to admission rates or side-effect profile.

Utility of portable spirometry in a pediatric emergency department in children with acute exacerbation of asthma.

OBJECTIVES: The primary purpose of this study was to determine if portable spirometers can be successfully used in an emergency department (ED) in children with an acute exacerbation of asthma. The secondary purpose of this study was to determine if a validated clinical asthma score (CAS) correlates with the spirometry results in children with an acute exacerbation of asthma. METHODS: Children between the ages of 6 and 17 years who presented to an urban free-standing children's hospital ED with an acute exacerbation of asthma were enrolled in our study. On arrival, the CAS was recorded and then portable spirometry was performed. Attempts were continued until acceptable and reproducible flow loop measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with the CAS. RESULTS: A total of 101 patients were enrolled in this study. Of those patients, only 35 (35%) were able to successfully perform portable spirometry. Successful spirometry attempts were associated with older age (10.4 vs. 8.9, p = .01), lower respiratory rates (24.8 vs. 30.2, p = .001), lower heart rates (110 vs. 124, p = .004), and lower CASs (8.4 vs. 9.7, p = .001). Increasing asthma severity correlated with a decreased likelihood of successfully obtaining a useful forced expiratory volume in 1 second (FEV(1)) measurement (p = .013). Compared with cases of mild asthma, a patient with moderate asthma is 33% less likely to be able to perform spirometry, and a patient with severe asthma 93% less likely to perform spirometry. The CAS correlated poorly with the more objective measure of FEV(1)% predicted in those with mild asthma. CONCLUSION: Many children are incapable of using portable spirometry for the evaluation of acute exacerbations of asthma in the ED. The clinical asthma scoring system demonstrated poor correlation with portable spirometry measurements in terms of severity classification.

Epinephrine auto-injectors: is needle length adequate for delivery of epinephrine intramuscularly?

OBJECTIVE: Studies show that intramuscular epinephrine results in peak plasma concentrations of epinephrine faster than the subcutaneous route, and therefore, epinephrine is recommended to be administered intramuscularly. The objective of this study was to determine if the needle length on epinephrine auto-injectors is adequate to deliver epinephrine intramuscularly in children. METHODS: Patients between the ages of 1 and 12 years who presented to a children's hospital were enrolled in the study. Ultrasound was used to determine the depth from the skin to the vastus lateralis muscle. The patient's body mass index was recorded. The data were analyzed using simple descriptive statistics, and logistic regression was used to identify variables that might predict whether or not the needle length was exceeded. RESULTS: A total of 256 children were enrolled. Of these, 158 children weighed less than 30 kilograms and would be prescribed the 0.15 mg epinephrine auto-injector. Nineteen of these children (12%) had a skin to muscle surface distance of >(1/2)'' and would not receive epinephrine intramuscularly from current auto-injectors. There were 98 children weighing >or=30 kilograms who would receive the 0.3 mg epinephrine auto-injector. Of these 98 children, a total of 29 (30%) had a skin to muscle surface distance of >(5/8)'' and would not receive epinephrine intramuscularly. CONCLUSION: The needle on epinephrine auto-injectors is not long enough to reach the muscle in a significant number of children. Increasing the needle length on the auto-injectors would increase the likelihood that more children receive epinephrine by the recommended intramuscular route.

Initial oxygen saturation as a predictor of admission in children presenting to the emergency department with acute asthma.

BACKGROUND: Previous studies have looked at the relationship between initial oxygen saturation (SaO (2)) and the need for admission in children presenting with an acute asthma exacerbation. If initial SaO (2) value is indeed predictive of admission, then the admission process could be initiated sooner, and time spent in the emergency department could be potentially lessened. STUDY OBJECTIVE: The objective of the current study was to examine whether initial room air SaO (2) in children presenting to the ED with acute asthma is a reliable predictor of hospital admission. METHODS: This was a prospective multicenter study during 1997 and 1998 at 44 North American EDs as part of the Multicenter Airway Research Collaboration. Inclusion criteria were physician diagnosis of acute asthma and age between 2 and 17 years. The association between hospital admission and SaO (2) was examined by using logistic regression. Likelihood ratios were used to assess the diagnostic value of SaO (2). RESULTS: Of the 1,184 children enrolled in the current study, 1,040 (88%) had a documented initial SaO (2) value on room air. The mean age of the cohort was 8+/-4 years, with a mean initial SaO (2) of 95%+/-4%. Overall, 241 (23%) children were admitted to the hospital. The mean SaO (2) value of children admitted to the hospital was 93%+/-5% versus 96%+/-3% for those not admitted (P <.001). The admission rate decreased with increasing SaO (2); 73% (30/41) of children with an SaO (2) value of 88% or less were admitted versus 8% (7/88) with an SaO (2) value of 100%. In the logistic regression model, children with an SaO (2) value of 88% or less were 32 (95% confidence interval 11 to 89) times more likely to be admitted than those with an SaO (2) value of 100%. The likelihood ratio for admission was 12 for children with an SaO (2) value of 88% or less (42/1,040) but decreased to 4.6 for children with an SaO (2) value of 91% or less (130/1,040) and 2.7 for children with an SaO (2) value of 94% or less (333/1,040). CONCLUSION: This large, clinical multicenter study does not support earlier findings that SaO (2) alone is a clinically useful predictor of hospital admission in children who present to the ED with acute asthma.