Relative lung deposition of salbutamol following inhalation from a spacer and a Sidestream jet nebulizer following an acute exacerbation.

UNLABELLED: What is already known about this subject. Studies have shown that a large volume spacer attached to a metered dose inhaler provides similar bronchodilator effects to nebulized dosing during the management of patients following an acute exacerbation. Due to the high doses used, these effects could be measured at the top of the dose-response relationship and the response limited due to the patient's exacerbation. Although clinical end-points are the gold standard to show comparability, some indication of similar lung deposition is useful to consolidate any claims. What this study adds. The urinary pharmacokinetic method we have used postinhalation provides an index of lung deposition for inhalation methods that can be incorporated into the routine management of patients with an acute exacerbation. This is the first study to identify and compare lung deposition and systemic delivery for inhalation methods within the setting of the routine management of asthma and chronic obstructive pulmonary disease patients following hospitalization due to an acute exacerbation. The study highlights the comparability of the doses for the two inhalation methods evaluated with respect to lung deposition, systemic delivery and bronchodilator response. BACKGROUND: Studies comparing inhalation methods in acute exacerbations have not assessed lung deposition. METHODS: Five 100-mug salbutamol doses were inhaled from a metered dose inhaler plus spacer (MDI + SP) and 5 mg was nebulized (NEB) following acute exacerbation hospitalization. Urinary salbutamol excretion was determined at 30 min (USAL0.5) and over 24 h (USAL24) postinhalation together with forced expiratory volume in 1 s (FEV(1)). RESULTS: The USAL0.5 mean ratio (90% confidence interval) post MDI + SP and NEB [n = 19 asthma, 11 chronic obstructive pulmonary disease (COPD)] was 1.01 (0.81, 1.26). USAL24 was less (P < 0.001) following MDI + SP, whereas FEV(1) was similar. Only a small difference between asthmatics and COPD patients was observed for the MDI + SP in that the USAL0.5 was higher in the asthmatics for the spacer method. CONCLUSION: The relative lung deposition after inhaling 500 mug salbutamol from MDI + SP is similar to 5 mg from a Sidestream nebulizer following an acute exacerbation.

Learning from death: a hospital mortality reduction programme.

PROBLEM: There are wide variations in hospital mortality. Much of this variation remains unexplained and may reflect quality of care. SETTING: A large acute hospital in an urban district in the North of England. DESIGN: Before and after evaluation of a hospital mortality reduction programme. STRATEGIES FOR CHANGE: Audit of hospital deaths to inform an evidence-based approach to identify processes of care to target for the hospital strategy. Establishment of a hospital mortality reduction group with senior leadership and support to ensure the alignment of the hospital departments to achieve a common goal. Robust measurement and regular feedback of hospital deaths using statistical process control charts and summaries of death certificates and routine hospital data. Whole system working across a health community to provide appropriate end of life care. Training and awareness in processes of high quality care such as clinical observation, medication safety and infection control. EFFECTS: Hospital standardized mortality ratios fell significantly in the 3 years following the start of the programme from 94.6 (95% confidence interval 89.4, 99.9) in 2001 to 77.5 (95% CI 73.1, 82.1) in 2005. This translates as 905 fewer hospital deaths than expected during the period 2002-2005. LESSONS LEARNT: Improving the safety of hospital care and reducing hospital deaths provides a clear and well supported goal from clinicians, managers and patients. Good leadership, good information, a quality improvement strategy based on good local evidence and a community-wide approach may be effective in improving the quality of processes of care sufficiently to reduce hospital mortality.