Current controversies: sinus disease and the lower airways.

This review explores the literature dealing with the relation between the upper and lower airways, including the possible link between chronic sinus disease and asthma, and between chronic sinus disease and cough. Imaging studies, microbiology, epidemiology, animal studies, and effects of treatment are discussed. Available studies do not prove that upper airway disease directly causes lower airway pathology. Allergic rhinitis causing nasal blockage needs treatment, as does symptomatic sinus disease. Where there is concurrent disease of the upper and lower airways, both conditions need to be treated adequately. Further research is required to establish the relation between upper and lower airways, and animal models may help to unravel the mechanisms and impact of treatment. Randomized, blinded, controlled trials are needed in both children and adults to assess therapies of chronic sinusitis and the response of asthma.

Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma.

OBJECTIVE: To compare the costs and effectiveness of albuterol by metered dose inhaler (MDI) and spacer versus nebulizer in young children with moderate and severe acute asthma. DESIGN: Randomized, double-blind, placebo-controlled trial in an emergency department at a children's hospital. The participants were children 1 to 4 years of age with moderate to severe acute asthma. Patients assigned to the spacer group received albuterol (600 microg) by MDI by spacer (AeroChamber) followed by placebo by nebulizer (n = 30). The nebulizer group received placebo MDI by spacer followed by 2.5 mg albuterol by nebulizer (n = 30). Treatments were repeated at 20-minute intervals until the patient was judged to need no further doses of bronchodilator, or a total of 6 treatments. RESULTS: Clinical score, heart rate, respiratory rate, auscultatory findings, and oxygen saturation were recorded at baseline, after each treatment, and 60 minutes after the last treatment. Baseline characteristics and asthma severity were similar for the treatment groups. The spacer was as effective as the nebulizer for clinical score, respiratory rate, and oxygen saturation but produced a greater reduction in wheezing (P =.03). Heart rate increased to a greater degree in the nebulizer group (11.0/min vs 0.17/min for spacer, P <.01). Fewer children in the spacer group required admission (33% vs 60% in the nebulizer group, P =.04, adjusted for sex). No differences were seen in rates of tremor or hyperactivity. The mean cost of each emergency department presentation was NZ$825 for the spacer group and NZ$1282 for the nebulizer group (P =.03); 86% of children and 85% of parents preferred the spacer. CONCLUSION: The MDI and spacer combination was a cost-effective alternative to a nebulizer in the delivery of albuterol to young children with moderate and severe acute asthma.