Management of children with chronic wet cough and protracted bacterial bronchitis: CHEST guideline and expert panel report

BACKGROUND: Wet or productive cough is common in children with chronic cough. We formulated recommendations based on systematic reviews related to the management of chronic wet cough in children (aged ≤ 14 years) based on two key questions: (1) how effective are antibiotics in improving the resolution of cough? If so, what antibiotic should be used and for how long? and (2) when should children be referred for further investigations? METHODS: We used the CHEST expert cough panel's protocol for systematic reviews and the American College of Chest Physicians (CHEST) methodologic guidelines and GRADE framework (the Grading of Recommendations Assessment, Development and Evaluation). Data from the systematic reviews in conjunction with patients' values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain consensus for the recommendations/suggestions made. RESULTS: Combining data from the systematic reviews, we found high-quality evidence in children aged ≤ 14 years with chronic (> 4 weeks' duration) wet/productive cough that using appropriate antibiotics improves cough resolution, and further investigations (eg, flexible bronchoscopy, chest CT scans, immunity tests) should be undertaken when specific cough pointers (eg, digital clubbing) are present. When the wet cough does not improve following 4 weeks of antibiotic treatment, there is moderate-quality evidence that further investigations should be considered to look for an underlying disease. New recommendations include the recognition of the clinical diagnostic entity of protracted bacterial bronchitis. CONCLUSIONS: Compared with the 2006 Cough Guidelines, there is now high-quality evidence for some, but not all, aspects of the management of chronic wet cough in specialist settings. However, further studies particularly in primary health) are required.

The misconception of using floating patterns as an accurate means of measuring the contents of metered-dose inhaler devices.

BACKGROUND: Patients and physicians have searched for a reproducible method of determining the amount of medication that a metered-dose inhaler (MDI) contains as well as a reliable method of determining when their MDI is empty. Previously, patients have been instructed to float their canister in water, and depending upon the position attained, have been able to estimate the amount of medication within the canister. OBJECTIVE: To investigate whether the floating patterns of MDIs are a reliable method of determining the contents contained within an inhaler canister, including that of the newer devices containing the non-chlorofluorocarbon (CFC) propellant. METHODS: Fifteen albuterol sulfate MDIs (Proventil HFA; Schering, Kenilworth, NJ), 15 triamcinolone acetonide MDIs (Azmacort; Rhjne-Poulenc Rorer, Collegeville, PA), and 15 fluticasone propionate MDIs (Flovent; GlaxoSmith Kline, Research Triangle Park, NC) were obtained from their respective companies. Each device was floated in a clear container full of water before any actuations. The devices were then actuated into the air at 2-minute intervals and each subsequently floated following 25%, 50%, 75%, and 100% of the prescribed number of actuations and its position within the container observed. The canisters were then actuated until no visual spray was produced from the nozzle and again their floating positions within the container observed. RESULTS: Each of the three MDIs tested had unique floating patterns both before any actuation as well as throughout the various actuations. CONCLUSIONS: This study demonstrates that the floating method is not an accurate means by which patients can identify the amount of medication contained within an inhaler device. This includes both conventional MDIs containing CFC propellant, as well as the newer non-CFC MDIs.

The ability of the community pharmacist to learn the proper actuation techniques of inhaler devices.

Today, greater responsibility is placed on community pharmacists for the education of patients than ever before. Thus community pharmacists were recruited for this study and asked to demonstrate the proper steps in the actuation sequences of 3 inhaler devices. Baseline measurements were followed by an instructional session on the proper actuation technique, and then a posttest was conducted 4 to 6 weeks later. The mean changes between baseline and postinstruction percentage scores for the metered-dose inhaler device, the Turbuhaler, and the Diskus were (mean +/- SD) 17.1% +/- 15.4%, 22.6% +/- 18.7%, and 38.4% +/- 19.6%, respectively. This study demonstrates that a single instructional session can dramatically improve a community pharmacist's ability to demonstrate the correct method of actuation.

Comparison of emergency room asthma care to National Guidelines.

BACKGROUND: National Asthma Education and Prevention Program (NAEPP) guidelines were first released in 1991. To date there have been no studies published comparing them with actual care given. OBJECTIVE: The aim of this study was to compare the documented care given in the emergency room (ER) of an urban tertiary care hospital with 1991 NAEPP guidelines. METHODS: A total of 1858 urban emergency room records with a diagnosis of asthma or reactive airway disease were recovered in 1 year (9/95 to 8/96) from pediatric and adult patients seen in the ER. Ten percent (n = 181) of the charts were reviewed for documentation of history, assessment of severity of attack, treatment given, and disposition. RESULTS: History of present attack was documented consistently in all age groups. Nocturnal symptoms were noted in 11%, and frequency of beta agonist use in 38% of the charts. Previous ER visits, hospitalization, ICU admissions, and intubations (HCUM) were documented in 70%. Accessory muscle use was recorded in 76% of the infants and 21% of the adults. Peak flows were obtained in 31% of children and 64% of adults. Steroids were given in the ER in 59% of infants, 83% of children, and 49% of adults. Pediatric patients were referred to their primary care provider 90%, and to pulmonary or allergy clinic 4% of the time. Adults were referred to allergists or pulmonologists 32% of the time. CONCLUSION: There are significant differences in ER evaluation and treatment when compared with the 1991 NAEPP guidelines. Differences also exist between various age groups within the same institution.

Seasonal variation in immediate skin test reactions.

Seasonal variation in the size of immediate prick skin tests was examined in relation to changes in seasonal pollen exposure. Immediate skin test reactions to serial 5-fold dilutions of: (1) a specific pollen during its season (short ragweed), (2) a specific pollen from an earlier season (tree), (3) a perennial allergen (D farinae, D pteronyssinus, or cat), and (4) histamine were examined at the projected trough of ragweed-specific IgE (2nd week in July), at the peak ragweed pollen count (3rd week August), at the estimated peak in ragweed-specific IgE (4th week in September) and at a time of no pollen exposure (2nd week in February). All 30 subjects had symptoms of rhinitis during the ragweed season and a 3 mm or greater wheal to: 100,000 AU/mL of short ragweed, 1:20 wt/vol of a tree exact, and a perennial allergen either 100,000 AU/mL of cat or 10,000 AU/mL of D farinae or D pteronyssinus. The median equivalent dose (dose of skin test material required to produce the median skin test index score) for the four time periods revealed significant seasonal differences. The reactions in October and February were significantly greater than those in July and August for all skin test agents. Histamine, ragweed, and trees showed maximal sensitivity in October, while perennial allergens demonstrated a peak in skin test sensitivity during mid-February.

Suggested approaches for research protocols involving the potential for life-threatening reactions.

These guidelines are intended to reduce the potential for serious or life-threatening reactions when clinical research is conducted. The following issues were addressed: identifying the risks involved in the research, providing adequate safeguards in the protocol design and during withholding of medication, anticipating risks, minimizing the chances for human error, providing resuscitative equipment sufficient to deal with the most serious anticipated life-threatening reactions, planning for medical support in case of a life-threatening emergency, and optimizing the use of medical personnel and expertise to handle emergency situations. The guidelines also discuss important general issues about protocol design and implementation and the human subject consent form, which should facilitate the approval of protocols by the governing institutional review board. The guidelines are not meant to be inflexible or applicable to all research situations. However, it is our hope that they will allow for clinical research to be conducted in a manner that affords the research subjects a high degree of protection from unnecessary and possibly fatal injuries.

Treatment of peanut allergy with rush immunotherapy.

Peanut and peanut products are a common food in the diet. Peanuts are also one of the most common foods responsible for food-induced anaphylaxis. Patients rarely lose sensitivity to peanuts. Although the ideal treatment is avoidance, this is often not possible because of hidden exposures; therefore, a more effective treatment is needed. Subjects with confirmed peanut allergy were treated in a double-blind, placebo-controlled study with peanut immunotherapy or placebo. Objective measures of efficacy included changes in symptom score during double-blind placebo-controlled peanut challenge (DBPCPC) and titrated end point prick skin tests (PST). Three subjects treated with peanut immunotherapy completed the study. These subjects displayed a 67% to 100% decrease in symptoms induced by DBPCPC. Subjects also had a 2- to 5-log reduction in end point PST reactivity to peanut extract. One placebo-treated subject completed the study. This subject had essentially no change in DBPCPC symptom scores or PST sensitivity to peanut. Two other placebo-treated subjects underwent a second PST session. These subjects had a 1- to 2-log increase in skin test sensitivity to peanut. All peanut-treated subjects were able to reach maintenance dose, and in no case did an anaphylactic reaction occur secondary to the peanut immunotherapy. The current study provides preliminary data demonstrating the efficacy of injection therapy with peanut extract and provides a future line of clinical investigation for the treatment of this potentially lethal disease. It should be noted, however, that the rate of systemic reactions with rush immunotherapy was 13.3%.(ABSTRACT TRUNCATED AT 250 WORDS)