Proficiency of pediatricians in the use of inhaled medication delivery systems for the management of asthma.

OBJECTIVE: To evaluate the proficiency of pediatricians in the demonstration of the proper use of metered-dose inhalers (MDIs) and to assess their theoretical knowledge of inhalation devices used in the management of asthma. DESIGN: Prospective cross-sectional survey. SETTING: Two university-affiliated hospitals. PARTICIPANTS: Seventy-one pediatricians and pediatric house staff. INTERVENTION: Each pediatrician's technique was graded by two trained observers using a checklist of six essential steps recommended by national guidelines. Theoretical knowledge of asthma devices was evaluated by a written questionnaire. RESULTS: Twenty (35.2%) pediatricians performed at least five steps correctly, 28 (39.4%) performed three or four steps correctly, and 18 (25.4%) performed two steps or less correctly. The most common errors were failure to start inhalation from functional residual capacity, failure to inhale slowly, and failure to wait at least 20 seconds before the next puff. Senior pediatricians were more skillful in the practical use of MDIs than were pediatric house staff (p = 0.03). The most common deficiencies in theoretical knowledge were related to estimation of the amount of medication in the canister (8.5% correct) and how valved holding chambers (VHCs) improve drug delivery to the lung (15.5% correct). CONCLUSION: Pediatricians in Kuwait have significant deficiencies regarding the practical and theoretical aspects of MDIs and other inhalation devices.

Varicella-associated purpura fulminans: chicken pox is not always benign.

OBJECTIVE: To report a 6-year-old boy with post-chicken pox purpura fulminans (PF). CLINICAL PRESENTATION AND INTERVENTION: A 6-year-old boy presented with purpura of the legs that rapidly progressed to other parts of the limbs and the buttocks. The patient had had chicken pox 10 days prior to presentation. He was afebrile and the chicken pox lesions were dry. He received anti-coagulants, a large volume of fresh frozen plasma, immunoglobulin and steroids. The skin lesions regressed but both hands and parts of the lower limbs remained necrotic; the patient was transferred to an orthopaedic hospital for amputation and skin grafting. CONCLUSION: This case report shows that PF can occur as a post-infection syndrome after primary varicella. Early and aggressive treatment of post-chicken pox PF might reduce the mortality and morbidity associated with this condition.