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La crisis climática es una enorme amenaza para la salud humana. La evidencia que el cambio climático está ocurriendo es abrumadora, impulsado por actividades humanas que aumentan los gases de efecto invernadero en la atmósfera. Los inhaladores de dosis medidas presurizados utilizaban propulsores de clorofluorocarbonos. Los propulsores de clorofluorocarbonos fueron prohibidos debido a su gran impacto en el agotamiento de la capa de ozono. El protocolo de Montreal, introducido para proteger la capa de ozono, estableció una eliminación planificada de los clorofluorocarbonos, reemplazándolos con los hidrofluorocarbonos que ahora se utilizan en los inhaladores de dosis medidas presurizados. Si bien los hidrofluorocarbonos no agotan la capa de ozono, son potentes gases de efecto invernadero tienen un potencial de calentamiento global muchas veces mayor que el del dióxido de carbono. El sector de la salud es un contribuyente significativo a las emisiones de gases de efecto invernadero a nivel mundial. Los aumentos de la temperatura global ya están teniendo un impacto significativo en nuestro clima. La lucha contra el cambio climático se ha descrito como la mayor oportunidad de salud pública del siglo XXI. Para reducir el impacto de los inhaladores en el cambio climático, hay varias opciones disponibles, incluidas el reciclaje de los inhaladores, el uso de dispositivos alternativos, reducir la cantidad del propulsor por dosis o usar un propulsor con un potencial de calentamiento global menor. Los profesionales sanitarios tenemos el deber de proteger y promover la salud de los pacientes y emprender acciones para disminuir los peores efectos del cambio climático. Se deben hacer todos los esfuerzos posibles para minimizar la emisión de gases de efecto invernadero si queremos proteger a las generaciones actuales y futuras.

The climate crisis is a massive threat to human health. The evidence that climate change is happening, driven by human activities which increase atmospheric greenhouse gases, is overwhelming. Pressurized metered-dose inhalers used chlorofluorocarbons propellants. Chlorofluorocarbons propellants were banned because of their big impact on the ozone layer depletion. The Montreal Protocol, introduced to protect the ozone layer, saw a planned phase-out of chlorofluorocarbons, replacing them with the hydrofluorocarbons now used in metered-dose inhalers used. While hydrofluorocarbons are not ozone depleting, they are potent greenhouse gases and have global warming potential many times that of carbon dioxide. The healthcare sector is a significant contributor to greenhouse gases emissions globally. Increases in global temperature are already having a significant impact on our climate. Combating climate change has been described as 'the greatest public health opportunity of the 21st century. To reduce the climate change impact of inhalers, several options are available including inhaler recycling, the use of alternatives devices, reduce the propellant quantity per dose or use a different propellant with a lower global warming potential. Healthcare professionals have a duty to protect and promote the health of patients and take actions to minimize the worst effects of climate change. Every effort must be made to minimize greenhouse gases release if we are to protect current and future generations

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INTRODUCTION: Inhaled medication is the cornerstone of pharmacological treatment for chronic respiratory diseases. Therefore, it is important to use a metered-dose inhaler (MDI) correctly to get the appropriate dosage and benefit from the drug. Health-care workers (HCW) are responsible for teaching the correct MDI technique. Unfortunately, numerous studies consistently show that HCW have poor MDI technique. This study aimed to evaluate the current knowledge of MDI technique in HCW working in three general hospitals. MATERIAL AND METHODS: A hospital-based, cross-sectional descriptive study was conducted in three general hospitals in Aguascalientes, México. Three surveyors simultaneously scored through a 14 dichotomic questions list as bad, regular, good, and very good MDI technique. Data were analyzed with SPSS version 16. Statistical analyses were performed using chi-square test or unpaired t-tests. An analysis of one-way ANOVA was used for comparison of three independent general hospitals. Values of p < 0.05 were considered to indicate statistical significance. RESULTS: A total of 244 HCWs were surveyed: 78.3% were nurses whereas 21.3% were physicians. The inter-observer concor-dance analysis among observers was 0.97. We observed that 32.4% (79) performed a bad technique, 51.6% (126) a regular technique, 13.5% (33) a good one, and 2.5% HCW (6) a very good technique. No difference between gender, labor category, schedule, service, age, seniority, and education degree between the three hospitals was observed. The most common mistakes were "insufficient expiration prior to activation of the device", and "the distance the inhaler was placed for inhalation" (83 and 84% respectively). CONCLUSION: We observed that a high percentage of HCW do not follow the MDI technique correctly, being this percentage even higher than the reported in other studies. These observations suggest the urgent need to establish frequent training programs for the correct use of MDI.

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OBJECTIVES: The benefits of metered-dose inhalers with a spacer (MDI+S) have increasingly been recognized as an alternative method of albuterol administration for treating pediatric asthma exacerbations. The aim of this systematic review was to compare the response to albuterol delivered through nebulization (NEB) with albuterol delivered through MDI+S in pediatric patients with asthma exacerbations. METHODS: We conducted an electronic search in MEDLINE/PubMed, EMBASE, Ovid, and ClinicalTrials. To be included in the review, a study had to a randomized clinical trial comparing albuterol delivered via NEB versus MDI+S; and had to report the rate of hospital admission (primary outcome), or any of the following secondary outcomes: oxygen arterial saturation, heart rate (HR), respiratory rate (RR), the pulmonary index score (PIS), adverse effects, and need for additional treatment. RESULTS: Fifteen studies (n = 2057) met inclusion criteria. No significant differences were found between the two albuterol delivery methods in terms of hospital admission (relative risk, 0.89; 95% confidence interval [CI], 0.55-1.46; I2 = 32%; p = .65). There was a significant reduction in the PIS score (mean difference [MD], -0.63; 95% CI, -0.91 to -0.35; I2 = 0%; p < .00001), and a significantly smaller increase in HR (better; MD -6.47; 95% CI, -11.69 to -1.25; I2 = 0%; p = .02) when albuterol was delivered through MDI+S than when it was delivered through NEB. CONCLUSIONS: This review, an update of a previously-published meta-analysis, showed a significant reduction in the PIS and a significantly smaller increase in HR when albuterol was delivered through MDI+S than when it was delivered through NEB.

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OBJECTIVES: Although the benefits of albuterol delivered via metered-dose inhalers with a spacer (MDI+S) have been increasingly recognized, the evidence regarding the cost-effectiveness of MDI+S compared to nebulization (NEB) is not sufficient, especially in less-affluent countries, where the clinical and economic burden of the disease is the greatest. The aim of the present study was to evaluate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations. METHODS: A decision-analysis model was developed to estimate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was the avoidance of hospital admission. RESULTS: For the base-case analysis, the model showed that compared to NEB, using MDI+S for the delivery of albuterol was associated with lower total costs (US$96.68 vs US$121.41 average cost per patient) and a higher probability of hospital admission avoided (0.9219 vs 0.8900), thus leading to dominance. CONCLUSIONS: This study shows that in Colombia, an MIC, compared with NEB, the use of MDI+S for delivering albuterol for the treatment of pediatric asthma exacerbations is the preferred strategy because it is associated with a lower probability of hospital admission at lower total treatment costs.

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RESUMO Objetivo: Comparar a eficácia no tratamento da asma pediátrica por nebulizador e inalador dosimetrado com uso de espaçador (MDI-espaçador), no emprego das técnicas de resgate de pacientes asmáticos atendidos em emergências pediátricas. Fontes de dados: Realizou-se uma revisão sistemática para identificar os principais estudos randomizados controlados que comparam a administração de broncodilatador (β-2 agonista) por meio das técnicas inalatórias nebulização e MDI-espaçador no tratamento da asma em unidades de emergência pediátrica. Foram pesquisadas as bases de dados PubMed, Scientific Electronic Library Online (SciELO) e ScienceDirect. Dois pesquisadores, de forma independente, aplicaram os critérios de elegibilidade, sendo incluídos na pesquisa apenas estudos randomizados controlados com o objetivo de comparar as técnicas inalatórias nebulização e MDI-espaçador no tratamento da asma em unidades de emergência pediátrica. Síntese dos dados: Foram pré-selecionados 212 artigos, dos quais apenas nove seguiram os critérios de elegibilidade e foram incluídos na metanálise. Os resultados apontam não existir diferenças nas técnicas inalatórias em nenhum dos quatro desfechos analisados: frequência cardíaca (diferença -Df: 1,99 [intervalo de confiança de 95% - IC95% -2,01-6,00]); frequência respiratória (Df: 0,11 [IC95% -1,35-1,56]); saturação de O2 (Df: -0,01 [IC95% -0,50-0,48]); e escore clínico de asma (Df: 0,06 [IC95% -0,26-0,38]). Conclusões: Os achados demonstram não haver diferenças na frequência cardiorrespiratória, na saturação de O2 nem nos escores de asma, na administração de β-2 agonista entre as técnicas inalatórias (nebulizador e MDI-espaçador) em pacientes asmáticos atendidos em emergências pediátricas.

ABSTRACT Objective: To compare the efficacy of pediatric asthma treatment by nebulizer and metered-dose inhaler with the use of a spacer (MDI-spacer) in rescue techniques for asthmatic patients assisted at pediatric emergency units. Data sources: A systematic review was conducted to identify the most relevant randomized controlled trials comparing the administration of a bronchodilator (β-2 agonist) by two inhalation techniques (nebulization and MDI-spacer) to treat asthma in children at pediatric emergency units. The following databases were searched: PubMed, Scientific Electronic Library Online (SciELO), and ScienceDirect. Two researchers independently applied the eligibility criteria, and only randomized controlled trials that compared both inhalation techniques (nebulization and MDI-spacer) for asthma treatment at pediatric emergency units were included. Data synthesis: 212 articles were pre-selected, of which only nine met the eligibility criteria and were included in meta-analysis. Results show no differences between inhalation techniques for any of the four outcomes analyzed: heart rate (difference - Df: 1.99 [95% confidence interval - 95%CI -2.01-6.00]); respiratory rate (Df: 0.11 [95%CI -1.35-1.56]); O2 saturation (Df: -0.01 [95%CI -0.50-0.48]); and asthma score (Df: 0.06 [95%CI -0,26-0.38]). Conclusions: The findings demonstrate no differences in cardiorespiratory frequency, O2 saturation, and asthma scores upon administration of β-2 agonist by both inhalation techniques (nebulization and MDI-spacer) to asthmatic patients assisted at pediatric emergency units.

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OBJECTIVE: The objective of the present study was to perform a systematic review of instruments aimed at evaluating pressurized metered-dose inhaler (pMDI) administration technique in children and evaluating the measurement properties of these instruments. METHODS: A systematic search of the literature was performed in order to identify studies in which an instrument (scale, checklist, or questionnaire) for evaluating pMDI administration technique in children was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, lack of ambiguity, and lack of value-laden or offensive content. RESULTS: A total of 24 instruments were identified. The age of the children ranged from 1 month to 18 years, the number of steps or items included in the instruments ranged from 3 to 21, and nearly half of the instruments distinguished between essential and non-essential steps or items. In only 7 of the 24 instruments was there a report of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, we determined four instruments to be the best of the available ones. CONCLUSIONS: Among the 24 instruments for the assessment of pMDI administration technique in children that were identified and systematically examined, four were considered to be the best ones available. However, additional evaluation of their measurement properties should be done before using them in clinical practice and for research purposes.

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BACKGROUND: Inhalation therapy has proven to be the best way to control the asthma and chronic obstructive pulmonary disease symptoms. The most commonly used delivery system to control these symptoms is the metered-dose inhaler. The primary goal of this study is to demonstrate an association between incorrect inhaler use and patient age. METHODS: This is a cross-sectional study, performed at Centro Médico Naval “Cirujano Mayor Santiago Távara”, in Callao, Peru, in 2014. Patients older than 18 years that used metered-dose inhalers were included. We used film recordings of patients using a metered-dose inhaler and compared their technique with the recommendations on the guidelines on the correct use of inhalers of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). The main variables measured were age and incorrect inhaler use. The results were analyzed with the Chi squared test for bivariate analysis, and for multivariate analysis we used the Poisson regression model with robust variance. RESULTS: We included 378 patients in the analysis; 167 were older than 60 years. An association was found between incorrect inhalator technique and age (p=0.014) (PR 1.19 95% CI 1.03 to 1.37). The highest prevalence of incorrect technique was found in the young adult population (88%). There was no association between the incorrect technique and the person who taught it (p=0.114). Finally, this study showed that 81.2% of the study population presented an incorrect inhalation technique. CONCLUSIONS: The percentage of incorrect inhaler use, in the general population is high. Even if we found no association between an incorrect technique and the person who taught it; still, there is a high percentage of errors and it was even demonstrated that being instructed by a pulmonologist does not guarantee a correct performance of metered-dose inhaler inhalations.

INTRODUCCIÓN : La terapia inhalatoria ha demostrado ser la más rápida y eficaz para el control del asma y la enfermedad pulmonar obstructiva crónica. El inhalador de dosis medida es el más usado por la población. El objetivo de este estudio es evidenciar la asociación entre la técnica inhalatoria incorrecta y la edad. MÉTODOS: Estudio observacional, analítico, de corte transversal realizado en Perú durante 2014. Se incluyeron pacientes desde los 18 años que utilizaran inhalador de dosis medida. Se utilizó una lista de verificación de pasos establecidos por la Sociedad Española de Neumología y Cirugía Torácica y filmaciones para evaluar la técnica inhalatoria de los pacientes. Las variables principales fueron la edad y la mala técnica inhalatoria práctica. Para el análisis bivariado se utilizó la prueba Chi cuadrado y para el análisis multivariado regresión de Poisson con varianza robusta. RESULTADOS: Se incluyeron 378 pacientes; 167 fueron mayores de 60 años. El estudio reveló que el 81,2% de la población presentó una incorrecta técnica inhalatoria. Se encontró asociación entre la edad y la técnica inhalatoria incorrecta (p=0,014) (PR 1,19 con IC 95% 1,03-1,37). El grupo etario con mayor frecuencia de técnica incorrecta fue el de adultos jóvenes (88%). CONCLUSIONES: La frecuencia de uso incorrecto del inhalador en la población es alta y esta característica predomina en el grupo de adultos jóvenes. A pesar de no haber asociación entre la persona que enseña la técnica inhalatoria y el desempeño de la misma, se demostró que existe alta frecuencia de errores, incluso en aquellos pacientes instruidos por un médico especialista.

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Introducción. Los episodios de tos, disnea y sibilancias son causa frecuente de consulta pediátrica. Su tratamiento de elección es la administración de fármacos a través de la aerosolterapia. El éxito de esta estrategia depende de la correcta aplicación de la técnica inhalatoria. Objetivo. Evaluar el conocimiento de padres de niños con patología obstructiva recurrente de la vía aérea en el uso de la aerosolterapia con aerocámara. Población y métodos. Estudio transversal, observacional, descriptivo. Se incluyeron aleatoriamente padres de niños menores de 6 años con tos, disnea y/o sibilancias con antecedentes de uso de aerocámara en la consulta al Servicio de Pediatría y/o de Alergia e Inmunología. Se evaluó el conocimiento en el empleo del inhalador mediante observación de la técnica. Resultados. Se incluyeron 114 niños, 51% masculino, con una edad promedio de 29,23 meses (DE=18,30). La persona a cargo de realizar la aerosolterapia tenía una media de edad de 32,28 años (DE=5,29); la mayoría de los responsables evaluados fueron madres (92,98%), con nivel de educación superior (71,05%). La forma de aprendizaje de la técnica fue demostrativa visual en 62 casos (54,4%), y el principal instructor de la misma fue el pediatra. Se demostró que 68 (72%) padres no realizaban en forma correcta la técnica y se encontró asociación entre edad del paciente y la correcta realización de la aerosolterapia (r=0,21; p=0,03). Conclusión. La mayoría de los padres realizan la aerosolterapia de forma incorrecta y la edad del niño influye en la técnica de la terapia inhalatoria.(AU)

Introduction. Symptoms of cough, dyspnea and wheezing are common cause for medical consultation. Their treatment is the administration of drugs through the aerosol. The success of this strategy depends on the correct application of inhalation technique. Objective. To evaluate the knowledge of parents of children with recurrent obstructive airway disease in the use of aerosol therapy with valved holding chamber. Population and Methods. Cross-sectional, observational, descriptive study. Randomly included parents of children under six years with cough, dyspnea and / or wheezing with a background of use in the office holding chamber of Pediatric and / or of Allergy and Immunology section of an Hospital. We evaluated the knowledge about the inhaler technique by medical observation. Results. We included 114 children, 51% male, with an average age of 29.23 months (SD=18.30). The median age o the caregiver responsible for conducting the aerosol therapy was 32.28 years (SD=5.29); the majority of evaluated makers were mothers (92.98%) with higher education level (71.05%). The most frequent way for learning was the visual demonstration technique in 62 cases (54.4%), and the main instructor was the pediatrician. Sixty-eight (72%) of parents did not perform properly the inhalation technique and a positive association was found between patient age and the proper realization of the aerosol (r=0.21; P=0.03). Conclusion. Most parents perform incorrectly aerosol therapy with valved holding chamber and the child's age influences the inhalation technique.(AU)

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El tratamiento del asma requiere del uso de medicamentos durante períodos largos para lograr el control de la enfermedad y la vía inhalada es la forma más adecuada para administrarlos. En las últimas 2 décadas se han desarrollado nuevos y mejores dispositivos para la entrega del medicamento, con marcadas diferencias respecto a su diseño, construcción, características de salida y tamaño de las partículas. El médico debe conocer los puntos tecnológicos más destacados de cada aparato para que pueda aprovechar sus ventajas y haga recomendaciones muy precisas. Existen varios dispositivos para administrar medicamentos inhalados: los más viejos y de uso cotidiano en hospitales son los nebulizadores y de manera más reciente se introdujeron los inhaladores de dosis medida presurizados o los inhaladores de polvo seco, que son más usados para el paciente ambulatorio. La condición particular de cada uno de estos dispositivos debe conocerse y aplicarse para ofrecer el máximo beneficio al paciente asmático.

Asthma management requires the use of many drugs for long time with the purpose of achieving control. Inhalator delivery of asthma medications is the best way. In the previous 2 decades, technology has improved delivery devices, changes in design, materials and outsize particles. Physicians should know all the technical points in order to take advantage of these new devises to be able to make appropriate recommendations for their use. There is a large quantity of options for the delivery of asthma medications: nebulizers, metered dose inhaler and dry powder inhalers. Particular characteristics of delivery devices should be known and applied in particular patients.The aim of this review article is assist physicians to choose the best device option.