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| Name | Class |
|---|---|
| University of Tennessee | OTHER |
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This study is determines if metered dose inhalers are as effective as breath actuated nebulizers for the treatment of mild to moderate asthma exacerbations in pediatric patients presenting to the emergency department. Half of the participating patients received albuterol via the metered dose inhaler whereas the other half received albuterol via the breath actuated nebulizer.
Albuterol administered via metered dose inhalers with spacers are more effective than small volume nebulizers in the treatment of acute pediatric asthma exacerbations. There is also supporting data that the breath actuated nebulizers are also more effective than small volume nebulizers. The effectiveness of breath actuated nebulization compared to MDI for treating asthma exacerbations is less well defined.
Metered dose inhalers with spacers are more readily available to the general population, are easily transportable and do not require a power source. Demonstrating equal effectiveness of albuterol delivery systems for treatment of acute pediatric asthma exacerbations would enable physicians to confidently utilize clinical encounters as opportunities to educate families on management of asthma exacerbations using their home appliance.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Albuterol by Metered Dose Inhaler | Active Comparator | Albuterol administered via MDI and spacer device with weight and severity based dosing. For weight less than 20 kg: mild and moderate disease 540mcg of albuterol per dose. For weight greater than or equal to 20 kg: mild disease 540 mcg of albuterol per dose and moderate disease 1080 mcg of albuterol per dose. |
|
| Albuterol Breath Actuated Nebulizer | Active Comparator | Subjects randomized to BAN were evaluated for proper breath actuation technique. For subjects unable to coordinate breath actuation, the RT attached an appropriately sized mask to the device, changed the setting to continuous nebulization and returned upon completion of the treatment. Albuterol dosing was based upon the subject's weight and presenting symptom severity. Children presenting in the mild and moderate severity category weighing less than 20kg, received 2500mcg of albuterol. Children weighing more than 20kg, received 2500mcg of albuterol if their presentation met mild severity criteria, or 5000mcg if they met moderate criteria. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Metered Dose Inhaler | Device | A metered dose inhaler (MDI) is a small hand held pressurized canister device that contains both a medication, in this case albuterol, and a propellant. Pressing the device delivers 90mcg of albuterol. The MDI is attached to a spacer device, which is a one way holding chamber which allows the medication to be delivered over a series of breaths. |
| Measure | Description | Time Frame |
|---|---|---|
| Number of Participant's Admitted to the Hospital for Further Treatment | Patient disposition is measured as subjects requiring further treatment and being admitted to hospital. We record the number of patients in each cohort that required admission to the hospital after being evaluated and treated in the Emergency Department. | 6 hours |
| Measure | Description | Time Frame |
|---|---|---|
| Emergency Department Length of Stay | Emergency department length of stay is defined as the point of time when the patient checked into the Emergency Department to the time of final disposition. | 6 hours |
| Number of Patients With Tachycardia After Treatment |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Mark A Snider, DO | University of Tennessee | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 23614823 | Background | Naar-King S, Lam P, Ellis D, Bruzzese JM, Secord E. Asthma medication device skills in high-risk African American adolescents. J Asthma. 2013 Aug;50(6):579-82. doi: 10.3109/02770903.2013.786725. Epub 2013 May 28. | |
| 24131031 | Background | Reznik M, Silver EJ, Cao Y. Evaluation of MDI-spacer utilization and technique in caregivers of urban minority children with persistent asthma. J Asthma. 2014 Mar;51(2):149-54. doi: 10.3109/02770903.2013.854379. Epub 2013 Oct 22. |
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| ID | Title | Description |
|---|---|---|
| FG000 | Albuterol by Metered Dose Inhaler | Albuterol administered via MDI and spacer device with weight and severity based dosing. For weight less than 20 kg: mild and moderate disease 540mcg of albuterol per dose. For weight greater than or equal to 20 kg: mild disease 540 mcg of albuterol per dose and moderate disease 1080 mcg of albuterol per dose. Metered Dose Inhaler: A metered dose inhaler (MDI) is a small hand held pressurized canister device that contains both a medication, in this case albuterol, and a propellant. Pressing the device delivers 90mcg of albuterol. The MDI is attached to a spacer device, which is a one way holding chamber which allows the medication to be delivered over a series of breaths. |
| FG001 | Albuterol Breath Actuated Nebulizer | Subjects randomized to BAN were evaluated for proper breath actuation technique. The device settings were changed to provide continuous nebulization with a facemask if the patient could not breath actuate. Children presenting in the mild and moderate severity category weighing less than 20kg, received 2500mcg of albuterol. Children weighing more than 20kg, received 2500mcg of albuterol if their presentation met mild severity criteria, or 5000mcg if they met moderate criteria. Breath Actuated Nebulizer: The breath actuated nebulizer (BAN) device is a device that converts liquid medication, into an aerosol. It consists of a mouthpiece, a medication reservoir, and connective tubing that attaches to a compressor. This BAN device delivers medication when the patient takes a breath, but it can be attached to a mask and set to continuous nebulization for patients that are not able to coordinate their breaths. |
| Title | Milestones | Reasons Not Completed | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Albuterol by Metered Dose Inhaler | Albuterol administered via MDI and spacer device with weight and severity based dosing. For weight less than 20 kg: mild and moderate disease 540mcg of albuterol per dose. For weight greater than or equal to 20 kg: mild disease 540 mcg of albuterol per dose and moderate disease 1080 mcg of albuterol per dose. Metered Dose Inhaler: A metered dose inhaler (MDI) is a small hand held pressurized canister device that contains both a medication, in this case albuterol, and a propellant. Pressing the device delivers 90mcg of albuterol. The MDI is attached to a spacer device, which is a one way holding chamber which allows the medication to be delivered over a series of breaths. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Count of Participants |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Number of Participant's Admitted to the Hospital for Further Treatment | Patient disposition is measured as subjects requiring further treatment and being admitted to hospital. We record the number of patients in each cohort that required admission to the hospital after being evaluated and treated in the Emergency Department. | Posted | Number | Participants admitted to the Hospital | 6 hours |
|
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Albuterol by Metered Dose Inhaler | Albuterol administered via MDI and spacer device with weight and severity based dosing. For weight less than 20 kg: mild and moderate disease 540mcg of albuterol per dose. For weight greater than or equal to 20 kg: mild disease 540 mcg of albuterol per dose and moderate disease 1080 mcg of albuterol per dose. Metered Dose Inhaler: A metered dose inhaler (MDI) is a small hand held pressurized canister device that contains both a medication, in this case albuterol, and a propellant. Pressing the device delivers 90mcg of albuterol. The MDI is attached to a spacer device, which is a one way holding chamber which allows the medication to be delivered over a series of breaths. |
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| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| Tachycardia | Cardiac disorders | Non-systematic Assessment | Incidence of age adjusted tachycardia prior to final disposition after receiving albuterol as per their randomized cohort according to our standard emergency department protocol |
Unblinded study, eligible subjects may have been overlooked for fear of treatment failure. Recheck times were not standardized possibly affecting EDLOS and tachycardia. Baseline acuity differences between cohorts.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Mark Snider DO, Principal Investigator | University of Tennessee Health Sciences College of Medicine/Le Bonheur Children's Hospital | 9012875986 | marksnider02@hotmail.com |
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| ID | Term |
|---|---|
| D001249 | Asthma |
| ID | Term |
|---|---|
| D001982 | Bronchial Diseases |
| D012140 | Respiratory Tract Diseases |
| D008173 | Lung Diseases, Obstructive |
| D008171 | Lung Diseases |
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| ID | Term |
|---|---|
| D036501 | Metered Dose Inhalers |
| ID | Term |
|---|---|
| D009330 | Nebulizers and Vaporizers |
| D004864 | Equipment and Supplies |
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|
|
| Breath Actuated Nebulizer | Device | The breath actuated nebulizer (BAN) device is a device that converts liquid medication, in this case albuterol, into an aerosol. It consists of a mouthpiece, a medication reservoir, and connective tubing that attaches to a compressor. This BAN device delivers medication when the patient takes a breath, but it can be attached to a mask and set to continuous nebulization for patients that are not able to coordinate their breaths. |
|
|
Defined as anytime after initiation of therapy when the patient's heart rate exceeded age adjusted normal sinus rhythm heart rates for their age. Not uncommonly, patient's experience tachycardia as an unintended side effect of receiving albuterol. Tachycardia can result in a patient requiring further observation in the Emergency department and therefore increasing Emergency Department length of stay. We want to determine if indeed tachycardia is unavoidable, or if its presence suggests that patients are receiving too much albuterol or if albuterol is being given by the wrong appliance. |
| 6 hours |
| Number of Patients Requiring Ondansetron Dosing | Defined as a patient needing ondansetron for symptomatic relief of their nausea after initiating therapy in the Emergency Department. | 6 hours |
| Number of Participants Requiring Repeat Visits | Defined as a repeat visit to the Emergency Department for a complaint related to their wheezing, within 7 days of initial enrollment in the study. | Within 7 days of initial presentation |
| 24336438 | Background | Reznik M, Jaramillo Y, Wylie-Rosett J. Demonstrating and assessing metered-dose inhaler-spacer technique: pediatric care providers' self-reported practices and perceived barriers. Clin Pediatr (Phila). 2014 Mar;53(3):270-6. doi: 10.1177/0009922813512521. Epub 2013 Dec 12. |
| 17699806 | Background | Osmond MH, Gazarian M, Henry RL, Clifford TJ, Tetzlaff J; PERC Spacer Study Group. Barriers to metered-dose inhaler/spacer use in Canadian pediatric emergency departments: a national survey. Acad Emerg Med. 2007 Nov;14(11):1106-13. doi: 10.1197/j.aem.2007.05.009. Epub 2007 Aug 15. |
| 19863282 | Background | Hussain-Rizvi A, Kunkov S, Crain EF. Does parental involvement in pediatric emergency department asthma treatment affect home management? J Asthma. 2009 Oct;46(8):792-5. |
| 17983880 | Background | National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138. doi: 10.1016/j.jaci.2007.09.043. |
| 9308864 | Background | Amirav I, Newhouse MT. Metered-dose inhaler accessory devices in acute asthma: efficacy and comparison with nebulizers: a literature review. Arch Pediatr Adolesc Med. 1997 Sep;151(9):876-82. doi: 10.1001/archpedi.1997.02170460014003. |
| 15539736 | Background | Leung K, Louca E, Coates AL. Comparison of breath-enhanced to breath-actuated nebulizers for rate, consistency, and efficiency. Chest. 2004 Nov;126(5):1619-27. doi: 10.1378/chest.126.5.1619. |
| 14966818 | Background | Liu LL, Gallaher MM, Davis RL, Rutter CM, Lewis TC, Marcuse EK. Use of a respiratory clinical score among different providers. Pediatr Pulmonol. 2004 Mar;37(3):243-8. doi: 10.1002/ppul.10425. |
| 17198210 | Background | Altamimi S, Robertson G, Jastaniah W, Davey A, Dehghani N, Chen R, Leung K, Colbourne M. Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma. Pediatr Emerg Care. 2006 Dec;22(12):786-93. doi: 10.1097/01.pec.0000248683.09895.08. |
| Background | Chameides L, Ralston M, American Academy of Pediatrics, American Heart Association. Pediatric Advances Life Support. Dallas, Tx: American Heart Association;2011 |
| 18929686 | Background | Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009 Apr;42(2):377-81. doi: 10.1016/j.jbi.2008.08.010. Epub 2008 Sep 30. |
| 21333060 | Background | Sabato K, Ward P, Hawk W, Gildengorin V, Asselin JM. Randomized controlled trial of a breath-actuated nebulizer in pediatric asthma patients in the emergency department. Respir Care. 2011 Jun;56(6):761-70. doi: 10.4187/respcare.00142. Epub 2011 Feb 11. |
| 22930778 | Background | Titus MO, Eady M, King L, Bowman CM. Effectiveness of a breath-actuated nebulizer device on asthma care in the pediatric emergency department. Clin Pediatr (Phila). 2012 Dec;51(12):1150-4. doi: 10.1177/0009922812458356. Epub 2012 Aug 28. |
| 22348319 | Background | Arunthari V, Bruinsma RS, Lee AS, Johnson MM. A prospective, comparative trial of standard and breath-actuated nebulizer: efficacy, safety, and satisfaction. Respir Care. 2012 Aug;57(8):1242-7. doi: 10.4187/respcare.01450. Epub 2012 Feb 17. |
| 23369770 | Background | Parone D, Stauss M, Reed CR, Sherman B, Smith L, Johnson R, Milcarek B, Hunter K. A comparative study of two nebulizers in the emergency department: breath-actuated nebulizer and handheld nebulizer. J Emerg Nurs. 2014 Mar;40(2):131-7. doi: 10.1016/j.jen.2012.10.006. Epub 2013 Jan 29. |
| 8345434 | Background | Kerem E, Levison H, Schuh S, O'Brodovich H, Reisman J, Bentur L, Canny GJ. Efficacy of albuterol administered by nebulizer versus spacer device in children with acute asthma. J Pediatr. 1993 Aug;123(2):313-7. doi: 10.1016/s0022-3476(05)81710-x. |
| 11668134 | Background | Ram FS, Wright J, Brocklebank D, White JE. Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering beta (2 )agonists bronchodilators in asthma. BMJ. 2001 Oct 20;323(7318):901-5. doi: 10.1136/bmj.323.7318.901. |
| 9827736 | Background | Rodrigo C, Rodrigo G. Salbutamol treatment of acute severe asthma in the ED: MDI versus hand-held nebulizer. Am J Emerg Med. 1998 Nov;16(7):637-42. doi: 10.1016/s0735-6757(98)90164-4. |
| 21464192 | Background | Doan Q, Shefrin A, Johnson D. Cost-effectiveness of metered-dose inhalers for asthma exacerbations in the pediatric emergency department. Pediatrics. 2011 May;127(5):e1105-11. doi: 10.1542/peds.2010-2963. Epub 2011 Apr 4. |
| 10393599 | Background | Schuh S, Johnson DW, Stephens D, Callahan S, Winders P, Canny GJ. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. J Pediatr. 1999 Jul;135(1):22-7. doi: 10.1016/s0022-3476(99)70322-7. |
| 10753248 | Background | Leversha AM, Campanella SG, Aickin RP, Asher MI. Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma. J Pediatr. 2000 Apr;136(4):497-502. doi: 10.1016/s0022-3476(00)90013-1. |
| 10738013 | Background | Rubilar L, Castro-Rodriguez JA, Girardi G. Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age. Pediatr Pulmonol. 2000 Apr;29(4):264-9. doi: 10.1002/(sici)1099-0496(200004)29:43.0.co;2-s. |
| 15289762 | Background | Castro-Rodriguez JA, Rodrigo GJ. beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. J Pediatr. 2004 Aug;145(2):172-7. doi: 10.1016/j.jpeds.2004.04.007. |
| 10920157 | Background | Ploin D, Chapuis FR, Stamm D, Robert J, David L, Chatelain PG, Dutau G, Floret D. High-dose albuterol by metered-dose inhaler plus a spacer device versus nebulization in preschool children with recurrent wheezing: A double-blind, randomized equivalence trial. Pediatrics. 2000 Aug;106(2 Pt 1):311-7. doi: 10.1542/peds.106.2.311. |
| 22400716 | Background | Staggs L, Peek M, Southard G, Gracely E, Baxendale S, Cross KP, Kim IK. Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems. J Med Econ. 2012;15(4):704-11. doi: 10.3111/13696998.2012.674587. Epub 2012 Mar 23. |
| 10501359 | Background | Zar HJ, Brown G, Donson H, Brathwaite N, Mann MD, Weinberg EG. Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial. Lancet. 1999 Sep 18;354(9183):979-82. doi: 10.1016/s0140-6736(98)12445-5. |
| 12144645 | Background | Zar HJ, Asmus MJ, Weinberg EG. A 500-ml plastic bottle: an effective spacer for children with asthma. Pediatr Allergy Immunol. 2002 Jun;13(3):217-22. doi: 10.1034/j.1399-3038.2002.01056.x. |
| 23966133 | Background | Griffiths B, Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Cochrane Database Syst Rev. 2013 Aug 21;2013(8):CD000060. doi: 10.1002/14651858.CD000060.pub2. |
| 10103297 | Background | Zorc JJ, Pusic MV, Ogborn CJ, Lebet R, Duggan AK. Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics. 1999 Apr;103(4 Pt 1):748-52. doi: 10.1542/peds.103.4.748. |
| 11732951 | Background | Goggin N, Macarthur C, Parkin PC. Randomized trial of the addition of ipratropium bromide to albuterol and corticosteroid therapy in children hospitalized because of an acute asthma exacerbation. Arch Pediatr Adolesc Med. 2001 Dec;155(12):1329-34. doi: 10.1001/archpedi.155.12.1329. |
| 25039574 | Background | Wyatt EL, Borland ML, Doyle SK, Geelhoed GC. Metered-dose inhaler ipratropium bromide in moderate acute asthma in children: A single-blinded randomised controlled trial. J Paediatr Child Health. 2015 Feb;51(2):192-8. doi: 10.1111/jpc.12692. Epub 2014 Jul 14. |
| Protocol Violation |
|
| BG001 | Albuterol Breath Actuated Nebulizer | Subjects randomized to BAN were evaluated for proper breath actuation technique. The device settings were changed to provide continuous nebulization with a facemask if the patient could not breath actuate. Children presenting in the mild and moderate severity category weighing less than 20kg, received 2500mcg of albuterol. Children weighing more than 20kg, received 2500mcg of albuterol if their presentation met mild severity criteria, or 5000mcg if they met moderate criteria. Breath Actuated Nebulizer: The breath actuated nebulizer (BAN) device is a device that converts liquid medication, into an aerosol. It consists of a mouthpiece, a medication reservoir, and connective tubing that attaches to a compressor. This BAN device delivers medication when the patient takes a breath, but it can be attached to a mask and set to continuous nebulization for patients that are not able to coordinate their breaths. |
| BG002 | Total | Total of all reporting groups |
| Participants |
|
| Age, Continuous | Mean | Standard Deviation | years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Region of Enrollment | Number | participants |
|
| Pediatric Asthma Score at Presentation | The Pediatric Asthma Severity Score is a composite score based upon the patient's respiratory rate, oxygen saturation, retractions, work of breathing and findings on auscultation. The score ranges from 5-15, with the higher score being associated with a more severe asthma exacerbation. A mild score ranges from 5-7, a moderate score of 8-11. The minimum score obtainable is 5, the maximum score is a 15. Any subject with a presenting score above 11 was not eligible for participation in this study as these would be classified as a severe exacerbation. | Mean | Standard Deviation | units on a scale |
|
| OG001 | Albuterol Breath Actuated Nebulizer | Subjects randomized to BAN were evaluated for proper breath actuation technique. The device settings were changed to provide continuous nebulization with a facemask if the patient could not breath actuate. Children presenting in the mild and moderate severity category weighing less than 20kg, received 2500mcg of albuterol. Children weighing more than 20kg, received 2500mcg of albuterol if their presentation met mild severity criteria, or 5000mcg if they met moderate criteria. Breath Actuated Nebulizer: The breath actuated nebulizer (BAN) device is a device that converts liquid medication, into an aerosol. It consists of a mouthpiece, a medication reservoir, and connective tubing that attaches to a compressor. This BAN device delivers medication when the patient takes a breath, but it can be attached to a mask and set to continuous nebulization for patients that are not able to coordinate their breaths. |
|
|
| Secondary | Emergency Department Length of Stay | Emergency department length of stay is defined as the point of time when the patient checked into the Emergency Department to the time of final disposition. | Posted | Mean | Standard Deviation | minutes | 6 hours |
|
|
|
| Secondary | Number of Patients With Tachycardia After Treatment | Defined as anytime after initiation of therapy when the patient's heart rate exceeded age adjusted normal sinus rhythm heart rates for their age. Not uncommonly, patient's experience tachycardia as an unintended side effect of receiving albuterol. Tachycardia can result in a patient requiring further observation in the Emergency department and therefore increasing Emergency Department length of stay. We want to determine if indeed tachycardia is unavoidable, or if its presence suggests that patients are receiving too much albuterol or if albuterol is being given by the wrong appliance. | Posted | Count of Participants | Participants | 6 hours |
|
|
|
| Secondary | Number of Patients Requiring Ondansetron Dosing | Defined as a patient needing ondansetron for symptomatic relief of their nausea after initiating therapy in the Emergency Department. | Posted | Count of Participants | Participants | 6 hours |
|
|
|
| Secondary | Number of Participants Requiring Repeat Visits | Defined as a repeat visit to the Emergency Department for a complaint related to their wheezing, within 7 days of initial enrollment in the study. | Posted | Count of Participants | Participants | Within 7 days of initial presentation |
|
|
|
| 0 |
| 445 |
| 0 |
| 445 |
| 101 |
| 445 |
| EG001 | Albuterol Breath Actuated Nebulizer | Subjects randomized to BAN were evaluated for proper breath actuation technique. For subjects unable to breath actuate, the RT attached an appropriately sized mask to the device, changed the setting to continuous nebulization and returned upon completion of the treatment. Albuterol dosing was based upon the subject's weight and presenting symptom severity. Children presenting in the mild and moderate severity category weighing less than 20kg, received 2500mcg of albuterol. Children weighing more than 20kg, received 2500mcg of albuterol if their presentation met mild severity criteria, or 5000mcg if they met moderate criteria. Breath Actuated Nebulizer: The breath actuated nebulizer (BAN) device is a device that converts liquid medication, in this case albuterol, into an aerosol. It consists of a mouthpiece, a medication reservoir, and connective tubing that attaches to a compressor. This BAN device delivers medication when the patient takes a breath, but it can be atta | 0 | 445 | 0 | 445 | 141 | 445 |
|
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| D012130 |
| Respiratory Hypersensitivity |
| D006969 | Hypersensitivity, Immediate |
| D006967 | Hypersensitivity |
| D007154 | Immune System Diseases |