Timothy R Myers

Comparison of racemic albuterol and levalbuterol for treatment of acute asthma

OBJECTIVE To determine whether levalbuterol resulted in fewer hospital admissions than racemic albuterol when used for treatment of acute asthma. Study design A randomized, double-blind, controlled trial was conducted in the emergency department (ED) and inpatient asthma care unit of an urban tertiary childrens hospital. Children age 1 to 18 years (n=482) provided a total of 547 enrollments. Patients received a nebulized solution of either 2.5 mg racemic albuterol or 1.25 mg levalbuterol every 20 minutes (maximum six doses). Patients admitted to the asthma care unit were treated in a standardized fashion by using the same blinded drug assigned in the ED. Hospitalization rate was the primary outcome. RESULTS Hospitalization rate was significantly lower in the levalbuterol group (36%) than in the racemic albuterol group (45 %, P=.02). The adjusted relative risk of admission in the racemic group compared with the levalbuterol group was 1.25 (95% confidence interval, 1.01-1.57). Hospital length of stay was not significantly shorter in the levalbuterol group (levalbuterol, 44.9 hours; racemic albuterol, 50.3 hours; P=.63). No significant adverse events occurred in either group. CONCLUSIONS Substituting levalbuterol for racemic albuterol in the ED management of acute asthma significantly reduced the number of hospitalizations.

Asthma: 2015 and Beyond

Asthma is a multifactorial, chronic inflammatory disease of the airways. The knowledge that asthma is an inflammatory disorder has become a core fundamental in the definition of asthma. Asthmas chief features include a variable degree of air-flow obstruction and bronchial hyper-responsiveness, in addition to the underlying chronic airways inflammation. This underlying chronic airway inflammation substantially contributes to airway hyper-responsiveness, air-flow limitation, respiratory symptoms, and disease chronicity. However, this underlying chronic airway inflammation has implications for the diagnosis, management, and potential prevention of the disease. This review for the respiratory therapy community summarizes these developments as well as providing an update on asthma epidemiology, natural history, cause, and pathogenesis. This paper also provides an overview on appropriate diagnostic and monitoring strategies for asthma, pharmacology, and newer therapies for the future as well as relevant management of acute and ambulatory asthma, and a brief review of educational approaches.

Improving Patient Outcomes with Tools for Asthma Self-Monitoring: A Review of the Literature

Despite recent advances in the therapeutic management of asthma, the prevalence, morbidity and mortality of this chronic disease continue to increase in most countries. The financial burden associated with asthma has received increasing scrutiny in the medical literature over the past two decades. In 1990, a study in the US demonstrated that all chronic disease conditions accounted for

Clinical pathways in treatment of asthma.

US425 billion in medical care costs. These chronic conditions accounted for 96% of home care visits, 80% of hospital days, 69% of hospital admissions, 66% of doctor and 55% of emergency department visits, and 55% of pharmacy prescriptions. This has led to an increased demand for improved outpatient management of asthma, and patients are now monitoring their asthma and gathering data in the ambulatory setting. Self-monitoring tools for patients with diabetes mellitus and hypertension have grown in recent years, but technological advances for self-monitoring of patients with asthma have been slow over the past several decades.This article reviewed the literature on self-monitoring tools currently available for improving outcomes in the patient with asthma. These tools currently consist of written treatment plans, peak flow meters and metered-dose inhaler monitoring devices. Patient education and training in self-management involving self-monitoring of either symptoms or peak expiratory flow, in conjunction with education and a written treatment plan, appears to improve health outcomes for both children and adults with asthma. Education allowing patients with asthma or their caregivers to intervene and adjust medications under the guidance of a written treatment plan appears to be more effective than other forms of asthma self-management.

Year in Review 2014: Aerosol Delivery Devices

Although the number of medications for the treatment of status asthmaticus is relatively limited, strategies for the management of acute asthma vary widely both among and within institutions. The choice of drugs, doses, timing of administration, duration of treatment, and assessment measures are often left to the discretion of individual physicians; plans are often not formulated on the basis of data showing efficacy, but rather on local availability and the experience and preference of physicians. The elimination of treatment that adds cost but not improved quality of care can be an effective strategy to optimize the care of acute asthma.

Thinking Outside the Box: Moving the Respiratory Care Profession Beyond the Hospital Walls

After centuries of discoveries and technological growth, aerosol therapy remains a cornerstone of care in the management of both acute and chronic respiratory conditions. Aerosol therapy embraces the concept that medicine is both an art and a science, where an explicit understanding of the science of aerosol therapy, the nuances of the different delivery devices, and the ability to provide accurate and reliable education to patients become increasingly important. The purpose of this article is to review recent literature regarding aerosol delivery devices in a style that readers of Respiratory Care may use as a key topic resource.

The Science Guiding Selection of an Aerosol Delivery Device

For centuries, hospitals have served as the cornerstone of the United States healthcare system. Just like the majority of the general population, the respiratory care profession was born inside the hospital walls, just over 6 decades ago. While the knowledge, skills, and attributes of the respiratory therapist are critically necessary in acute care settings, the profession must move itself to a stronger position across the entire continuum of care of patients with acute and chronic cardiopulmonary diseases within the next several years to stay ahead of the curve of healthcare reform. In this paper, based on the 28th annual Philip Kittredge Memorial Lecture, I will examine the necessary strategies and values that the profession of respiratory care will need to successfully embrace to “think outside the box” and move the profession beyond the hospital walls for patient- and outcomes-focused, sustainable impact in the future healthcare delivery system.

The value of care algorithms

Aerosol therapy continues to be considered as one of the cornerstones of the profession of respiratory care, even after 60 years. Aerosol therapy serves as a critical intervention for both exacerbations and chronic maintenance for a variety of respiratory care conditions. Aerosol therapy uniquely blends both the art and science of medicine together to produce the practical and necessary clinical outcomes for patients with respiratory diseases. This review was presented as part of the New Horizons Symposium on how to guide the scientific selection of an appropriate aerosol device.

Respiratory Care Year in Review 2012: Asthma and Sleep-Disordered Breathing

The use of protocols or care algorithms in medical facilities has increased in the managed care environment. The definition and application of care algorithms, with a particular focus on the treatment of acute bronchospasm, are explored in this review. The benefits and goals of using protocols, especially in the treatment of asthma, to standardize patient care based on clinical guidelines and evidence‐based medicine are explained. Ideally, evidence‐based protocols should translate research findings into best medical practices that would serve to better educate patients and their medical providers who are administering these protocols. Protocols should include evaluation components that can monitor, through some mechanism of quality assurance, the success and failure of the instrument so that modifications can be made as necessary. The development and design of an asthma care algorithm can be accomplished by using a four‐phase approach: phase 1, identifying demographics, outcomes, and measurement tools; phase 2, reviewing, negotiating, and standardizing best practice; phase 3, testing and implementing the instrument and collecting data; and phase 4, analyzing the data and identifying areas of improvement and future research. The experiences of one medical institution that implemented an asthma care algorithm in the treatment of pediatric asthma are described. Their care algorithms served as tools for decision makers to provide optimal asthma treatment in children. In addition, the studies that used the asthma care algorithm to determine the efficacy and safety of ipratropium bromide and levalbuterol in children with asthma are described.

Role of the Respiratory Therapist in the NICU

Asthma has long been recognized as a common respiratory disease, and the recognition of sleep-disordered breathing is becoming more prevalent. Patients with these disorders are commonly seen by clinicians caring for patients with respiratory disease. There is also much academic interest in asthma and sleep-disordered breathing. The purpose of this paper is to review the recent literature related to asthma and sleep-disordered breathing in a manner that is most likely to have interest to the readers of Respiratory Care.