Download Butz AM, Eggleston P, Huss K, Kolodner K, Rand C. Nebulizer use in inner-city children with asthma: morbidity, medication use, and asthma management practices. Arch Pediatr Adolesc Med. 2000;154(10): p.984-90.

ARTICLE
Nebulizer Use in Inner-City Children With Asthma
Morbidity, Medication Use, and Asthma Management Practices
Arlene M. Butz, ScD, RN; Peyton Eggleston, MD; Karen Huss, DNSc, RN, FAAN;
Ken Kolodner, PhD; Cynthia Rand, PhD
Objective: To assess the frequency of nebulizer use, de-
scribe morbidity and patterns of medication administration, and examine the potential relationships between inhaled anti-inflammatory medication administration,
asthma morbidity, and asthma management practices in
children with asthma using a nebulizer compared with
children with asthma not using a nebulizer.
Research Design: A cross-sectional, descriptive sur-
vey of previous events.
Setting: Elementary schools and participants’ homes in
Baltimore, Md, and Washington, DC.
Participants: Six hundred eighty-six families of children aged 5 to 12 years with a diagnosis of at least mild,
persistent asthma.
Interventions: None.
Measurements and Main Results: Asthma morbidity, health care utilization, pattern of asthma medication administration, nebulizer use, and asthma man-
agement data were collected by telephone survey
administered to caregivers. Nebulizer use was defined as
use at least 1 or more days per month during the last 6
months. Of 686 children identified, 231 (33%) reported
current nebulizer use. Nebulizer users had significantly
increased lifetime hospital admissions, hospitalizations,
and emergency department visits in the last 6 months
compared with nonnebulizer users. Inhaled corticosteroid administration was low for both groups (nonnebulizer users, 8%; nebulizer users, 15%). In the nebulizer
users group, administration of inhaled anti-inflammatory medications was associated with increased asthma
morbidity (increased hospitalizations, days and nights
with symptoms, and oral steroid use).
Conclusions: Nebulizer use by inner-city children with
asthma is higher than anticipated but is not associated
with reduced asthma morbidity. This group of high-risk
children was undertreated with inhaled corticosteroids
for long-term control of asthma despite reports of adequate monitoring by a primary care physician.
Arch Pediatr Adolesc Med. 2000;154:984-990
T
From Departments of Pediatrics
(Drs Eggleston and Butz) and
Pulmonary Medicine
(Dr Rand), The Johns Hopkins
University School of Medicine,
and the School of Nursing
(Drs Butz and Huss), and
Innovative Medical Research,
INC (Dr Kolodner),
Baltimore, Md.
HE PREVALENCE of asthma,
the most common longterm disease of childhood,
significantly increased in
children aged 5 to 14 years
from 1980 to 1994 (42.8 to 74.4 per 1000
children).1 Children with a history of frequent emergency department (ED) care
and hospitalizations are at the greatest risk
for reduced quality of life, increased school
absences, and life-threatening asthma exacerbations.2-5 This increased risk is related to young age, poor access to medical care, undertreatment of asthma, and
poor asthma self-management.4,6
Studies indicate that there is no difference in efficacy between using a metered-dose inhaler (MDI) with a spacer and
using a nebulizer for administration of inhaled albuterol to older children with mild
to severe asthma. Both devices are the ideal
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
984
delivery system for inhaled b-adrenergic
agonists.7-14 However, home nebulizer use
is favored over MDI use when there is difficulty in coordinating inspiration with
MDI actuation, particularly in acutely ill,
crying, or dyspneic children with asthma.15
It is estimated that more than 50% of patients have problems using MDIs.16
See also pages 977 and 979
Current National Asthma Education Prevention Program (NAEPP) guidelines17 recommend nebulizer use for children younger than age 2 years and patients
unable to use an MDI with a spacer. Recent trends in asthma care encourage early
initiation of home nebulizer use for relief
of acute, severe symptoms, especially in
young children,15,18 to decrease ED visits
and hospitalization.19,20
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.
PATIENTS, MATERIALS,
AND METHODS
This study has a cross-sectional design, using data collected from parents or caregivers of children with asthma
enrolled in 2 community-based asthma intervention studies in Baltimore, Md, and Washington, DC. The first
study (Community-Based Adherence Intervention for
African American Children With Asthma) tested the
effectiveness of school-based asthma education and community health worker intervention on reducing ED visits,
hospitalizations, school absences, and asthma care practices.21 The second study (A+ Asthma Partnership for
Minority Children With Asthma) examined the effectiveness of a community physician educational program to
increase knowledge of asthma management and skills of
community physicians and to reduce ED visits and hospitalizations in inner-city children with asthma. Both intervention studies were approved by the Institutional Review
Boards of the Johns Hopkins Medical Institutions, Baltimore, and the Howard University College of Medicine,
Washington.
PARTICIPANTS
Seven hundred thirty children (338 enrolled in CommunityBased Adherence Intervention for African American Children With Asthma; 392, A+ Asthma Partnership for Minority Children With Asthma) were included in the data
presented in this article. Study participants with a physician diagnosis of asthma were recruited from 42 elementary schools in Baltimore and Washington during September 1992 through June 1996.
Criteria for inclusion were physician-diagnosed asthma
based on parent and school health record reports. Of the
enrolled children, 60% reported asthma symptoms consistent with mild, persistent asthma or a greater severity of
asthma based on the NAEPP guidelines17 (eg, daytime or
nighttime cough or wheeze .2 times a week). Another 29%
of these children reported symptoms consistent with mild
intermittent asthma (eg, daytime or nighttime cough or
wheeze #2 times a week). No asthma symptoms were reported by 11% of the children. For each child identified
from school records, a short survey was sent home to the
parent to confirm that the child had asthma and that the
parent agreed to participate in the study. Exclusion criteria included any current participation in other asthma studies. Excluded from this analysis were children with multiple missing data (n = 26) or missing data regarding
nebulizer use (n=5) and children younger than age 5 years
(n=13). These exclusions resulted in a final sample of 686
(94%) from the total children enrolled in both studies.
MEASURES
Baseline study data were obtained via telephone interview
after obtaining written parental or legal guardian consent.
The 30-minute telephone survey was conducted by professional interviewers from June 1994 through June 1998
to families of children with asthma enrolled in either study.
Families without telephones or those who could not be contacted were mailed a card with a toll-free telephone number to call, which linked them to an interviewer who
administered the interview. These families were sent a $20
incentive after completion of the interview.
Data were collected using a 170-item baseline questionnaire that included questions in 5 domains: sociodemographic, asthma morbidity, health care utilization
(asthma as well as primary care), asthma medication use,
and asthma self-care management practices. Nebulizer use
was ascertained by asking, “Do you have a nebulizer (a special machine that gives prescribed medicines) in your home
for your child’s asthma?” and “How many times in the last
30 days did you use the nebulizer (mist machine) for your
child’s asthma?” Children were defined as a nebulizer user
(NU) if they reported use of a nebulizer at least 1 or more
days per month during the last 6 months.
Assessment of asthma morbidity included number of
symptom (cough or wheeze) days and nights per month in
the last 6 months, number of school absences due to asthma
in the last 12 months, number of times receiving oral steroids in the last 12 months and past 30 days, and current
use of oral steroids. Health care utilization items included
the number of hospitalizations in the child’s lifetime and in
the last 6 months, number of ED visits in the child’s lifetime and the last 6 months, and number of physician visits
for regular asthma care in the last 12 months. Asthma medication administration was assessed using items asking asthma
medication type, frequency of administration, and type of
medication administration (oral or inhaled) used presently
and during the last 6 to 12 months. Assessment of asthma
management included having a regular source of asthma care,
peak flow meter use, and receiving allergy skin testing.
DATA ANALYSIS
Data were summarized by examining frequency distributions for all sociodemographic, asthma morbidity, health
care utilization, asthma medication, and asthma management variables for 686 participants. Child participants were
categorized either as NUs (use of a nebulizer $1 day during the past month) or nonnebulizer users (NNUs) (no
nebulizer use or ,1 day per month of nebulizer use). Categories of asthma medications were created by examining
the pattern of medication administration across all participants and were collapsed into the 5 most common patterns: (1) b-adrenergic agonist and/or theophylline only;
(2) b-adrenergic agonist and cromolyn sodium with or without theophylline; (3) inhaled corticosteroids and b-adrenergic agonist with or without cromolyn, or inhaled corticosteroids and theophylline with or without cromolyn; (4)
inhaled corticosteroid only or in combination with cromolyn, or cromolyn only; or (5) no medication. Children
receiving inhaled corticosteroids and cromolyn were further classified into an inhaled anti-inflammatory group.
Bivariate analysis of NUs vs NNUs were examined using x2 analysis for the categorical variables (previous ED
visits [ever] and hospitalized last 6 months [yes/no]) and
t test for continuous variables (mean number of days and
nights with symptoms, mean number of visits to regular
physician for care). We additionally analyzed the NU group
for differences in asthma morbidity measures and asthma
management characteristics by administration of inhaled
anti-inflammatory (receiving inhaled corticosteroids or cromolyn vs not receiving anti-inflammatory medications). All
data analysis was conducted using SAS 7.0 (SAS Institute,
Cary, NC).
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
985
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.
Table 1. Sociodemographic Characteristics for Nonnebulizer Users and Nebulizer Users*
Characteristic
Sex
M
F
Race/ethnicity
African American
White or other
Age, y†
5-6
7-8
9-10
$11
Parent education
,High school
High school graduate or GED
Some college/technical training
Not available
No. of household members
2
3-4
5-6
$7
Type of health insurance
Medical assistance plan
Family income/y, $
,10 000
10 000-20 000
.20 000
Received AFDC in past 12 mo
Yes
Nonnebulizer Users
(n = 455)
Nebulizer Users
(n = 231)
248 (54.5)
207 (45.5)
144 (62.3)
87 (37.7)
x21 = 3.80
.05
452 (99.3)
3 (0.7)
224 (96.9)
7 (3.1)
x21 = 5.90
.01
90 (19.8)
134 (29.5)
156 (34.3)
75 (16.5)
61 (26.4)
78 (33.8)
70 (30.3)
22 (9.5)
x23 = 9.90
.02
122 (26.8)
206 (45.3)
124 (27.3)
3 (0.6)
54 (23.4)
123 (53.2)
53 (22.9)
1 (0.4)
x22 = 3.80
.15
41 (9.0)
233 (51.2)
128 (28.1)
53 (11.7)
19 (8.2)
113 (48.9)
80 (34.6)
19 (8.2)
x23 = 4.10
.25
271 (59.6)
152 (65.8)
x22 = 0.85
.36
182 (40.0)
108 (23.7)
142 (31.2)
95 (41.1)
59 (25.5)
73 (31.6)
x224 = 0.08
.96
235 (51.7)
124 (53.6)
x21 = 0.15
.69
Statistic Test
P
*GED indicates general education diploma; AFDC, Aid to Families With Dependent Children. Values given as No. (%), except where indicated.
†Mean (SD) age: nonnebulizer users, 8.5 (2.0) years; nebulizer users, 7.9 (1.9) years.
While there are data describing short-term morbidity in children with asthma using MDIs,9,11 there are little
data describing the morbidity, medication administration, and asthma management characteristics for children using nebulizers and even less data describing innercity children’s use of nebulizers. The objectives of this
study were (1) to assess the frequency of nebulizer use
in an inner-city pediatric population, (2) to describe the
morbidity, pattern of medication administration, and
asthma management in children with asthma using a
nebulizer compared with children with asthma not using a nebulizer, and (3) to examine potential relationships between inhaled anti-inflammatory medication administration, asthma morbidity, and asthma management
practices in children with current nebulizer use.
RESULTS
SAMPLE CHARACTERISTICS
OF ALL PARTICIPANTS
Overall, children were primarily male (58%), African
American (98.6%), and had a mean age of 8.2 years (age
range, 5-12 years). Most respondents (89%) were either
the child’s biological mother or father. Most parents (75%)
reported receiving at least a high school education or general education diploma. The number of household members was high with more than two thirds (68%) report-
ing 4 or more people living in the household. Although
most mothers (79%) reported they did not have asthma,
more than half (54%) reported other family members with
asthma. More than half (60%) reported medical assistance as the child’s type of medical insurance, and half
(53%) reported receiving Aid to Families With Dependent Children (AFDC) or welfare.
Of 686 identified children with mild, persistent
asthma or a greater severity of asthma, 231 (33%) reported using a nebulizer for medication administration
at least 1 or more days per month. Three hundred twelve
(45%) reported having a nebulizer machine at home.
Nebulizer users were significantly younger (P =.02) and
more likely to be male (P = .05) compared with NNUs
(P = .02) (Table 1). A logistic regression model indicated that age and sex were independently associated with
nebulizer use (children aged 2-6 years, odds ratio
[OR]=2.4, P=.003; aged 7-8 years, OR=2.0, P=.01; aged
9-10 years, OR=1.5, P=.13) (reference groups, aged $11
years, male, OR=1.4, P =.03). Although there was a statistically significant difference by ethnicity, there was very
little variation by ethnicity in the total sample.
NEBULIZER USE BY AGE
Nebulizer use was significantly more frequent in children
younger than age 8 years (Table 1) (P=.02). Among NUs,
though there was no significant difference between the mean
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
986
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.
Table 2. Asthma Morbidity in Children by Nebulizer Use*
Nonnebulizer Users
(n = 455)
Characteristic
No. of lifetime admissions for asthma (n = 676)
None
1-2
3-4
$5
Hospitalized during the last 6 mo
Yes
No. of days and nights with symptoms, last 6 mo
Mean (SD)
No. of school days missed this year due to asthma
None
1-5
6-10
$11
No. of ED visits for asthma in past 6 mo
None
1-2
$3
Previous ED visit for asthma (ever)
Yes
Mean No. of times for oral steroid administration, past year
Oral steroid administration (daily or PRN) in last 30 d
Yes
Nebulizer Users
(n = 231)
Statistic Test
P
264 (58.8)
119 (26.5)
37 (8.2)
29 (6.5)
79 (34.8)
58 (25.6)
30 (13.2)
60 (26.4)
x23 = 66.6
.001
41 (9.0)
60 (25.9)
x21 = 35.1
.001
t230,454 = −5.1
,.001
13.7 (12.5)
19.1 (13.6)
143 (31.2)
179 (39.1)
80 (17.5)
49 (10.7)
37 (16.1)
67 (29.0)
55 (23.8)
70 (30.3)
x23 = 55.2
.001
213 (46.5)
141 (30.8)
97 (21.2)
60 (25.9)
85 (36.8)
86 (37.2)
x22 = 32.7
.001
238 (52.3)
1.3 (6.0)
171 (74.0)
3.8 (9.4)
x21 = 28.7
t315 = −3.6
.001
,.001
24 (5.3)
32 (13.9)
x21 = 15.0
.001
*ED indicates emergency department; PRN, as required. Missing data not included. Values given as No. (%), except where indicated.
number of times using a nebulizer in the past 30 days by
age (F3 =0.90, P=.44), children younger than age 11 years
tended to report a higher mean number of times of use (aged
6 years, 25.4 times; aged 7-8 years, 23.8 times; aged 9-10
years, 24.6 times; and aged $11 years, 13.6 times).
Table 3. Pattern of Medication Administration
by Nonnebulizer Users vs Nebulizer Users*
Medication
ASTHMA MORBIDITY BY NEBULIZER USE
As given in Table 2, the NU group had significantly more
lifetime hospital admissions (P=.001), a higher rate of hospitalizations during the past 6 months (P=.001), a higher
mean number of days and nights with symptoms (P=.001),
more children with at least 11 school absences in the past
year (P=.001), a higher proportion of 3 or more ED visits in the last 6 months (P=.001), and a higher proportion
of children with a previous ED visit compared with the
NNU group (P=.001). Additionally, NUs had a higher rate
of oral steroid administration in mean number of times receiving oral steroids in the last 12 months (P=.003) and a
higher percentage of children reporting oral steroid administration in the last 30 days (P=.001) compared with NNUs.
PATTERN OF ASTHMA MEDICATION
USE BY NEBULIZER USE
Administration of a b-adrenergic agonist medication alone
or in combination with theophylline was the predominant type of asthma medication for both groups (51%,
NNUs; 46%, NUs) (Table 3). The NUs had a higher percentage of cromolyn administration in combination with
a b-adrenergic agonist with and without theophylline
compared with the NNUs (NNUs, 9%; NUs, 33% ). Theophylline administration was low for both groups (NNUs,
10 [2%] of 455; NUs, 9 [4%] of 231). Inhaled cortico-
b-Adrenergic agonist and/or theophylline
only
b-Adrenergic agonist + cromolyn sodium
± theophylline
Inhaled steroid + b-adrenergic agonist ±
cromolyn, or inhaled steroid ±
theophylline ± cromolyn
Inhaled steroid only or ± cromolyn
Cromolyn only
None or missing
Nonnebulizer Nebulizer
Users
Users Only†
(n = 455)
(n = 231)
230 (50.5)
105 (45.5)
39 (8.6)
76 (32.9)
33 (7.3)
32 (13.8)
3 (0.6)
6 (1.3)
144 (31.7)‡
3 (1.3)
2 (0.9)
13 (5.6)§
*Values given as No. (%).
†Excluding short-burst oral steroid use.
‡No medication use reported.
§Missing type of medication use.
steroid administration only or in combination with a bronchodilator was low for both groups (NNUs, 36 [8%] of
455; NUs, 35 [15%] of 231), and there was a significant
difference between the 2 groups (x21 =7.89, P=.004). No
medication was received by almost one third (32%) of
the NNUs. Data for type of medication administered were
missing for 6% of NUs.
ASTHMA MORBIDITY IN NUs BY INHALED
ANTI-INFLAMMATORY ADMINISTRATION
Children receiving inhaled anti-inflammatory medications, defined as any cromolyn or inhaled corticosteroid, had increased morbidity as evidenced by a signifi-
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
987
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.
Table 4. Asthma Morbidity by Inhaled Anti-inflammatory Administration for Nebulizer Users*
No Inhaled
Anti-inflammatory
Administration
(n = 118)
Characteristic
Hospitalized during the last 6 mo
Yes
No. of days and nights with symptoms, last 6 mo
1-15/mo
$15/mo
No. of school days missed during last year
None
1-5
6-10
$11
No. of ED visits in last 6 mo
None
1-2
$3
No. of nebulizer treatments in past 30 d, mean (SD)
No. of times of oral steroid (daily or PRN) administration in past
12 mo, mean (SD)
Inhaled
Anti-inflammatory
Administration
(n = 113)†
Statistic Test
P
21 (17.8)
39 (34.5)
x21 = 8.39
.004
59 (50)
59 (50)
40 (35.4)
73 (64.6)
x21 = 5.03
.03
18 (15.4)
33 (28.2)
33 (28.2)
33 (28.2)
19 (16.9)
34 (30.4)
22 (19.6)
37 (33.1)
x23 = 2.40
.50
35 (29.7)
48 (40.7)
35 (29.7)
15.5 (26.1)
2.9 (7.5)
25 (22.1)
37 (32.7)
51 (45.1)
31.8 (31.9)
4.8 (10.9)
x22 = 5.96
.05
F112,117 = 1.50
F107,113 = 2.14
.03
,.001
*ED indicates emergency department; PRN, as required. Values given as No. (%), except where indicated.
†Defined as cromolyn sodium or inhaled corticosteroid medications.
Table 5. Asthma Management Practices by Inhaled Anti-inflammatory Administration in Nebulizer Users*
Asthma Management
Practices
No. of visits to physician for regular asthma care in past 12 mo, mean (SD)
Child has regular source of asthma care
Yes
No
Peak flow meter in the home
Yes
No
Received allergy skin testing (n = 222)
Yes
No
No Inhaled
Anti-inflammatory
Administration
(n = 118)
Inhaled
Anti-inflammatory
Administration
(n = 113)
Statistic Test
P
4.5 (7.6)
5.3 (6.2)
F116,110 = 1.51
.03
115 (97.5)
3 (2.5)
112 (99.1)
1 (0.9)
x21 = 0.30
.58
40 (35.1)
74 (64.9)
66 (60)
44 (40)
x21 = 13.90
.001
48 (42)
66 (58)
59 (55)
49 (45)
x21 = 3.00
.08
*Values given as No. (%), except where indicated.
cantly increased rate of a hospitalization in the past 6 months
(P=.004), increased number of days and nights with symptoms (P=.03), more children with 3 or more ED visits in
the last 6 months (P=.05), and an increased mean number of nebulizer treatments in the last 30 days (group not
receiving inhaled anti-inflammatory medications, 16 times;
group receiving inhaled anti-inflammatory medications, 32
times; P=.03) (Table 4). Administration of oral steroids
in the past 12 months was reported significantly more often by those receiving inhaled anti-inflammatory medications (P,.001). There were no significant differences in
the number of school days missed by administration of inhaled anti-inflammatory medications.
sician visits for regular asthma care in the past 12 months
(P=.03) and had a peak flow meter in the home (P=.001)
compared with children receiving noninhaled antiinflammatory medications. Although not statistically significant, there was a trend for the children receiving antiinflammatory medications to have undergone allergy testing
(P=.08). The 2 groups did not differ by having a regular
source of asthma care; more than 97% of children in both
groups reported having a regular source of asthma care. Last,
there were no differences in sociodemographic status by
administration of inhaled anti-inflammatory medications
(income, P=.60; receiving medical assistance, P=.26; receiving AFDC, P=.29; or caregiver unable to afford asthma
medicines or physician visits, P=.79).
ASTHMA MANAGEMENT IN NUs BY INHALED
ANTI-INFLAMMATORY ADMINISTRATION
COMMENT
As given in Table 5, children receiving inhaled antiinflammatory medications reported significantly more phy-
These data confirm that nebulizer use is high in innercity children with asthma (33%), consistent with a re-
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
988
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.
cent prevalence rate for nebulizer use for patients with
asthma of all ages (32%).22 In our study, one third of children older than age 6 years reported nebulizer use at least
1 day per month. Although nebulizer use was significantly more frequent in children younger than age 8 years,
40% of NUs were aged 8 years or older. This high rate of
nebulizer use in older children is concerning. The NAEPP
guidelines suggest nebulizer use for children aged 2 years
or younger or when a proper MDI with spacer technique cannot be achieved.17 Considerable research supports that MDIs with spacers and nebulizers are equally
efficient in administering inhaled medications to children with asthma,9,11-14,23-27 suggesting that the preferred
mode of asthma medication delivery for children is use
of an MDI with a spacer. Cost-savings of MDI use vs nebulizer use were reported to be 4-fold in reducing billing
charges for acutely ill, hospitalized patients with acute
exacerbation of obstructive airway disease.24 In children, similar reductions of nebulizer use and increase of
MDI use should yield comparable cost-savings. However, owing to some regulatory issues, medical assistance insurance may not cover the cost of a spacer for
MDI use, resulting in less effort and out-of-pocket expense for some caregivers to obtain a nebulizer.
Even though an MDI with a spacer is the preferred
mode of delivery of inhaled medications,28 many physicians continue to prescribe nebulizers for home use.29 Ideally, the decision to prescribe an MDI or nebulizer is based
on family needs and the child’s inhalation and coordination skill level.30 Physicians who treat inner-city children with asthma may believe that nebulizer use improves morbidity in this group of children, particularly
if parents are more prone to use a nebulizer than an MDI
for acute asthma episodes. Anecdotally, many families
reported requesting a nebulizer for their child to avoid
an ED visit by having the “same machine as they use in
the emergency room.” Additionally, families reported
“sharing” a nebulizer among family members and neighbors. While we lack objective data to support these claims,
it is troubling to consider that a nebulizer may be misused or may lead to delay in seeking medical care for a
child experiencing an acute exacerbation of asthma.
We observed a high rate of morbidity in this population, including increased hospitalizations, ED visits,
days and nights with symptoms, and school absences,
suggesting a more severe asthma that requires longterm, inhaled corticosteroid therapy.17 Despite the high
prevalence of nebulizer use in this sample, an extraordinarily low rate of children (15%) reported receiving
inhaled corticosteroids. While this is contrary to
NAEPP guidelines, 17 it is consistent with previous
reports of low rates of inhaled corticosteroid administration in inner-city pediatric populations.31 This lack of
inhaled corticosteroid therapy may be a major contribution to poor asthma control 21 as evidenced in this
sample. Our data indicate serious undertreatment of an
identified high-risk group of children with asthma
whose morbidity was significantly increased compared
with NNU counterparts.
On the other hand, use of anti-inflammatory medication in the NU group was not associated with a decrease in asthma morbidity as evidenced by the in-
creased number of ED visits, administration of oral
steroids, and days and nights with symptoms in those receiving inhaled anti-inflammatory medications vs those
not receiving them. Perhaps this reflects a subgroup of
NUs who receive anti-inflammatory medications but
whose symptoms are more severe and require more ED
visits for control of asthma. An alternative hypothesis
may be confounding by severity32-34 in which anti-inflammatory medications are more likely to be prescribed to children who have more severe asthma, which
is associated with a higher probability of an ED visit or
hospitalization. Sociodemographic factors such as income, receiving medical assistance, or receiving AFDC
did not influence the administration of inhaled antiinflammatory medication. Thus, there was no disparity
of inhaled anti-inflammatory administration in the more
disadvantaged families. It is unclear if this low rate of inhaled anti-inflammatory administration is a result of physicians not following clinical practice guidelines due to
lack of awareness, familiarity, agreement, or outcome expectancy35 or families’ failure to fill or adhere to prescribed medications.36-40 Considerable failure to refill medication was shown in a pediatric asthma study in which
63% of caregivers reportedly were out of albuterol for their
child when the child was seen in the ED and the caregiver indicated that 1 of their child’s medications was albuterol.38 In either case, low rates of administration of
inhaled corticosteroid medication is of great concern based
on the high morbidity we observed and indicates the need
for increased attention to both provider and patient education regarding preventive therapy. There is some evidence that this subgroup of children receiving inhaled
corticosteroids demonstrated a pattern of receiving more
NAEPP guideline–based care (eg, more physician visits
for regular asthma care, more likely to have a peak flow
meter, and a trend toward receiving allergy tests, a marker
for specialty care).
This study’s findings must be interpreted with some
caution. This study relied on a structured interview rather
than clinical records, so it is likely that parental reports
of asthma morbidity are subject to recall bias. Furthermore, all surveyed families had consented to participating in a school- or home-based asthma education program. Therefore, this sample might be biased toward
families that are either more concerned about their child’s
asthma or more in need of asthma education and services. However, the asthma morbidity and health care utilization baseline data found in this intervention study are
remarkably similar to other inner-city asthma surveys that
did not enroll participants in an asthma intervention.41,42 For this reason, we believe that our participants are representative of urban African American families with a child with asthma. Another caveat with our
self-reported data is that we are unable to determine if a
nebulizer or medication was not prescribed or whether
there was poor adherence with a prescribed treatment
plan. Verification of type of medications and presence of
a peak flow meter in the home was not conducted owing to budgetary restraints. However, families were asked
to obtain all of their child’s medications at the beginning of the interview so that the parent could read the
label for medication name and instructions for use. We
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
989
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.
feel that we report actual practice in the home, which reflects the reality of the child’s asthma care.
In conclusion, we observed high nebulizer use in inner-city children despite the limited evidence base for
nebulizer use in children older than age 2 years. We also
observed that this group of high-risk children was undertreated (6 of 7 children) with inhaled corticosteroids
for long-term control of their asthma. We recommend
that nebulizer therapy should not be used in the absence of an NAEPP guideline–based preventive medication regimen. Further studies need to carefully evaluate
the clinical benefit and cost-effectiveness of homebased nebulizer therapy on asthma morbidity in innercity children.
Accepted for publication May 30, 2000.
This research was supported by the National Heart, Lung,
and Blood Institute, National Institutes of Health, Bethesda,
Md, grants R18-HL52013 and HL52833 (Dr Rand).
The authors thank Barbara Calabrese, RN, Francine
Lampros-Klein, MEd, and David Lang, MD, for their thoughtful review of the manuscript.
Reprints: Arlene M. Butz, ScD, RN, Department of
Pediatrics, Johns Hopkins University, School of Medicine,
600 N Wolfe St, Baltimore, MD 21287-3144 (e-mail:
[email protected]).
REFERENCES
1. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma—United
States, 1960-1995. Mor Mortal Wkly Rep CDC Surveill Summ. 1998;47:1-27.
2. Rand CS, Wise RA. Adherence with asthma therapy in the management of asthma.
In: Szefler SJ, Leung DYM, eds. Severe Asthma: Pathogenesis and Clinical Management: Lung Biology in Health and Disease. New York, NY: Marcel Dekker Inc;
1996:435-464.
3. Weitzman M, Gortmaker S, Sobol A. Racial, social and environmental risks for
childhood asthma. AJDC. 1990;144:1189-1194.
4. Kesten S, Chew R, Hanania NA. Health care utilization after near-fatal asthma.
Chest. 1995;107:1564-1569.
5. Campbell DA, McLennan G, Coates JR, et al. A comparison of asthma deaths
and near-fatal asthma attacks in South Australia. Eur Respir J. 1994;7:490-497.
6. Jones SL, Jones PK, Katz J. Compliance in acute and chronic patients receiving
a health belief model intervention in the emergency department. Soc Sci Med.
1991;32:1183-1189.
7. Lemanske RF Jr, Busse WW. Asthma. JAMA. 1997;278:1855-1873.
8. Pallares DE, Pilarski BR, Rodriguez JL, Leickly FE. A comparison of bronchodilator responses to albuterol delivered by ultrasonic versus jet nebulization in moderate to severe asthma. Ann Allergy Asthma Immunol. 1996;77:292-297.
9. Karem E, Levison H, Schuh S, et al. Efficacy of albuterol administered by nebulizer versus spacer device in children with acute asthma. J Pediatr. 1993;123:
313-317.
10. Lewis RA, Fleming SS. Factional deposition from a jet nebulizer: how it differs
from a metered dose inhaler. Br J Dis Chest. 1985;79:361-367.
11. Chou KJ, Cunningham SJ, Crain EF. Metered-dose inhalers with spacers vs nebulizers for pediatric asthma. Arch Pediatr Adolesc Med. 1995;149:201-205.
12. Freelander M, Van Asperen PP. Nebuhaler versus nebulizer in children with acute
asthma. BMJ. 1984;288:1873-1874.
13. Lin YZ, Hsieth KH. Metered dose inhaler and nebulizer in acute asthma. Arch Dis
Child. 1995;72:214-218.
14. 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;135:22-27.
15. Canny GJ, Levison H. Aerosols: therapeutic use and delivery in childhood asthma.
Ann Allergy. 1988;60:11-20.
16. Crompton GK. Problems patients have using pressurized aerosol inhalers. Eur J
Respir Dis. 1982;63(suppl 119):101-104.
17. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Baltimore, Md: National Institutes of Health; 1997. Publication 97-4051.
18. Barry PW, O’Callaghan CO. Nebuliser therapy in childhood. Thorax. 1997;52
(suppl 2):S78-S88.
19. Madge PJ, Nisbet L, McColl J, Vallance A, Paton JY, Beattie JO. Home nebuliser
use in children with asthma in two Scottish Health Board areas. Scott Med J.
1995;40:141-143.
20. Zimo DA, Gaspar M, Akhter J. The efficacy and safety of home nebuliser therapy
for children with asthma. AJDC. 1989;143:208-211.
21. Rand CS, Butz AM, Huss K, Kolodner K, Eggleston PE. Emergency department
utilization of urban African American children with asthma. J Allergy Clin Immunol. 2000;105:83-90.
22. Neville RG, Hoskins G, Smith B, Clark RA. How general practitioners manage acute
asthma attacks. Thorax. 1997;311:153-156.
23. Wildhaber JH, Dore ND, Wilson JM, Devadason SG, LeSouef PN. Inhalation
therapy in asthma: nebulizer or pressurized metered-dose inhaler with holding
chamber? in vivo comparison of lung deposition in children. J Pediatr. 1999;
135:28-33.
24. Summer W, Elston R, Tharpe L, Nelson S, Haponik EF. Aerosol bronchodilator
delivery methods: relative impact on pulmonary function and cost of respiratory
care. Arch Intern Med. 1989;149:618-623.
25. Robertson CF, Norden MA, Fitzgerald DA, et al. Treatment of acute asthma: salbutamol via jet nebulizer vs spacer and metered dose inhaler. J Paediatr Child
Health. 1998;34:142-146.
26. Lewis RA, Fleming JS. Fractional deposition from a jet nebulizer: how it differs
from a metered dose inhaler. Br J Dis Chest. 1985;79:361-367.
27. Rodrigo C, Rodrigo G. Salbutamol treatment of acute severe asthma in the ED:
MDI versus hand-held nebulizer. Am J Emerg Med. 1998;16:637-642.
28. Amirav I, Newhouse MT. Metered-dose inhaler accessory devices in acute asthma:
a literature review. Arch Pediatr Adolesc Med. 1997;151:876-882.
29. Newhouse MT. Asthma therapy with aerosols: are nebulizers obsolete? a continuing controversy. J Pediatr. 1999;135:5-8.
30. Andersson L, Boethius G. Effect of domiciliary treatment with nebulized beta
2-stimulants: a retrospective follow-up of 102 patients. Eur J Respir Dis. 1984;
136:205-212.
31. Eggleston PA, Malveaux FJ, Butz AM, et al. Medications used by children with
asthma living in the inner city. Pediatrics. 1998;101:349-354.
32. Blais L, Ernst P, Boivin JF, Suissa S. Inhaled corticosteroids and the prevention
of readmission to hospital for asthma. Am J Respir Crit Care Med. 1998;158:
126-132.
33. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R.
Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277:
887-891.
34. Lieu TA, Quesenberry CP, Capra AM, Sorel ME, Martin KE, Mendoza GR. Outpatient management practices with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics. 1997;100:334-341.
35. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282:1458-1465.
36. Celano M, Geller RJ, Phillips KM, Ziman R. Treatment adherence among lowincome children with asthma. J Pediatr Psychol. 1998;23:345-349.
37. Winkelstein ML, Eggleston PE, Huss K, Vargas P, Butz A, Rand C. Factors associated with medication self-administration in children with asthma. Clin Pediatr. 2000;39:337-345.
38. Simon HK. Caregiver knowledge and delivery of a commonly prescribed medication (albuterol) for children. Arch Pediatr Adolesc Med. 1999;153:615-618.
39. Vargas P, Rand CS. Concordance between patient self-reported and physician
reported asthma regimen in low-income, minority children with asthma [abstract]. Am J Respir Crit Care Med. 1999;159:A267.
40. DiMatteo MR. Enhancing patient adherence to medical recommendations. JAMA.
1994;271:79, 83.
41. Mak H, Johnston P, Abbey H, Talamo RC. Prevalence of asthma and health service utilization of asthmatic children in an inner city. J Allergy Clin Immunol. 1982;
70:367-372.
42. Fisher EB, Sussman LK, Arfken C, et al. Targeting high risk groups: neighborhood organization for pediatric asthma management in the neighborhood asthma
coalition. Chest. 1994;106:248S-259S.
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, OCT 2000
990
WWW.ARCHPEDIATRICS.COM
Downloaded From: http://archpedi.jamanetwork.com/ by
a Johns
HopkinsMedical
University
User on 07/25/2012
©2000
American
Association.
All rights reserved.