Download Butz AM, Eggleston P, Huss K, Kolodner K, Vargas P, Rand C. Children with asthma and nebulizer use: parental asthma self-care practices and beliefs. J Asthma. 200;38(7): p.565-73.

Journal of Asthma, 38(7), 565–573 (2001)
ORIGINAL ARTICLE
Children with Asthma and Nebulizer Use:
Parental Asthma Self-Care Practices
and Beliefs
Arlene M. Butz, Sc.D., R.N.,1,2 Peyton Eggleston, M.D.,1
Karen Huss, D.N.Sc., R.N., F.A.A.N.,2 Ken Kolodner,
Ph.D.,4 Perla Vargas, Ph.D.,5 and Cynthia Rand, Ph.D.3
1
School of Medicine, Department of Pediatrics, 2School of Nursing, and
Pulmonary Medicine Department, The Johns Hopkins University,
Baltimore, Maryland
4
Innovative Medical Research, Inc., Baltimore, Maryland
5
Department of Pediatrics, The University of Arkansas for Medical
Sciences, Little Rock, Arkansas
3
ABSTRACT
We examined demographic characteristics, patterns of medication use, asthma
morbidity, and asthma self-management practices and beliefs among inner-city
children currently using a nebulizer. We also describe the relationship between
asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room
visits, hospitalizations, symptom days and nights, and school absences in this
group of school-aged children with asthma. More than three-quarters (81%)
reported asthma symptoms consistent with mild persistent or greater severity of
asthma, and therefore these subjects should be taking AI medications. Another
16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more
likely to agree with the belief that children should use asthma medications daily
even when the child is not reporting any symptoms.
Address correspondence to Arlene M. Butz, Sc.D., R.N., Department of Pediatrics, Johns Hopkins University, School of
Medicine, 600 N. Wolfe Street, Baltimore, MD 21287-3144. E-mail: [email protected]
565
Copyright # 2001 by Marcel Dekker, Inc.
www.dekker.com
566
Butz et al.
KEY WORDS: Anti-inflammatory medications; Asthma; Asthma self-management; Nebulizer use.
INTRODUCTION
Nebulizers are medication delivery systems commonly used to deliver inhaled medications to infants
and young children who are unable to use a metereddose inhaler (MDI) and/or to children with severe,
symptomatic asthma. Aerosolized delivery of medications, either by MDI or a nebulizer, is ideal for
asthma because drug delivery to the small airway is
maximized and undesirable systemic effects are generally minimized (1). Studies indicate that there is no
difference in efficacy between an MDI with spacer and
a nebulizer when used for administration of inhaled
albuterol to older children with mild to severe asthma
(2–7). When there is difficulty in coordinating inspiration with MDI actuation, particularly in acutely ill
children or dyspneic children with asthma, home
nebulizer use is favored (8). Current National Asthma
Education Prevention Program (NAEPP) Guidelines
recommend nebulizer use for children less than 2
years of age and patients unable to use an MDI with
spacer (9), yet the role of the nebulizer within guideline-based asthma management is unclear.
Consistent with reports of others (10), we found
high rates of nebulizer use observed in an inner-city
school-age population with asthma (11). Approximately 45% of children enrolled in a communitybased asthma study reported having a nebulizer in
the home and 33% of these school age children
reported regular use of a nebulizer, defined as at
least 1 or more days within the last month, in the
management of their asthma (11). Although nebulizers appear to be an important component of
asthma management practice within inner-city communities, little is known regarding how nebulizers
are integrated into the overall asthma therapy of
inner-city children with asthma.
Current NAEPP guidelines recommend long-term
control medications in addition to the quick-relief
medications for the treatment of asthma in children
with persistent moderate to severe asthma (9). Antiinflammatory (AI) medications (e.g., inhaled corticosteroids or cromolyn) are the most effective
long-term control medications recommended for use
in treatment of moderate persistent to severe persistent asthma in children (12). Underuse of AI
medications has been associated with increased hospitalization rates (13) and may place these children
at risk for increased morbidity and mortality (14).
Several studies have reported physician nonadherence (either failure or resistance) with the NAEPP
prescribing guidelines recommending the use of AI
medication in children with persistent asthma. In
addition, child nonadherence with AI use has been
reported in multiple studies (15–17).
Patient and caregiver beliefs have been suggested
to be one contributing factor in AI medication poor
adherence or refusal, either with MDI and spacer, or
by nebulizer delivery. There are no data describing
the asthma management practices and beliefs of
parents of inner-city children with mild or moderate
persistent to severe persistent asthma who use a
nebulizer for administration of their medication.
Understanding the practices and beliefs of these
families may improve adherence with prescribed
asthma medication therapy. The objectives of this
study were to describe the patterns of asthma nebulizer medication use, morbidity, asthma management
and beliefs, and the relationship between asthma
management practices and beliefs and AI therapy in
a group of caregivers of children with mild persistent
to severe asthma who currently use nebulizers.
METHODOLOGY
This study was a cross-sectional design using
baseline data collected from parents/caregivers of
children with asthma enrolled in two communitybased asthma intervention studies in Baltimore, MD,
and Washington, DC. The two studies used identical
sample selection, subject identification, and data collection instruments. The first study (Community
Based Adherence Intervention for African-American
Children with Asthma) tested the effectiveness of a
school-based asthma education and community
health worker intervention on reducing emergency
room visits, hospitalizations, and school absences,
and promoting asthma care practices (18). The
second study (Aþ Asthma Partnership for Minority
Children with Asthma) examined the effectiveness of
a community physician educational program on
Parental Asthma Self-Care Practices
567
Criteria for inclusion were doctor-diagnosed
asthma based on parent and school health record
reports and self-report of nebulizer use at least 1 or
more days within the last month for the past 6
months. Children participating in other asthma
studies were excluded.
Data were collected using a 170-item baseline
questionnaire that included questions in five 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
nebulizer users 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 in
the last 6 months, number of school absences due to
asthma in the last 12 months, number of times oral
steroids were taken in the last 12 months and past 30
days, and current use of oral steroids. Healthcare
utilization items included the number of hospitalizations in the child’s lifetime and in the last 6 months,
the number of emergency department visits in the
child’s lifetime and in the last 6 months, and the
number of physician visits for regular asthma care in
the last 12 months. Asthma medication use was
assessed using items asking name of asthma medication, frequency of use, and mode of medication
administration (i.e., oral or inhaled) at present and
during the last 6–12 months.
Assessment of asthma management included (a)
practices, such as peak flow meter use or allergy
skin test performed; (b) beliefs about side effects of
asthma medications, and taking asthma medications
daily without symptoms; and (c) satisfaction with
child’s medical care.
Measures
Data Analysis
Baseline study data were obtained via telephone
interview after obtaining written parental/legal guardian consent and child assent. The 30-min telephone
survey was conducted by professional interviewers
from June 1994 to June 1998 of 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 number to call,
which linked them to an interviewer who administered the interview. Families without telephones
were sent a $20.00 incentive after completion of the
interview.
Data were summarized by examining frequency
distributions for all sociodemographic, asthma morbidity, healthcare utilization, asthma medication, and
asthma management variables for all 231 participants
who were currently using nebulizers. Categories of
asthma medications were created by examining the
pattern of medication use across all participants
and were collapsed into the five most common patterns: (a) b-adrenergic agonist and/or theophylline
only; (b) b-adrenergic agonist and cromolyn theophylline; (c) inhaled corticosteroids and b-adrenergic
agonist cromolyn or inhaled corticosteroids and
increasing asthma management knowledge and skills
of community physicians and reducing emergency
room 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, MD, and
the Howard University College of Medicine,
Washington, DC. Parental consent and child assent
were obtained for each child enrolled in the community-based studies.
Subjects
A total of 686 children, 6–12 years old, were
identified with physician-diagnosed asthma from 42
elementary schools from September 1992 through
June 1996. Of the 686 children, almost half (312
children, 45%) reported having a nebulizer machine
in the home and 231 of these children or 74% (231
of 312) reported current nebulizer use at least 1 or
more days within the last month for the past 6
months for which results are presented (11). We
previously reported on nebulizer use among innercity children with asthma (11). This paper presents
additional data on self-care practices and asthma
health beliefs among children with asthma who are
currently using a nebulizer.
Inclusion Criteria
568
Butz et al.
theophylline cromolyn; (d ) inhaled corticosteroid
only or in combination with cromolyn, or cromolyn
only; or (e) no medication. Children using inhaled
corticosteroids or cromolyn sodium were further
classified as inhaled AI users. No children reported
using leukotriene modifier medications.
Bivariate analyses of AI users were examined
using w2 analysis for the categorical variables (i.e.,
use of peak flow meter and asthma management
beliefs) and Student’s t-test for the continuous
variable of mean number of visits to physician for
regular asthma care in the past 12 months. Differences in asthma morbidity measures and asthma
management characteristics were analyzed by use
of inhaled AI (use of AI medication versus no AI
use). All data analysis was conducted using SAS
7.0 (19).
RESULTS
Child and Parent Characteristics
Children were primarily male (62%), African
American (97%), and had a mean age of 7.9 years
(range 5–12 years) (Table 1). Most respondents
(89%) were the child’s biological parent (i.e., mother
or father). Most parents (76%) reported at least a
high school education or graduate equivalency
diploma (GED). More than one-third (42%) reported
five or more people living in the household.
Table 1
Child and Parent Sociodemographic Characteristics (N ¼ 231)
Characteristic
Child sociodemographic characteristics
Gender
Male
Female
Race/ethnicity
African American
Caucasian/other
Age in years
5–6
7–8
9–10
11þ
Parent sociodemographic characteristics
Parent education
<High school
High school graduate/GED
Some college/technical
Missing
Number of household members
2
3–4
5–6
7þ
Type of health insurance
Medical assistance plan
Family income/year
<$10,000
$10,000–20,000
>$20,000
Receive AFDC in past 12 months
Yes
Number (%)
144 (62.3)
87 (37.7)
224 (96.9)
7 (3.1)
Mean ¼ 7.9 (SD 1.9)
61 (26.4)
78 (33.8)
70 (30.3)
22 ( 9.5)
54 (23.4)
123 (53.2)
53 (22.9)
1 (0.4)
19 (8.2)
113 (48.9)
80 (34.6)
19 (8.2)
152 (65.8)
95 (41.1)
59 (25.5)
73 (31.6)
124 (53.6)
Parental Asthma Self-Care Practices
569
Although most mothers (79%) reported they did
not have asthma, more than half (54%) reported
other family members with asthma. Two-thirds
reported medical assistance as the child’s type of
medical insurance, and half (54%) reported receiving Aid to Families with Dependent Children
(AFDC) or welfare.
cromolyn sodium use in combination with b-adrenergic agonist with and without theophylline. Inhaled
corticosteroid use either alone or in combination with
a bronchodilator was low (35 of 231, 15%) as
recommended by the NAEPP guidelines (9). Type of
medication use was missing for 6% of the subjects.
Asthma Morbidity
Pattern of Asthma Medication Use
As seen in Table 2, use of a b-adrenergic agonist
medication alone or in combination with theophylline was the predominant (46%) type of asthma
medication use. One third of the children reported
As seen in Table 3, approximately one-quarter
(26%) of the children reported a hospitalization,
more half (57%) reported 15 or more symptom
days and nights during the last 6 months, and almost
one-third (30%) reported missing 11 or more school
Table 2
Pattern of Medication Use ( N ¼ 231) Excluding Short-Burst Oral Steroid Use
Medication
Number (%)
b-Adrenergic agonist and/or theophylline only
b-Adrenergic agonist þ cromolyn theophylline
Inhaled steroid þ b-adrenergic agonist cromolyn
or inhaled steroid theophylline cromolyn
Inhaled steroid only or cromolyn
Cromolyn only
None or missing
105 (45.5)
76 (32.9)
32 (13.8)
3 (1.3)
2 (0.9)
13 (5.6)
Table 3
Asthma Morbidity for Children Using Nebulizers ( N ¼ 231)
Characteristic
Hospitalized during the last 6 months
Yes
Number days and nights symptoms last 6 months
1–15/month
15þ/month
Number school days missed during last year
None
1–5 days
6–10 days
11 þ days
Missing
Number emergency room visits in last 6 months
None
1–2
3þ
Number of nebulizer treatments in past 30 days
Number of times oral steroid (daily or as-needed) used in past 12 months
Number (%)
60 (26.0)
99 (42.9)
132 (57.1)
37 (16.0)
67 (29.0)
55 (23.8)
70 (30.3)
2 (0.9)
60 (26.0)
85 (36.8)
86 (37.2)
Mean (SD)
23.5 (30.2)
3.4 (7.0)
570
days during the last year. More than one-third
(37%) reported three or more emergency room visits
within the last 6 months. The mean number, standard deviation (SD), and median of nebulizer treatments used within the last 30 days was 23.5 times
(SD ¼ 30.2; median ¼ 6) and the mean number of
times oral steroids were taken during the past 12
months was 3.4 (SD ¼ 7.0; median ¼ 2).
Asthma Morbidity by Inhaled AI Use
Children reporting taking inhaled AI medications, defined as any cromolyn sodium or inhaled
corticosteroid, had increased morbidity as evidenced
by a significantly higher rate of a hospitalization in
the past 6 months (AI users, 34.5% and AI nonusers, 17.8%; w2 ¼ 8.39, df ¼ 1, p ¼ 0.004); higher
number of days and nights with symptoms (greater
than 15 days and nights per month: AI users, 65%
and AI nonusers, 50%; w2 ¼ 5.03, df ¼ 1, p ¼ 0.03);
more children with three or more emergency department visits in the last 6 months (AI users, 45% and
AI nonusers, 30%; w2 ¼ 5.96, df ¼ 2, p ¼ 0.05); and
higher mean number of nebulizer treatments in the
last 30 days (AI users, 31.8 times and AI nonusers,
15.5 times; t-test ¼ 4.25, df ¼ 216, p ¼ 0.0001). There
were no significant differences in the number of
times oral steroids were used in the past 12 months
or number of school days missed by use of inhaled
AI medications.
Asthma Management and Beliefs
by Inhaled AI Use
As seen in Table 4, children reporting taking
inhaled AI medications reported having a peak flow
meter in the home significantly more often
( p ¼ 0.001) than did noninhaled AI users. The two
groups did not differ regarding number of physician
visits for regular asthma care in the past 12 months,
having a regular source of asthma care, or receiving
allergy skin testing.
Few caregiver beliefs about asthma care differed
by use of inhaled AI medications. Significantly more
parents of inhaled AI users reported that they agree
that ‘‘children should take asthma medications daily
even when they have no symptoms’’ ( p ¼ 0.001), and
reported that they disagree or strongly disagree that
‘‘doctors don’t care if patients worry’’ ( p ¼ 0.02).
There were no differences by inhaled AI use in the
parent’s beliefs of ‘‘satisfaction with medical care for
Butz et al.
my child,’’ ‘‘physician explains what medications do
and how to use them,’’ ‘‘physicians always treat their
patients with respect,’’ ‘‘medical care for my child
could be better,’’ or ‘‘my beliefs about my child’s care
conflict with the beliefs of my child’s doctor.’’ Most
caregivers (92%–96%) agreed or strongly agreed
that they were very satisfied with the medical care
for their child. However, almost one-third of
parents in both groups reported that their beliefs
about their child’s care did conflict with their doctor’s beliefs (noninhaled AI users: 32%; inhaled AI
users: 29%).
DISCUSSION
We observed a high rate of morbidity in children
with asthma who currently used nebulizers, including frequent emergency room visits, hospitalizations,
symptom days and nights, and school absences.
Despite the fact that the majority of children
reported asthma symptoms consistent with persistent asthma and 74% reported an emergency room
visit in the prior 6 months, very few children (15%)
in this study reported taking AI medications.
Although this is contrary to NAEPP guidelines (9),
it is consistent with previous reports of low AI
use in inner-city pediatric populations (15). This
lack of inhaled AI therapy may be a major contribution to poor asthma control (20–22) as evidenced in this sample. Our data indicate serious
undertreatment of an identified high-risk group of
children with asthma based on current use of a
nebulizer.
It is unclear if this low inhaled AI use is a result
of physicians not following clinical practice guidelines (23), or the family’s failure to fill or adhere to
prescribed medications (24–27). Considerable failure
to refill medication was shown in one pediatric
asthma study in which 63% of caregivers reportedly
were out of albuterol for their child when the child
presented to the emergency room (26). The low use
of AI medication is of great concern, particularly
considering the high morbidity we observed in this
study.Alternatively, it is possible that AI therapy
was prescribed only to children with the more
severe asthma. Regardless of the reason for lack of
AI use, it remains a concern that these children
experienced increased morbidity. These findings
indicate the urgent need for increased attention
Parental Asthma Self-Care Practices
571
Table 4
Parental Asthma Management Practices and Beliefs by Inhaled AI Use ( N ¼ 231)
No Inhaled AI
(N ¼ 118)
Mean (SD)
Inhaled AI Use
(N ¼ 113)
Mean (SD)
4.5 (7.6)
5.3 (6.2)
t-test ¼ 0.86,
df ¼ 221, p ¼ 0.39
Number (%)
Number (%)
p Value
40 (35.1)
74 (64.9)
66 (60.0)
44 (40.0)
w2 ¼ 13.94,
df ¼ 1, p ¼ 0.001
115 (97.5)
3 (2.5)
112 (99.1)
1 (0.9)
w2 ¼ 0.30,
df ¼ 1, p ¼ 0.58
48 (42.1)
66 (57.9)
59 (54.6)
49 (45.4)
w2 ¼ 3.03,
df ¼ 1, p ¼ 0.08
48 (42.9)
64 (57.1)
80 (77.7)
23 (22.3)
w2 ¼ 26.9,
df ¼ 1, p ¼ 0.001
22 (18.6)
76 (64.4)
20 (17.7)
13 (11.5)
91 (80.5)
9 (8.0)
w2 ¼ 7.73
df ¼ 2, p ¼ 0.02
109 (92.3)
4 (3.4)
5 (4.3)
108 (95.6)
3 (2.7)
2 (1.7)
w2 ¼ 1.32
df ¼ 2, p ¼ 0.52
96 (82.8)
11 (9.5)
8 (6.8)
1 (0.9)
99 (87.6)
10 (8.8)
3 (2.7)
1 (0.9)
w2 ¼ 2.33,
df ¼ 3, p ¼ 0.51
93 (78.8)
100 (88.5)
w2 ¼ 4.92,
df ¼ 2, p ¼ 0.09
Disagree/strongly disagree
Not sure
Medical care for my child could be better
Strongly agree/agree
15 (12.7)
10 (8.5)
10 (8.8)
3 (2.7)
59 (50.0)
45 (39.8)
Disagree/strongly disagree
Not sure
My beliefs about my child’s care conflict
with the beliefs of my child’s doctor
Strongly agree/agree
45 (38.1)
14 (11.9)
54 (47.8)
14 (12.4)
38 (32.2)
32 (28.3)
68 (57.6)
12 (10.2)
72 (63.7)
9 (8.0)
Asthma Care Practices
Number of visits to doctor for regular
asthma care in past 12 months
Peak flow meter in the home
Yes
No
Child has regular source of asthma care
Yes
No
Received allergy skin testing (N ¼ 222)
Yes
No
Statistical
Test and
p Value
Asthma Care Beliefs
Children should take asthma medications
daily even when they have no symptoms?
Yes
No
Doctors don’t care if patients worry
Strongly agree/agree
Disagree/strongly disagree
Not sure
I am very satisfied with the medical
care for my child
Strongly agree/agree
Disagree/strongly disagree
Not sure
Physician explains what medications do and how to use them
All of the time
Most of the time
Some of the time
None of the time
Physicians always treat their patients with respect
Strongly agree/agree
Disagree/strongly disagree
Not sure
w2 ¼ 2.59,
df ¼ 2, p ¼ 0.27
w2 ¼ 1.27,
df ¼ 2, p ¼ 0.53
572
to both provider and patient education regarding
preventive therapy.
Our data also suggest that patient beliefs may
play an important role in the use of controller medication. We found that parents of children reporting
use of daily AI medication were more likely to
agree that children should take asthma medications
daily (even when they had no symptoms) as compared to parents of children not reporting use of AI
therapy. AI medication use was more likely to be
reported by children with more severe disease (e.g.,
higher number of days and nights with symptoms).
Parental misunderstanding of the rationale of regular prophylactic therapy includes either unconvincing evidence of the benefits of AI medications or
fear of the side effects of the AI medications (22).
This suggests that targeting parent’s beliefs about
daily asthma medication use, despite the lack of evident symptoms in their child, is critical to increasing
adherence to AI therapy for children.
Some evidence exists that this subgroup of children taking AI medications demonstrated a pattern
of receiving more NAEPP guideline-based management including a greater likelihood of having a peak
flow meter. Of concern is the finding that almost
one-third of all nebulizer users reported conflict
between themselves and the physician’s beliefs about
the care of their child. We were unable to determine
if this conflict is related to nebulizer or medication
use or other aspects of their child’s medical care.
This study’s findings should be interpreted with
some caution. This study relied upon a structured
parental interview rather than clinical records, so it
is likely that parental reports of asthma morbidity
are subject to recall bias. In addition, all surveyed
families had consented to participating in a schoolbased or a 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
healthcare 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 (28,29). Another
caveat with our self-reported data is that we are
unable to determine if a medication was not prescribed or whether there was poor adherence with a
prescribed treatment plan. However, families were
asked to obtain all of their child’s medications at
the beginning of the interview so that the parent
Butz et al.
could read the label for medication name and
instructions for use.
CONCLUSIONS
We observed a high rate of morbidity, including
frequent emergency room visits, hospitalizations,
symptom days and nights, and school absences in a
group of school-aged children with asthma who
were currently using nebulizers. More than threequarters (81%) reported asthma symptoms consistent with mild or greater persistent asthma, yet only
1 out of 7 children reported taking AI medications.
In addition, we observed that parents’ beliefs about
the value of long-term controller medication use
were associated with the use of AI medication.
Further studies need to carefully evaluate the value
of nebulizer delivery systems in the management of
persistent asthma, its effect on adhering to AI medication use (i.e., if the reliance of children on nebulizer therapy discourages adherence to AI medication
use), and the factors determining underuse of AI
medication in these high-risk children.
ACKNOWLEDGMENT
This research was supported by the National
Heart, Lung, and Blood Institute, NIH Grant Nos.
HL52013 and HL52833.
REFERENCES
1.
2.
3.
4.
5.
Lemanske, R.F.; Busse, W.W. Asthma. JAMA 1997,
278, 1855–1873.
Karem, E.; Levison, H.; Schuh, S.; O’Brodovich, H.;
Reisman, J.; Bentar, L.; Canny, G.J. Efficacy of
Albuterol Administered by Nebulizer Versus Spacer
Device in Children with Acute Asthma. J. Pediatr.
1993, 123, 313–317.
Lewis, R.A.; Fleming, S.S. Fractional Deposition from
a Jet Nebulizer: How it Differs from a Metered Dose
Inhaler. Br. J. Dis. Chest 1985, 79, 361–367.
Chou, K.J.; Cunningham, S.J.; Cramer, J. MeteredDose Inhalers with Spacers vs Nebulizers for Pediatric
Asthma. Arch. Pediatr. Adolesc. Med. 1995, 149,
201–205.
Freelander, M.; Van Asperen, P.P. Nebuhaler Versus
Nebulizer in Children with Acute Asthma. Br. Med. J.
1984, 288, 1873–1874.
Parental Asthma Self-Care Practices
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Lin, Y.Z.; Hsieth, K.H. Metered Dose Inhaler and
Nebulizer in Acute Asthma. Arch. Dis. Child. 1995,
72, 214–218.
Schuh, S.; Johnson, D.W.; Stephens, D.; Callahan, S.;
Winders, P.; Canny, G.J. 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.
Canny, G.J.; Levison, H. Aerosols: Therapeutic Use
and Delivery in Childhood Asthma. Ann. Allergy
1988, 60, 11–20.
National Asthma Education and Prevention Program.
Expert Panel Report 2: Guidelines for the Diagnosis
and Management of Asthma, NIH Publication No.
97-4051; National Heart, Lung and Blood Institute,
National Institutes of Health, Bethesda, MD, 1997.
Neville, R.G.; Hoskins, G.; Smith, B.; Clark, R.A.
How General Practitioners Manage Acute Asthma
Attacks. Thorax 1997, 311, 153–156.
Butz, A.M.; Eggleston, P.; Huss, K.; Kolodner, K.;
Rand, C. Nebulizer Use in Inner-City Children with
Asthma. Arch. Pediatr. Adolesc. Med. 2000, 154,
984–990.
Kerrebijin, K.R.; van Essen-Zandvliet, E.E.; Neijens,
H.J. Effects of Long-Term Treatment with
Corticosteroid and b2-Agonist on the Bronchial
Responsiveness in Children with Asthma. J. Allergy
Clin. Immunol. 1987, 79, 653–659.
Gottlieb, D.J.; Beiser, A.S.; O’Connor, G.T. Poverty,
Race and Medication Use Are Correlates of Asthma
Hospitalization Rates: A Small Area Analysis in
Boston. Chest 1995, 108, 28–35.
Strunk, R.C.; Mrazek, D.A.; Fuhrmann, G.S.;
LaBreque, J.F. Physiologic and Psychological
Characteristics Associated with Deaths Due to
Asthma in Childhood. JAMA 1985, 254, 1193.
Eggleston, P.A.; Malveaux, F.J.; Butz, A.M.; Huss,
K.; Thompson, L.; Kolodner, K.; Rand, C.S.
Medications Used by Children with Asthma Living
in the Inner City. Pediatrics 1998, 101, 349–354.
Milgrom, H.; Bender, B.; Ackerson, L.; Bowry, P.;
Smith, B.; Rand, C. Noncompliance and Treatment
Failure in Children with Asthma. J. Allergy Clin.
Immunol. 1996, 98, 1051–1057.
Coutts, J.A.; Gibson, N.A.; Paton, J.Y. Measuring
Compliance with Inhaled Medications in Asthma.
Arch. Dis. Child. 1992, 67, 332–333.
573
18. Rand, C.S.; Butz, A.M.; Huss, K.; Kolodner, K.;
Eggleston, P.E. Emergency Department Utilization
of Urban African-American Children with Asthma.
J. Allergy Clin. Immunol. 2000, 105, 83–90.
19. SAS Institute. SAS Users Guide: Statistics, Version
7.0; SAS Institute: Cary, NC, 1999.
20. Newhouse,
M.T.
Emergency
Department
Management of Life-Threatening Asthma. Are
Nebulizers Obsolete? Chest 1993, 103, 661–663.
21. Bender, B.; Milgrom, H.; Rand, C.; Ackerson, L.
Psychological Factors Associated with Medication
Nonadherence in Asthmatic Children. J. Asthma
1998, 35, 347–353.
22. Gibson, N.A.; Ferguson, A.E.; Aitchison, T.C.;
Paton, J.Y. Compliance with Inhaled Asthma
Medication in Preschool Children. Thorax 1995, 50,
1274–1279.
23. Cabana, M.D.; Rand, C.S.; Powe, N.R.; Wu, A.W.;
Wilson, M.H.; Abboud, P.; Rubin, H. Why Don’t
Physicians Follow Clinical Practice Guidelines?
JAMA 1999, 282, 1458–1465.
24. Celano, M.; Geller, R.J.; Phillips, K.M.; Ziman, R.
Treatment Adherence Among Low-Income Children
with Asthma. J. Pediatr. Psychol. 1998, 23, 345–349.
25. Winkelstein, M.L.; Eggleston, P.E.; Huss, K.; Vargas,
P.; Butz, A.; Rand, C. Factors Associated with
Medication Self-Administration in Children with
Asthma. Clin. Pediatr. 2000, 39, 337–345.
26. Simon, H.K. Caregiver Knowledge and Delivery of a
Commonly Prescribed Medication (Albuterol) for
Children. Arch. Pediatr. Adolesc. Med. 1999, 153,
615–618.
27. Vargas, P.; Rand, C.S. Concordance Between Patient
Self-Reported and Physician Reported Asthma Regimen in Low-Income, Minority Children with Asthma.
Am. J. Resp. Crit. Care Med. 1999, 159, A267.
28. Mak, H.; Johnston, P.; Abbey, H.; Talamo, R.C.
Prevalence of Asthma and Health Service Utilization
of Asthmatic Children in an Inner City. J. Allergy
Clin. Immunol. 1982, 70, 367–372.
29. Fisher, E.B.; Sussman, L.K.; Arfken, C.; Harrison,
D.; Munro, J.; Sykes, R.K.; Sylvia, S.; Strunk, R.C.
Targeting High Risk Groups. Neighborhood
Organization for Pediatric Asthma Management in
the Neighborhood Asthma Coalition. Chest 1994,
106, 248S–259S.
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