JOURNAL CLUB

M M Khan

ST6

• 4 year• 2nd wheezy episode• O/E mild distress . Sats borderline • Management :

Salbutamol

Ipratropium bromide

Steroid

Hypertonic Saline and Acute Wheezing in Preschool Children

PediatricsVol 129 6 June 2012 .On line May 2012

Background • Rhinovirus - common cause of lower airway

inflammation

• Change in electrolyte and water movement on the luminal surface of epithelial cells similar to RSV infection increases ATPase leading to decrease ATP level

• This decreases electrolyte movement and dehydration at luminal level

• Hypertonic saline in theory may reverse some of the physiologic abnormalities

CLINICAL QUESTION Population Preschool children

Intervention 5% Hypertonic saline

Comparison Placebo

Outcome Reduce hospitalisation and duration of stay

Design Randomised double blind controlled trial

Literature search • Hypertonic saline and wheeze

Methods • A prospective, randomized double-blind controlled trial to

investigate the efficacy of inhaled HS treatment of 1to 6-year-old children presented to the ED with acute wheezing episodes from January 2009 to January 2011

• Inclusion criteria were children aged 1to 6 years who presented with acute wheezing illness and a CS ≥6

• During RSV season, 2 to 6-year-old children were recruited to exclude infants with RSV bronchiolitis

Asthma Clinical Severity ScoreModified from Qureshi et al.

1 Point 2 Point 3 Point

Respiratory rate (breath/min)

2–3 yr ≤34 35-39 ≤40

4–5 y ≤30 31-35 ≤36

Oxygen saturation (%), room air

>95 90-95 <90

Auscultation Normal or end-expiratory wheezing Expiratory wheezing Intercostals, substernal and

supraclavicular Retractions Non or intercostals

Intercostals and substernal Intercostals, substernal and supraclavicular

Dyspnea Speaks in sentences or coos and babbles

Speaks in partial sentences

or utters short cries Speaks in single words or short phrases or grunts

CASP

• Is the trial valid? • What are the results? • Will the results help locally?

A/ Are the results of the trial valid?

Screening Questions

1 Did the trial address a clearly focused issue?

Yes Can't tell No

2 Was the assignment of patients to treatments randomized?

Yes Can't tell No

3 Were all of the patients who entered the trial properly accounted for at its conclusion

Yes Can't tell No

• Were patients analysed in the groups to which they were randomised?

Yes Can't tell No

Detailed Questions

4 Were patients, health workers and study personnel ‘blind’ to treatment?

Yes Can't tell No

5 Were the groups similar at the start of the trial?

Yes Can't tell No

Epidemiologic CharacteristicsHS n = 16 NS n = 25 All N = 41 P

Age (mo) 30 ± 13.4 19.7 ± 33.1 17.4 ±3 1.9 .6

Gender (female/male) 9:7 19:6 28:13 .3

Parent with asthma 37.5% 40% 39% 1.0

Atopic dermatitis 18.8% 8% 12.2% .35

Wheezing in the past 75% 84% 80.5% .7

Multiple-trigger past wheezing 43.8% 48% 46.3% 1.0

Age of first wheeze (mo) 9.4 ± 9.2 13.4 ± 12.3 11.7 ± 11 .482

Number of ED visits past year ± 0.751.1 0.88 ± 1 0.82 ± 1 1.0

Smoking in the family 68.8% 52% 58.5% .34

6 Aside from the experimental intervention, were the groups treated equally?

Yes Can't tell No

B/ What are the results?

7 How large was the treatment effect?

Kaplan-Meier graph for length of stay.

Ater D et al. Pediatrics 2012;129:e1397-e1403

©2012 by American Academy of Pediatrics

8 How precise was the estimate of the treatment effect?

9 Were all clinically important outcomes considered?

Yes No

10 Are the benefits worth the harms and costs?

Yes No

C/ Will the results help locally?

11 Can the results be applied to the local population? Yes Can't tell No