JOURNAL CLUB M M Khan ST6

4 year 2 nd wheezy episode O/E mild distress. Sats borderline Management : Salbutamol Ipratropium bromide Steroid

Hypertonic Saline and Acute Wheezing in Preschool Children Pediatrics Vol 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 PopulationPreschool children Intervention5% Hypertonic saline ComparisonPlacebo OutcomeReduce hospitalisation and duration of stay DesignRandomised 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 Score Modified from Qureshi et al. 1 Point2 Point3 Point Respiratory rate (breath/min) 2–3 yr≤ ≤40 4–5 y≤ ≤36 Oxygen saturation (%), room air > <90 AuscultationNormal or end-expiratory wheezing Expiratory wheezing Intercostals, substernal and supraclavicular RetractionsNon or intercostals Intercostals and substernal Intercostals, substernal and supraclavicular DyspneaSpeaks 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 4Were 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 Characteristics HS n = 16NS n = 25All N = 41 P Age (mo)30 ± ± ± Gender (female/male)9:719:628:13.3 Parent with asthma37.5%40%39%1.0 Atopic dermatitis18.8%8%12.2%.35 Wheezing in the past75%84%80.5%.7 Multiple-trigger past wheezing43.8%48%46.3%1.0 Age of first wheeze (mo)9.4 ± ± ± Number of ED visits past year± ± ± 11.0 Smoking in the family68.8%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