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Case write-up

A 7 year old boy with cough and shortness of breath

 Case: 7 year old boy with cough and shortness of breath for 7 days

 Article: Metered dose inhaler-spacer use education effects on achieve asthma

control in children

 Date: 5/8/19
 Name: Ali Hassan
 Age: 7 years
 Date of Birth: 21st January 2012
 Sex: Male
 Source of History: Mother
Presenting Complaint: Cough and Shortness of breath for 1 week

 Patient was in usual state of health when he presented to the OPD with a 7
day history of cough.
 It was non productive and paroxysmal.
 It was relieved by nebulization at a local hospital. It was exacerbated at
 There is associated wheeze and watery nasal discharge.
 No associated fever, weight loss or vomiting. There was associated shortness
of breath with noisy breathing (wheeze). No associated cyanosis, fit,
orthopnea or edema. Patient also complains of mild redness and irritation of
the eyes
 Review of Systems:
 General: Child has decreased activity. Normal appetite. No fever or weight loss
 RES: cough, shortness of breath, wheeze
 ENT: rhinorrhea
 CVS: unremarkable
 GIT: unremarkable
 GU: unremarkable
 MS: unremarkable
 CNS: unremarkable
 Past Surgical History: not significant
 Past Medical History: patient has had a previous episode of cough last year around same
time but of less intensity. It was managed by repeated nebulization.
 Drug History: Nebulization. No known allergy.
 Family History: Grandmother has eczema. No Diabetes, Hypertension or TB
Birth History:
 Mother took all supplements and tetanus prophylaxis. No significant illness during
pregnancy. Baby delivered via c section.
 Up to date
 Child is social and active. Studies in class 3 and performs adequately. Is friendly with
siblings and class fellows
 Father is 35 years old a laborer. Mother is 27 years old, housewife. Has a younger brother, 2
years of age. No one has similar symptoms. No smoke exposure. No pets. Drink “chashmay
ka pani”.
 Vitals: pulse: 90 bpm, RR: 20/min BP: 100/65, Temperature: Afebrile
 GPE:
 Hands: No clubbing, palmar erythema, visible deformities, koilonychia,
 Eyes: No pallor and jaundice. Mild hyperemia bilaterally.
 Face: no central cyanosis, normal oral hygiene.
 Neck: no lymphadenopathy, no visible mass
 Axilla: no palpable lymph nodes
 Feet: no pedal edema
 Respiratory Exam:
 Equal chest expansion bilaterally. No obvious deformity. No use of accessory muscles when
breathing. Patient is breathing from mouth as well. No bony tenderness. Inspiratory wheeze
heard in whole chest bilaterally upon auscultation.

Provisional diagnosis: Asthma

 Management/Plan:
 Nebulization
Problem formulation with plan (SOAP)

Problem list Subjective Objective Analysis Plan Question

Biological, Cough 1 week Inspiratory Hyper CBC Number of

social SOB 1 week wheeze reactive Chest X ray undocumented
airways Nebulization cases of
Rhinorrhea Familial asthma due to
and mild history of Resolved viral stigma
conjunctivitis atopy infection
Repeated Asthma inhaler
incidence technique
leading to

 Type of question:
 Patients: Children with Asthma
 Intervention: providing standardized education of using a metered dose
inhaler with spacer and its effects on asthma symptoms
 Comparison: no prior education
 Outcome: Providing standardized education about MDI-Spacer device use to
children and parents leads to correct MDI-Spacer device use and is associated
with improvement in asthma symptom score and asthma control
Search strategy and conclusion from
 MeSH terms used: asthma; metered dose inhalers

 Source of evidence: PubMed

 Applicability issues: Study was performed in a hospital where patients had

access to subspecialized doctors and can afford a metered dose inhaler with
Article critique
 Title:
 no mention of study population or location
 No abbreviations

 Number of authors: 3
 Author details have been mentioned

 Journal: Tuberculosis and Thorax ISSN 0494-1373

 Place of study: Department of Pediatric Allergy and Pulmonology, Faculty of
Medicine, Celal Bayar University, Manisa, Turkey
 Introduction: Improper Metered Dose Inhaler (MDI)-spacer use technique can result in less than optimal
delivery of medicine to the lungs and poor asthma outcomes. The aim of this study was to evaluate the
influence of standardized education on proper MDIspacer use and asthma control in children with asthma
and to identify the factors associated with these results.
 Materials and Methods: This is a cohort study that evaluated the influence of standardized education
about MDI-Spacer device use on asthma control in children. Asthmatic children using MDI-Spacer device
and their parents were enrolled in this study. Children were followed up for two months after standardized
education and the change in asthma control was recorded.
 Results: Thirty-eight children (14 females and 24 males) aged between 2.5 and 13 years were enrolled in
the study. Mean age of the children was 7.5 ± 2.8 years. Six patients were lost to follow up and thirty two
patients completed the study. Mean inhalation technique score was 4.9 ± 1.3 before education and
increased significantly to 7.8 ± 0.4 after education (p< 0.001). Mean Asthma Control Questionnaire (ACQ)
score decreased significantly with education (0.77 ± 0.9 vs 0.1 ± 0.1 respectively, p< 0.001). Similarly,
mean asthma symptom score (ASS) decreased significantly from 4.3 ± 3.6 to 0.2 ± 0.7 with education (p<
0.001). Most common mistake in use of MDI-Spacer device use was detected to be lack of mouth rinsing
after use before education in 78.9% of the patients.
 Conclusion: Providing standardized education about MDI-Spacer device use to children and parents leads
to correct MDI-Spacer device use and is associated with improvement in asthma symptom score and
asthma control.
 Key words: Asthma control, children, inhalation technique, metered dose inhaler, spacer, education

 Type of abstract: structured

 Components: 5 sections (Introduction, Methods, Results, Conclusion, Key
 Abstract manages to present all the relevant information in a concise and
clear manner

 Some background information GINA (Global Initiative for Asthma)

 Inhaled corticosteroids are mainstay treatment. Effective asthma management is
via self management and optimal use of inhaler device
 Improper techniques lead to inefficacious treatment
 Study rationale is that while MDI-spacers are an effective method to
administer therapy in children, improper technique may eliminate this
advantage. The proper technique should be demonstrated by parents/health
care providers.
 Aim of the study is to evaluate the change in asthma control and after
standardized education on proper MDI-spacer use.
 Time period: 2 months (exact calendar time was not mentioned)
 Study design: Cohort study
 Inclusion criteria: Being diagnosed as having uncontrolled asthma despite treatment,
using inhaled treatment MDI-Spacer
 Exclusion criteria: Having a chronic lung disease other than asthma that may influence
Asthma control questionnaire (ACQ) results. Having received a standardized education
MDI-Spacer use from a physician previously
 Study tools: Mean MDI Spacer use scores, Asthma symptom score and Asthma Control
Questionnaire (ACQ)
 Mode of administration of study tools: Mean MDI Spacer scores were given by an 8 point
Inhalation technique evaluation form. Asthma Symptom Score consisted of four item
questionnaire scored 0 to 3 evaluated for all subjects. Asthma Control Questionnaire was
filled by the parents at the start and end of the study

 Sample size was initially 38 children (14 females and 24 males) aged between
2.5 and 13 years. Mean age of the children was 7.5 ± 2.8 years.
 Sample size calculation was not mentioned neither was software.
 The study was approved by the ethical committee of the University and
informed consent was taken from the parents of children.
 Data was entered in SPSS 15.0
 38 patients were recruited, 6 dropped out due to unable to follow up
 Sociodemographic and clinical findings, Frequency of correct MDI-spacer use step
before and after education and Comparison of ACQ, MDI-spacer use and asthma
symptom scores before and after education were all presented in a tabulated
form, with the latter also present as a bar graph
 Bar graph represented the Frequency of correct MDI-spacer use step before and
after education
 Percentages, Standard deviations and Pearson correlation coefficient were
 Overall presentation of data was clear and presented in a way where an easy
comparison could be made between before and after standardized MDI-spacer
use education.
 Most common mistakes were mentioned

Noted that the results of the study were significant and there was an improvement in asthma
control and symptom control post standardized education about MDI-spacer use, which was in
concordance with international guidelines
Previous, related studies were referenced, comparing them with this study
 Identified that not only children but adults had improper MDI technique
 Noticed that lack of repeated education of asthma patients resulted in improper techniques.
 Health care providers at times did not inform patients over guidelines or even if they did,
were not entirely correct to begin with

Limitations of the study were mentioned

 Lack of a large sample size, but the results were significant
 Noted that in previous researches there was an improvement of asthma
symptoms with proper education. However also identified others in which
results were not significant, reasoning that there might not have been a
standardized guideline or the asthma symptoms were not significant enough
to see a change/improvement in them to begin with
Other information

 Acknowledgements provided, however author contributions were not

 Conflict of interest was not mentioned

 Style of referencing: Vancouver style

 Number of references: 36
 Complete references were listed, in the correct pattern
 Referenced studies were from 2014 (most recent) to 1999 (oldest)
Thank you.