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1 VOLUME 20 NO 3 ISSN September 2014

2 WITH Gentle-Haler Taking the air out of inflated prices up to 60 % saving with 1 R114,07 2 R153,31 2 R206,23 2 REFERENCE: 1. Versus the Generic and Originator Salmeterol/Fluticasone Combinations (Single Exit Price. DoH Website accessed 17/06/2014.) 2. DoH website - accessed 17/06/2014 Cipla Medpro (Pty) Ltd. Reg. No. 1995/004182/07, Parc du Cap, Building 9, Mispel Street, Bellville, 7530, RSA. Tel (021) , Fax (021) Website:

3 South African RESPIRATORY JOURNAL Editorial Asthma education and management: still a knowledge gap - Prof Refiloe Masekela 82 Original Paper: Use of nebulisers in the management of childhood asthma: Physicians knowledge and practice in a tertiary and secondary health facility - Adeniyi Oluwafunmilayo F, Soremekun Rebecca O and Raheem Afusat A 84 Breath-taking News 89 SATS News President s Report 90 AIRWAVES CONGRESS: Citations: SATS Honorary Fellowships 91 Awards 93 Who s Who in SATS 95 Diary of Congresses and CME events 95 Product News 96 Instructions to Authors 98 Editor-in-Chief: Deputy Editor: Prof K Dheda Prof C Koegelenberg Section editor: Breath-taking news: Prof E Irusen Editorial board: Prof G Ainslie, Prof E Bateman, Prof K Dheda, Prof R Green, Prof E Irusen, Prof M Jeebhay, Prof P Jeena, Dr C Koegelenberg, Prof U Lalloo, Prof A Linegar, Prof R Masekela, Dr K Nyamande, Dr J O Brien, Dr R Raine, Prof G Richards, Dr R van Zyl Smit, Prof M Wong, Prof H Zar International Editorial Board Members: Prof Adithya Cattamanchi - USA Prof Fan Chung - UK Prof GB Migliori - Italy Prof Surendra Sharma - India Prof Wing Wai Yew - China President SA Thoracic Society: Dr Sabs Abdool-Gaffar Address for Correspondence: PO Box Mowbray 7705 Telephone: Fax: The South African Respiratory Journal acknowledges the support of contributors, sponsors and advertisers. Whilst the material is carefully scrutinised, the Journal cannot bear responsibility for inaccuracies or individual authors opinions. Printing: Tandym Print Sponsors: Aspen GSK division Bayer Healthcare Boehringer Ingelheim Novartis 81

4 Editorial Asthma education and management: still a knowledge gap Prof Refiloe Masekela Paediatric Pulmonologist, Department of Paediatrics, University of Pretoria, South Africa Asthma remains a highly prevalent condition in Africa with the highest burden in Sub-Saharan Africa. 1 Although there may be a number of barriers to asthma diagnosis in children in Africa; which includes respiratory infections: tuberculosis, viral infections and worm infestations; lack of access to healthcare facilities and unavailability of specialized diagnostic tools like spirometry to confirm the airflow limitation. It is also not surprising that in this context access to the correct asthma management and access to guideline recommended therapy is limited or not adhered to by healthcare providers. Studies have revealed that the costs of asthma management in developing countries are driven by asthma hospitalisations and indirect costs related to asthma 2,3 and that poor asthma education is also a cost-driver in asthma. It is therefore imperative that the key principles of good asthma treatment should include education to both healthcare professionals and patients on the need for chronic asthma medication use with the lowest possible dose of inhaled corticosteroids and use of the correct device for medication delivery. 4 The barriers to access to treatment as well as lack of knowledge on asthma educational principles is highlighted in the article by Oluwafunmilayo FA et al. In their study of children seen in a secondary and tertiary health facility with asthma, only 1.5% had MDI and spacer for home use for asthma treatment, with the majority (over 30% of children) treated with oral therapy. It is well known that the use of systemic corticosteroid therapy is associated with a higher risk of side effects, with growth stunting being of the most concern in the paediatric setting. Of interest is also the fact that over half the children in the study had access to electricity, a clear barrier to home nebuliser use. This clearly demonstrates that there is a need for cheaper alternatives to expensive nebulisers and spacer devices. Zar et al. clearly showed in their study that even in low socioeconomic settings a cheap homemade spacer device could be fashioned for use in children, with excellent medication delivery in young children. 5 The education on these low cost alternatives therefore needs to be emphasized for use in this setting. In the same study, knowledge of nebuliser use was found to be independent of level of experience with management of asthma in children. This may seem paradoxical, but unfortunately may reflect a lack of focus of non-communicable diseases in the curriculum or as part of continuous medical education educational activities. In South Africa asthma is still one of the top ten causes of mortality and should therefore be a focus in core educational activities and this is still to a large extent a preventable cause of death. It is therefore imperative that we keep asthma on the educational map, and keep it as a core part of education on non-communicable diseases. The use of national formularies, national guidelines and asthma 82 education advocacy groups can aid in local best-practice asthma management in Africa. References 1. Masoli M, Fabian D, Holt S, Beasley R. GINA: Global Burden of Asthma Report. GINABurdenREport.pdf. Accessed 25/09/ Smith DH, Malone DC, Lawson KA, Okamoto LJ, Battista C, Saunders WB. A National estimate of the economic costs of asthma. Am J Respir Crit Care Med 1997;156: Serra-Batlles J, Plaza V, Morejon E, Comella A, Brugues J. Costs of asthma according to the degree of severity. Eur Respir J. 1998;12: A pocked guide for asthma management and prevention in children 5 years and younger. Accessed 28/09/ Zar HJ, Streun S, Levin M, Weinberg EG, Swingler GH. Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction. Arch Dis Child 2007;92: Refiloe Masekela Associate Professor Department of Paediatrics and Child Health Division of Pulmonology University of Pretoria

5 FOXAIR everyone and it s yours to give Air is for Why wait to raise expectations in your patients? S4 FOXAIR 50/100, 50/250 and 50/500 ACCUHALER - 42/21.5.4/0581; 0582; Each blister contains a mixture of salmeterol xinafoate equivalent to 50 µg of salmeterol and microfine fluticasone propionate (100 µg, 250 µg or 500 µg). S4 FOXAIR 25/50, 25/125 and 25/250 INHALER - 42/21.5.4/0244; 0245; Each single actuation provides salmeterol xinafoate equivalent to 25 µg of salmeterol and fluticasone propionate (50, 125 or 250 µg). Applicant: GlaxoSmithKline South Africa (Pty) Ltd. (Co. Reg. No. 1948/030135/07). 39 Hawkins Avenue, Epping Industria 1, Cape Town, For full prescribing information plese refer to the package insert approved by the Medicines Regulatory Authority. All adverse events should be reported by calling the Aspen Medical Hotline number or directly to GlaxoSmithKline on FO/0713/933 A /13

6 Use of nebulisers in the management of childhood asthma: Physicians knowledge and practice in a tertiary and secondary health facility Adeniyi Oluwafunmilayo F 1, Soremekun Rebecca O 2 and Raheem Afusat A 3 1 Lecturer/Consultant, Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital 2 Senior Lecturer, Department of Clinical Pharmacy and Biopharmacy, University of Lagos 3 Pharmacy Department, Lagos State Rehabilitation Centre, Lagos 84 Abstract Background: The use of inhalation delivery systems; nebulisers and metered dose inhalers (MDIs), has been incorporated into the management of asthma as they are believed to enhance patient participation in the treatment of the condition. In developing countries such as Nigeria, especially in the emergency room setting, the nebuliser still plays a major role in medication delivery for the management of acute exacerbations of asthma. Methods This study was a prospective cross-sectional study involving all 72 physicians working at the paediatric departments of two major health facilities (tertiary and secondary) in Lagos state, Nigeria. The survey was conducted with a self administered structured questionnaire. Information obtained included the knowledge of the use of nebulisers, number of nebulisers prescribed in one month, age groups of patients and constraints to the prescription of home nebulisers. Results Fifty one (70.8%) respondents had a good knowledge of nebuliser use. There was a statistically significant relationship between the designation of the respondents and the knowledge of nebuliser use (P=0.0004). 68.2% of the respondents were not prescribing nebulisers and only one prescribed 6-10 within a month period. MDIs and spacers were rarely prescribed. Delay in seeking medical attention was the highest constraint to the prescribing of nebulisers. Conclusion This study revealed that although most of the physicians were aware of the use of nebulisers in administering asthma medications, nebulisers are rarely prescribed for use in children. There is a need to re-orientate and encourage physicians to use MDIs. Introduction The use of inhalation delivery systems; namely nebulisers and metered dose inhalers (MDI), in the management of asthma appears to enhance patient participation in the treatment of the condition. 1 However, many studies have reported that the use of an MDI with a spacer device to deliver the inhalation agents has the same efficacy and is cheaper than the use of nebulisers. Currently, asthma management recommendations and guidelines in developed countries advocate the use of MDIs and spacers for the day to day management of asthma and even in the management of acute exacerbations. 2-5 Nevertheless, there remain indications for nebuliser use in the management of asthma. Such indications include the patient requiring large or high doses of inhaled bronchodilator therapy, or in patients too young or too ill to coordinate handheld devices. 6 Previous guidelines recommended nebuliser use for children younger than 2 years and children who are unable to use an MDI with spacer. Thus the early initiation of home nebuliser use for relief of acute, severe symptoms, especially in young children, was encouraged and believed to decrease emergency department visits and hospitalisation. 7-8 Although the use of MDIs and spacers is advocated in current guidelines, there is still a need for physicians involved in the management of asthma to be familiar with and competent in the use of nebulisers in many settings. This is even more important in developing countries, such as Nigeria, where awareness of their use is still very low, spacers are not readily available and may even be out of reach of many patients from lower socioeconomic groups. Thus, most physicians managing asthma patients with acute exacerbations still have to rely on the use of nebulisers in the emergency room setting. However, even in developed countries, knowledge of the use and prescription of nebulisers by physicians is yet to be extensively evaluated. In a study of 55 physicians, only 40 percent of the participants correctly performed more than four of the seven steps that constitute a correct inhalation manoeuvre for nebuliser use. 9 The need to assess the knowledge of use of this device in physicians and the frequency of prescription is still very relevant in developing countries where MDIs with spacers have not achieved popular use. Nebulisers therefore still play a significant role in the management of acute exacerbations, especially in the emergency room setting and at home for young children. This study aims to determine the knowledge of use of this

7 device and its prescription by physicians attending to children with asthma in two health facilities (secondary and tertiary) in Lagos, Nigeria. Methodology This was a cross sectional study involving doctors attending to children with asthma in two public health facilities: Massey Street Children s Hospital, Lagos Island (a secondary health facility) and the Department of Paediatrics of the Lagos University Teaching Hospital (LUTH), Idi Araba, Lagos (a tertiary health facility). A convenience sample of all doctors who were willing to participate in the study at these two centres was sought. A self administered structured questionnaire was used to obtain adequate information from the study participants and the study was carried out over a period of two months (July-September 2012). The information obtained included demographic data, designation, number of years of qualification, years of experience with asthma in paediatrics and the number of asthmatic children seen in the last month. The methods of diagnosis and methods of assessment of severity of asthma in children by the doctors were also ascertained. The route of drug administration prescribed for the management of children with asthma, the age range of the children for whom nebulisers were prescribed, the number of nebulisers prescribed in the last one month and the type of drugs prescribed for children who cannot use a metered dose inhaler were documented. Knowledge of the use of nebulisers, limitations and constraints to the prescription of portable nebulisers were also recorded. A scoring system was used to analyse the doctor s knowledge of the nebuliser. 10 To have a good knowledge score, doctors needed to know at least three of the following four points: Nebulisers are best used while the child is in an upright position. The dose of a drug is higher when a nebuliser is used as compared to a metered-dose inhaler When a mask is used, the mask should cover both the child s nose and mouth. It is necessary to wash hands with soap and water and dry completely before beginning treatment with a nebuliser. Doctors who knew only two of the above points were scored as having a fair knowledge while those who knew less than two points had a poor knowledge score. The answers given were scored and the percent scores calculated and graded as follows: Good: % Fair: 40-59% Poor: <40% Statistical analysis The data was analysed using Statistical Package for Social Sciences (SPSS) version The mean of continuous variables was determined and the association of the categorical variables with the doctors knowledge of the nebuliser and its frequency of prescription was determined using the Chisquare test analysis. The relationship between the type of drug taken and the study centre and the age of the child was also determined. Significance was set at p <0.05. Ethical consideration Ethical approval for the study was obtained from the Health Research and Ethics Committee, Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos and the Lagos State Health Service Commission, which permitted the research to be carried out in Massey-Street Children s Hospital. Informed consent was obtained from the doctors prior to the commencement of the study. Results Clinical characteristics Seventy two (72) doctors participated in the study. 48 (66.7%) were from LUTH and 24 (33.3%) were from Massey-Street Children s Hospital. 22 (30.5%) of the participants were males. 16 (22.2%) were intern doctors, 16 (22.2%) medical officers, 23 (31.9%) registrars, 13 (18.2%) senior registrars while only 4 (5.5%) were consultants. In terms of year of qualification (See Table 1) 80% of the participants had qualified in the last 10 years and 8.1% had been qualified for more than 20 years. Although the majority of the participants were practicing from the tertiary centre, only 6.4% of the doctors in LUTH were seeing up to cases of asthma in a month. Massey Children s Hospital had more cases of asthma, with 39% of the doctors attending to the same number of cases (p=0.0004) Route of delivery of drugs prescribed for the management of asthma. Out of 65 respondents, 20 (30.8%) prescribed only oral medications for the management of asthma in children who cannot use an MDI. Only 1 (1.5%) doctor would add a spacer device to the MDI and 2 (3.1%) would prescribe a nebuliser Table 1: Clinical characteristics of physician and experience in childhood asthma management Parameters Years of qualification N = (80.2) (14.1) >20 4 (6.7) Clinical experience with asthma (years) < 5 51 (71.8) (15.4) > 10 9 (12.8) Frequency (%) Number of children seen in 1 month LUTH Massey None 3 (6.4) 2 (8.7) (87.2) 10 (43.5) (6.4) 9 (39.1) >20 0 (0) 2 (8.7) All percentages are row percentages. LUTH - Lagos University Teaching Hospital Massey - Massey Children s Hospital c 2 =17.92 P=

8 Table 2: Prescription for home-management of children with asthma or MDI with a spacer device. For those patients unable to use an MDI, 8 (12.3%) of the doctors would prescribe a home/portable nebuliser. Knowledge of the use of nebulisers Table 3 demonstrates nebuliser knowledge grades among the study participants and their designations, years of qualification and clinical experience in the management of asthma. Out of the 72 respondents, 51 (70.8%) had a good score on questions about the use of the nebuliser in asthma management, 20 (27.7%) had a fair score while 1 (1.5%) had a poor score. The study centre was not significantly related to the nebuliser knowledge (p=0.544) but more doctors at LUTH (72.1%) than at Massey (65.1%) had a good knowledge of the device. The designation of the respondents, on the other hand, was significantly related to the knowledge of nebuliser use (p=0.024) and the majority of the senior doctors had good nebuliser knowledge scores. However, there was no statistical significant relationship between the years of qualification and knowledge of the nebuliser. Sixty seven percent (66.7%) of the doctors who had graduated between years ago had a fair knowledge of the device. On the other hand 100% and 91.3% respectively of doctors who graduated between years ago and 6 to 10 years ago had good nebuliser knowledge scores. The respondents years of experience in treating asthma was not significantly related to the nebuliser knowledge scores. However, 72.7% and 75% of the respondents who had 5-10 years of experience and >10 years respectively had good knowledge scores. Nebuliser prescription and constraints 66 of the respondents indicated the number of nebulisers prescribed in one month for home use. 45 (68.2%) of these doctors did not prescribe nebulisers, while only 1 (14.2%) of the respondents prescribed more than 9 nebulisers in a month (Table 4). The age of asthmatic children for which nebulisers were prescribed was also documented by 35 of the respondents. 16 (45.7%) of these doctors were prescribing nebulisers for the age group 3-5 years while only 14.2 % were prescribing 86 No Prescription Frequency Percent 1 Oral medication Injectables Home-nebulisers Advise care-givers to rush them to the hospital Oral medication + nebuliser and 4 above and 4 above , 3 and 4 above Others: MDI + spacer device Nebuliser or MDI + space device MDI- metered dose inhaler Table 3: Respondents characteristics and knowledge of nebuliser use (n=71) Study Centre Good n (%) Grades of knowledge of nebuliser use Fair n (%) Poor n (%) Test LUTH 36 (72.1) 12 (25.6) 1 (2.3) c 2 = 1.217, Massey 15 (65.2) 8 (34.8) 0 (0) P = Designation House officer 5 (33.3) 10 (66.7) 0 (0) c 2 = 17.63, Medical officer 14 (87.5) 2 (12.5) 0 (0) P = Registrar 18 (78.3) 4 (17.3) 1 (4.4) Senior registrar 11 (84.6) 2 (15.4) 0 (0) Consultant 2 (50) 2 (50) 0 (0) Years of qualification (56.2) 13 (40.7) 1 (3.1) c 2 = 14.43, (91.3) 2 (8.7) 0 (0) P = (100) 0 (0) 0 (0) (33.3) 2 (66.7) 0 >20 2 (50) 2 (50) 0 Years of experience with paediatric asthma <5 31 (67.4) 14 (30.4) 1 (2.2) c 2 = 0.58, (72.7) 3 (27.3) 0 (0) P = >10 6 (75) 2 (25) 0 (0) All percentages are line percentages LUTH - Lagos University Teaching Hospital Massey - Massey Children s Hospital Table 4: Nebuliser prescription and constraints Number of home/portable nebulisers prescribed in the last one month (n=66) N (%) 66 (100) None 45 (68.2) (24.2) (6.1) (1.5) Age range (Years) N (%) (100) (22.8) (45.7) 9 and above 6 (17.1) 5 (14.2) Constraints N (%) 67 Care-giver can abuse it (use an overdose) 32 (47.8) Always requires an electric power supply 33 (49.2) It is not cost effective 16 (23.8) It may delay seeking medical attention 35 (52.2) It is not necessary 2 (2.9) It is not readily available 23 (34.3) It is technically different to use 9 (13.4) Age range Age range of children for whom home-nebulisers were prescribed them for children 9 years and above. Delay in seeking medical advice as reported by 52.2% of the respondents was the commonest constraint in prescribing the nebuliser. This

9 was followed by the requirement for electricity to power the device (49.2%) and the possibility of abuse by the caregivers. Unavailability of the equipment was also a constraint observed by 34.3% of the respondents. Lack of necessity to use the equipment was considered to be the least important constraint to the use of the device and was only documented by 2 (2.9%) of the study participants. Discussion MDIs with spacers remain the current recommended delivery method for the administration of aerosol therapy in the management of asthma but in developing countries such as Nigeria, especially in the emergency room setting but even at home, nebulisers still play a major role in medication delivery for the management of acute exacerbations of asthma. This study reveals that a very small proportion of the doctors were prescribing MDIs (1.5%) while 12.3% were prescribing nebulisers. A significant proportion (70.8% [72.8% in the tertiary and 65.2% in the secondary health facilities]) of the doctors studied had good knowledge scores on the basic concepts of the use of nebulisers. Similar findings on knowledge of nebuliser use have been documented by other workers. 11,12 However, in a more detailed study of 45 health professionals on the use of nebulisers, the researchers noted an insufficient knowledge of the procedure amongst the study participants. 11 The knowledge of nebuliser use in this present study appeared to be influenced by the designation of the respondents. It is expected that knowledge of the doctors should increase with degree of specialisation. The doctors involved in specialty training should have a better knowledge of asthma management and the equipment used for the treatment and control of the condition. However, neither the study centre, years of qualification or years of experience with working with asthmatic children was significantly related to nebuliser knowledge scores in this present study. Generally speaking, knowledge is influenced by the effort of the physician to familiarise himself with the current concepts on patient management and unless this is done, the length of qualification or years of experience may not significantly influence the knowledge of patient management. Nevertheless, a good proportion of the respondents (72.7% and 75% with 5-10 years experience and >10 years respectively) had good knowledge scores on the use of the device. This study reveals that the prescription of nebulisers was low, despite the fact that a significant proportion of the physicians had a good knowledge score of its use. 68.2% of the doctors did not prescribe any nebuliser in a month while 24.2 % prescribed only 1 or 2 within a month. Yet 50% of the asthmatic children seen in the clinics during the course of this study were aged 5 years or less and this category of patients would benefit more from the use of nebulisers rather than syrups. This is similar to the findings of Sahid et al 13 in a study of 440 family physicians who also observed that 80.9% of the doctors were aware of the benefits of nebulisation in asthma management but only 40% of the doctors prescribed nebulised medication for acute attacks both at home and in the hospital. The reason for the low prescription rate in our study may be related to the constraints noted by the doctors. However, the prescription for MDIs and spacers was even lower than that for nebulisers. The reason for this is unclear. Plausible explanations may be that most of the doctors were unaware of the current recommendations, or due to the fact that spacers are not readily available, they were not prescribed for the younger children. Delay in seeking medical attention was the highest reported constraint to the prescription of nebulisers while the need for electricity to power them was another important constraint reported by most of the doctors (51.6%). This reveals that the doctors were not aware of the availability of battery-operated portable nebulisers. Cost of the nebulisers, another reported constraint, is an important factor in many developing countries where the purchasing of the device may be out of reach for many low income families. Cost has been one of the major reasons for the use of MDIs and spacers rather than nebulisers in the current guidelines. 2 Nevertheless, in many developed/affluent countries, some physicians still prescribe nebulisers for home use. 6,14 However, other researchers are of the opinion that the decision to prescribe an MDI or nebuliser should be based on the family s needs and finances, in addition to the child s inhalation and coordination skill level. 1 Unavailability of the device in health facilities is another observed constraint to the use of this device in many developing countries. 15 For example in India 13 and Nigeria 16 only 45.5% and 41.2% of the primary care physicians respectively had nebulisers in their clinics. In South East Nigeria, the use of nebulisers was more common in the tertiary facilities than in other facilities. 11 The National Asthma Education and Prevention Program (NAEPP) guidelines recommend the use of nebulisers in children under 2 years or in children who are unable to use MDIs. 17 In this study, however, 14.1% of the doctors prescribed nebulisers for children 9 years and above. Other workers have observed that 3.2% of the doctors reserved nebulisers for adult asthmatics. The reservation of nebulisers for older children and adults reflects a poor knowledge of the benefits of nebulisers and by extension, the management of asthma. For children who cannot use an MDI, 30.8% of the doctors reported that they prescribed oral medications while only 12.8% prescribed nebulisers alone. The others would prescribe a combination of these treatments or ask the caregivers to bring the children to the hospital during an acute exacerbation while an oral medication or nothing is given. This finding is similar to those of Fawibe et al 18 who documented that oral medications were commonly prescribed by doctors for the home management of asthma. Kelloway et al 19 reported that patients were more compliant with oral medications than inhaled therapy. This practice is in sharp contrast to the Global Initiative for Asthma (GINA) guidelines. 20 Although, medical attention should be sought when there is an acute exacerbation, reliever medications such as short acting b 2 agonist should first be given via the inhalation route to quickly reverse broncho-constriction and relieve its symptoms. 21,22 Although a significant proportion of the doctors in this study had good knowledge scores on the use of nebulisers, rates of their prescription, and indeed also that for MDIs with spacers, was quite poor. This may be a result of the combination of constraints outlined earlier and other factors that may not have been explored in this study. Limitations The limitations of the present study may be the number of health facilities used and the relatively small number of study 87

10 participants. However, these were the physicians willing to participate in the study. A first hand assessment of the doctors nebulising their patients would have been interesting to document but this was not evaluated in this study. Conclusion This study revealed that although most of the physicians were aware of the use of nebulisers in administering asthma medications, nebulisers are rarely prescribed for use in children. MDIs with spacers were also rarely prescribed. Delay in seeking medical attention, abuse of nebuliser use, cost and unavailability are the major constraints to the prescription of nebulisers. There is a need for reinforcement of the inhalation route as the ideal route of administration of asthma medications and reorientation of the physicians on the use of nebulisers and MDIs with spacers in the management of the disease in children. Hospital and community pharmacies should make home/portable nebulisers available for sale in situations where it is indicated. References 1. Butz AM, Eggleston P, Huss K, Koldoner K, Rand C. Nebuliser use in the inner city children with asthma. Morbidity, medication use and asthma management practices. Arch Paediatr Adolesc 2000; 154 Suppl 10: Cates CJ,Crilly JA,Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2006; 2: CD Sannier N, Tismit S, Cojocaru B, Leis A, Wille C, Garel D, et al. Metered dose inhaler with spacer vs. nebulization for severe and potentially severe acute asthma treatment in the pediatric emergency department. Arch Pediatr 2006; 13: Castro-Rodriguez JA, Rodrigo GJ. Beta-agonists through metered-dose inhaler with valved holding chamber versus nebuliser for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with metaanalysis. J Pediatr 2004; 145: Doan Q, Shefrin A, Johnson D. Cost-effectiveness of metereddose inhalers for asthma exacerbations in the pediatric emergency department. Pediatrics 2011; 127(5): Boe J, Dennis JH, Driscoll B. European Respiratory Society Guidelines on the use of nebulisers. Eur Respir J 2001; 18: Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, et al. Global strategy for asthma management and prevention: GINA executive Summary. Eur Resp J. 2008; 31 Suppl 1: Warman, KL, Silver, EJ, McCourt, MP, Stein, RE. How does home management of asthma exacerbations by parents of inner-city children differ from National Heart Lung and Blood Institute (NHLBI) guideline recommendations? Paediatrics 1999; 103 Suppl 2: Kelling JS, Strohl KP, Smith RL, et al. Physician knowledge in the use of canister nebulisers. Chest 1983; 83: Lustosa GM, Britto MC, Bezerra PG. Acute asthma management in children: knowledge of the topic among health professionals at teaching hospitals in the city of Recife, Brazil. J Bras Pneumol. 2011; 37(5): Ayuk, A, Ilor, K, Obumneme-Anyim, I, Ilechukwu G, Oguonu T. Practice of asthma management among doctors in south-east Nigeria. AJRM. 2010; 6 Suppl 1: Patel AM. Using the Internet in Asthma Management: Current concepts and challenges. Dis Manage Health Outcome 2005; 13 Suppl 5: Shahid, G. Bhinder, J. Dhanjal: Knowledge, attitudes and practices (KAP) of primary care physicians of central Mumbai suburbs about childhood asthma. Internet J Asthma, Allergy and Immunol. 2007; 6 (1). DOI: /dc Lagerlov P, Veninga CC, Muskova M, Hummers-Pradier E, Stalsby C, Andrew M, Haaijer-Ruskamp FM. Asthma management in five European countries: doctors knowledge, attitudes and prescribing behavior. Drug Education Project (DEP) group. Eur Respir J. 2000; 15: Onyedum CC, Ukwaja KN, Desalu OO, Ezeudo C. Challenges in the management of bronchial asthma among adults in Nigeria: A systematic review. Ann Med Health Sci Res. 2013; 3: Desalu, OO, Onyedum, CC, Iseh, KR, Salawu, FK & Salami, AK. Asthma in Nigeria: Are the facilities and resources available to support internationally endorsed standards of care? Health Policy. 2011; 99: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, NIH Publication No ; National Heart, Lung and Blood Institute, National Institutes of health, Bethseda, MD, 1997; 5: Fawibe AE, Onyedum CC, Sogaolu OM, Ajayi A O, Fasae A J. Drug prescription pattern for asthma among Nigerian doctors in general practice: A cross-sectional survey. Ann Thorac Med 2012; 7: Kelloway D, Richard A, Wyatt MD, Adlis SA. Comparison of patients compliance with prescribed oral and inhaled asthma medications. MS Arch Intern Med. 1994; 154(12): Global strategy for asthma management and prevention. Global initiative for asthma (GINA report 2011) 21. Pollart SM, Compton RM, Elward KS. Management of acute asthma exacerbations. Am Fam Physician 2011; 84 Suppl 1: Zimo DA, Gaspar MA, Makhtar J. The efficacy and safety of home nebuliser therapy for children with asthma. Am J Dis Child 1989; 143:

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