Case study 20: Managing bronchitis April 2002

Transcription

1 Case study 20: Managing bronchitis April 2002 National Prescribing Service Limited Level 1/31 Buckingham Street, Surry Hills NSW 2010 Phone: Fax: Net:

2 Inside Case study 20: Managing bronchitis Scenario and questions page 3 Results Summary page 4 In detail page 5 Commentaries Dr David Looke page 9 Dr Nigel Stocks page 11 References page 13 Brand names page 15 Patient leaflet page 16 I»ve got a troublesome cough: will an antibiotic make me better? The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence. Any treatment decision based on this information should be made in the context of the individual clinical circumstances of each patient. 2

3 Case study 20: Managing bronchitis Mrs HP, a sixty-year-old retired woman, presents with a three-day history of purulent rhinitis, coughing purulent sputum. She has not been short of breath. She tells you she had one episode of asthma as a child, but none since. She has never smoked, is on no regular medications and is not allergic to any medication. On examination she has a respiratory rate of 12, pulse rate of 70 and temperature of 37.5ÏC. On auscultation she has normal breath sounds with occasional wheezy sounds throughout her chest. 1. What investigations (if any) would you order? a. b. c. 2. If you chose to prescribe a medication, please fill in your choice: Drug Strength Frequency Duration 3. If you chose not to prescribe a medication please explain why not: 4. What advice if any would you provide? Based on a case study developed by the National Preferred Medicines Centre, Wellington, New Zealand 3

4 Summary Results At the time of publication, 1375 responses had been received from doctors 200 responses were aggregated for feedback. 70% of respondents (n=141) chose to prescribe at least one medication. Of those who prescribed medications: 51% prescribed bronchodilators and 43% chose a short-acting beta 2 -agonist 48% prescribed antibiotics and 34% chose amoxycillin 26% recommended paracetamol. Reasons given for not prescribing antibiotics: Acute bronchitis is most often a viral infection and does not require antibiotic therapy (68%) An antibiotic is not recommended for acute bronchitis according to Therapeutic Guidelines: Antibiotic Version 11 1 (3%). Advice given: Review or return to the surgery (68%) Bed rest (43.5%) Increased fluid intake (39.5%) Paracetamol or aspirin if fever occurs (32%). Key points Viral infections are presumed to be the predominant causes of acute bronchitis in otherwise healthy adults and 85% of patients spontaneously improve without antibiotics. 2 Antibiotics provide modest benefit for a minority of patients with acute bronchitis and they are, therefore, not necessary for all patients with acute bronchitis. 2 This modest benefit needs to be weighed against the risk of adverse effects with antibiotics. A recent UK study showed that the use of antibiotics was reduced where patients were provided with a patient information leaflet reinforced by verbal advice about the natural course of the illness and uncertainty of benefit from antibiotics. 3 4

5 Results in detail Question 1: What investigations (if any) would you order? Table 1: Investigations % respondents* (n=200) Nil 57.0 Spirometry, peak flow measurement 25.0 Sputum culture 18.5 Chest X-ray 13.5 Other** 7.5 *respondents may have more than one response **nasal swab, sinus X-ray, and erythrocyte sedimentation rate Question 2. If you chose to prescribe a medication, please fill in your choice: 70% of respondents prescribed at least one medication 27% prescribed two or more medications 33% prescribed an antibiotic Of those who prescribed medications (n=141):! 51% prescribed bronchodilators! 48% prescribed antibiotics! 26% recommended paracetamol! 8% recommended an oral cough and cold preparation. Table 2a. Antibiotics prescribed Dose Frequency Duration (days) %respondents* (n=141) Amoxycillin mg every 8 hours Roxithromycin 300 mg daily Amoxycillin+clavulanate 500/125 mg every 8 hours Cefaclor 375 mg twice daily Cephalexin 250 mg every 6 hours Doxycycline 100 mg 2 at once then 1 twice daily Erythromycin 250 mg every 8 hours *respondents may have more than one response 5

6 Table 2b. Symptomatic management recommended Dose Frequency Durations (days) % respondents* (n=141) Analgesics Paracetamol 500 mg 2 tabs every 8 hours when required Bronchodilators Inhaled salbutamol 100 micrograms/dose Inhaled terbutaline 500 micrograms/dose 2 puffs every 6 hours when required 2 puffs every 6 hours when required Terbutaline elixir 0.3 mg/ml ml every 8 hours Choline theophyllinate oral liquid 10 mg/ml 20 ml every 8-12 hours Cough and cold preparations Pseudoephedrine tablet 60 mg 3-4 times daily Pholcodine linctus 1 mg/ml 3-4 times daily Choline theophyllinate with guaiphenesin oral liquid 10 mg/ml 3-4 times daily Bromhexine oral liquid 0.8 mg/ml 3-4 times daily *respondents may have more than one response Practice points Antibiotics provide only a modest benefit for a minority of patients with acute bronchitis and they are, therefore, not necessary for all patients with acute bronchitis. 2 The recent Cochrane review does not support the routine use of short-acting beta 2 -agonists for patients with no underlying pulmonary disease who present with an acute cough or acute bronchitis. 4 6

7 Question 3: If you chose not to prescribe a medication please explain why not: 68% responded that acute bronchitis is most often a viral infection and does not require antibiotic therapy. All these agreed to provide symptomatic and supportive treatment at this consultation. 3% responded that antibiotics are not recommended for acute bronchitis according to Therapeutic Guidelines: Antibiotic Version Table 3: Reasons for not prescribing % respondents* (n=112 ) Viral disease antibiotics are not indicated, symptomatic treatment only required 68.0 Systemically well and no signs of respiratory distress 20.5 Wait and watch for clinical signs and symptoms 9.0 No clinical signs of lower respiratory tract infection 9.0 Therapeutic Guidelines: Antibiotic does not recommend antibiotics for acute bronchitis 3.0 *respondents may have more than one response some respondents who prescribed an antibiotic in question 2 also provided reasons for not prescribing Practice points Viral infections are presumed to be the predominant causes of acute bronchitis in otherwise healthy adults. 5 Antibiotics provide only a modest benefit in the treatment of acute bronchitis a systematic review found that 14 patients need to receive antibiotics for one patient to generally improve. 6 7

8 Question 4: What advice if any would you provide? 68% would advise the patient regarding review or return to surgery. Most would review the patient in 2 5 days or earlier if symptoms such as fever, tightness in the chest, wheezing or increased severity of cough occurred. % respondents* (n=200) Return for review 68.0 Bed rest 43.5 To drink plenty of fluids 39.5 If fever, take paracetamol/aspirin 32.0 Symptomatic treatment 24.5 Steam inhalation 22.0 Reassure/explain the nature of illness 10.5 Deep breathing exercises 7.5 Suggest influenza vaccine 2.0 * respondents may have more than one response Practice points A recent UK study showed that the use of antibiotics was reduced where patients were provided with a patient information leaflet reinforced by verbal advice about the natural course of the illness and uncertainty of benefit from antibiotics. 3 The symptomatic management pad, a tear-off «prescription», is available from the NPS to assist doctors to recommend symptom relief in acute URTIs and acute bronchitis. A patient information sheet on cough that explains the limited role of antibiotics is enclosed for your use (see page 16). Electronic copies can be downloaded from 8

9 Commentary 1 Dr David Looke Deputy Director Infection Management Services Princess Alexandra Hospital, Queensland What would I do if Mrs HP was my patient? The case: This 60-year-old woman has a short 3-day history of rhinorrhoea and productive cough but no severe constitutional symptoms or breathlessness. There are no signs of pneumonia on chest examination. She is a non-smoker and has a distant past history of one episode of asthma as a child. The disease: This is a typical case of acute bronchitis, part of the spectrum of the common cold syndrome. It is common, with weekly attack rates of up to 170 cases per 100,000 in winter. It is most often associated with respiratory viruses such as rhinoviruses, coronaviruses, influenza, parainfluenza, adenovirus and respiratory syncytial virus. A very small proportion may be caused by Bordetella pertussis, Mycoplasma pneumoniae or Chlamydia pneumoniae. The role of Streptococcus pneumoniae and Haemophilus influenzae in causing this syndrome is uncertain, as they are often normal residents of the respiratory flora. Up to 35% of those infected with rhinovirus experience a cough with 70% or more with influenza coughing. A hoarse voice is a common accompaniment. The natural course of the cough is to persist longer than the other symptoms of the cold with 45% of patients still coughing after 2 weeks and 25% after three. Sputum production is common. Purulence is not a reliable indicator of bacterial infection. This is more common in smokers. Management: After a thorough physical examination to rule out signs of parenchymal lung disease, I would reassure this patient that she had acute bronchitis that was caused by a virus and would not require antibiotics. A recent Cochrane review concluded that antibiotics may have a modest beneficial effect in bronchitis, but the effect was equal to or outweighed by the adverse effects of the drugs. Patients who had symptoms of less than one week did not benefit at all. 6 At this early stage I would not perform any investigations. I would suggest a number of symptomatic remedies, such as paracetamol. I would suggest that she rests and also some simple hygienic measures such as hand washing to reduce the chance of spread in the household. Although she has a distant past history of asthma, it is not apparent at this consultation that it has relapsed. Nevertheless, it can occur at any age and if there was any suggestion of breathlessness, then bedside spirometry would be indicated. I would explain that the cough may persist for 2 3 weeks and would ask her to return if she developed dyspnoea or systemic symptoms such as fever and chills for further evaluation. An information sheet outlining simple self-care measures is a useful adjunct to the consultation. Samples of these are available at a number of websites including the National Prescribing Service website at Commentary on responses to the case: In terms of investigations, the majority would not order any. Twenty five percent would order spirometry or peak flow meter, given the past history. This is understandable and really could be considered part of the bedside examination. Chest X-ray will probably not be helpful at this early stage with a low pick-up rate of pneumonia. If the patient had more severe systemic features and/or signs of consolidation, it would then be helpful in confirming the diagnosis of pneumonia. If the cough persisted for 3 weeks or more it would be indicated to rule out other potential pathology. 9

10 Sputum examination is not helpful, as most labs do not isolate common viral pathogens. In the influenza season however, a rapid test for flu antigen would mean that the use of an anti-influenza agent such as zanamivir or oseltamivir could be useful. The treatment with zanamivir or oseltamivir should be commenced as early as possible after symptoms occur, but no more than 48 hours after the onset of initial symptoms of infection. In the case of a prolonged cough a sputum test or serology for pertussis would be indicated. It is beyond the scope of this discussion to outline further the approach to chronic cough. Seventy percent prescribed some medication with an inhaled bronchodilator the most common. I would be guided by history and spirometry before doing so. Thirty three percent prescribed antibiotics, however the evidence now shows that they are not useful. Patient pressure is often cited as a reason, however recent research has shown that most patients are satisfied if they have a good explanation and some advice on symptom management. In general, the other advice given was sensible and demonstrated a caring approach. Patients are often fearful of more serious diagnoses such as pneumonia or lung cancer but will not overtly ask, so it is good practice to broach the subject, put the likelihood of these diagnoses into perspective and offer a lifeline to return if they are concerned. 10

11 Commentary 2 Dr Nigel Stocks Senior Lecturer Department of General Practice Adelaide University, South Australia Key points concerning the management of acute bronchitis Most episodes of acute bronchitis are viral in origin. Symptoms can be distressing and cough lasts for an average of two to three weeks. Investigations have a limited role in determining management. The use of short acting beta 2 agonists 4 and cough suppressants 7 are not supported by research. There may be role for antibiotics in patients who: are systemically unwell (HR >100, temp >38 o C, RR >24), have chest signs (crackles or crepitations), aged >55 years or have significant comorbidity. Definition of acute bronchitis Acute bronchitis, chest infection and acute cough are terms that are used synonymously for a collection of signs and symptoms. Studies from the UK, US and the Netherlands demonstrate that there are variations in diagnostic criteria between general practitioners (GPs) and even randomised trials of antibiotic treatment for acute bronchitis do not have uniform case definitions. 8 In this case study Mrs. HP is an otherwise healthy 60-yearold woman who presents with purulent cough with occasional wheezy sounds on auscultation. This matches the International Classification of Primary Care (ICPC) definition of acute bronchitis. Sinusitis is unlikely with the absence of additional symptoms such as maxillary or tooth pain. 9 Scope of the problem In Australia consultation for acute respiratory infection (ARI) is very common. In the early 1990s approximately 3.9% of all consultations for a new problem was for acute bronchitis, 10 with antibiotics being prescribed in about 80% of cases. 11 Acute bronchitis can have considerable impact on patients» lives with patients coughing for an average of 2 3 weeks and 25% not returning to their usual daily activities for up to 2 weeks. 12 Up to 20% will visit their GP again, 13 often to receive a further prescription for antibiotics. 14 However antibiotics are thought to be over prescribed for this condition and a recent systematic review of treatment concluded that the benefit from antibiotic treatment was modest. 6 What investigations (if any) would you perform? As the diagnosis is acute bronchitis and she is otherwise well investigations have a very limited role in her management. Some doctors may be concerned about the presence of wheezy sounds on examination but acute bronchitis is associated with bronchial obstruction and inflammation, including wheezing, and this is usually transient and resolves after the infection clears. 15 If wheeze had been a recurrent problem and was a troublesome symptom peak expiratory flow measurements and/or spirometry might be helpful in determining management and they are easily performed in the general practice setting. On the other hand sputum culture will be of limited value in community settings because of nasopharyngeal contamination and it is thought that outcomes are unrelated to the identified pathogen. 16 Similarly a chest X-ray has no role in the investigation of acute bronchitis unless there is a suspicion of community acquired pneumonia (CAP). Unfortunately there is no hard or fast rule for determining if a patient has CAP based on the clinical examination, however the absence of 11

12 any combination of heart rate >100, respiratory rate >24, temperature >38 o C, night sweats or focal chest signs indicates that the need for an X-ray is very low. 17 C reactive protein has been used to predict which patients with acute bronchitis have poorer outcomes 18 and may be useful in diagnosing acute maxillary sinusitis 19 but its routine use cannot be recommended at this time. What medication should be prescribed? Current Australian antibiotic guidelines recommend that acute bronchitis should not be treated with antibiotics because it is predominately of viral origin. 1 Recent studies suggest a mixed viral, bacterial and atypical picture; 13 the usual pathogens isolated being M. pneumoniae, C. pneumoniae and B. pertussis 12, 20, 21 although S. pneumoniae, H. influenzae and M. catarrhalis have also been implicated, 12 however it is unclear if antibiotics are beneficial for patients with non-viral causes who are systemically well. In the UK GPs use the presence of purulent sputum, fever and crepitations/crackles on chest examination when deciding whom to treat acute bronchitis with antibiotics. 22 However although an association between the presence of focal chest signs and radiographic pneumonia has been reported, 13 the prognostic significance of sputum and chest signs has been questioned 17 and there is no evidence that the appearance of sputum is related to bacterial colonisation or the efficacy of antibiotics. 23 Fever may be an important sign, but probably only in association with other factors such as age, respiratory rate, pulse and co-morbidity. 24 Patient factors are clearly important in the decision to prescribe antibiotics. The influence of patient expectations has been shown to affect the prescribing behaviour of GPs for both upper 25 and lower ARI. 26 These expectations may be driven by the patient view that they have an «infection» and therefore require antibiotics and many GPs believe prescribing an antibiotic assists maintenance of a good relationship with their patient. However patient satisfaction is not always increased when an antibiotic is prescribed, and depends more on doctorƒ patient communication than on antibiotic treatment. 27 It may be that the GPs opinion about patient expectation is the strongest determinant for prescribing. 28 What are the alternatives to antibiotics and what advice should be given? In the UK 22 most GPs suggest fluids and paracetamol which along with rest and sickness certification may be appropriate. The use of bronchodilators for acute bronchitis although common is not supported by recent research 4 and cough suppressants are of doubtful value. 7 If antibiotics are expected or requested simple strategies such as delayed prescribing 29 and patient information leaflets 30 decrease antibiotic use and reconsultation. An explanation about the natural history of the illness, in particular the duration of symptoms will be very helpful for most patients, sometimes patients may only want their GP to rule out a serious cause for their symptoms. 31 Finally clinical review would be appropriate for individuals who are systemically unwell or get worse. 12

13 References 1. Therapeutic Guidelines: Antibiotic, Version 11, North Melbourne: Therapeutic Guidelines Ltd, Smucny J, Becker L, Glazier R, Mc Issac W. Are antibiotics effective treatment for acute bronchitis? J Fam Pract 1998;47: Macfarlane J, Holmes W, Gard P, Thornhill D, Macfarlane R, Hubbard R. Reducing antibiotic use for acute bronchitis in primary care: Blinded, randomised controlled trial of patient information leaflet. BMJ 2002;324: Smucny J, Flynn C, Becker L, Glazier R. Are beta 2 agonists effective treatment for acute bronchitis or acute cough in patients without underlying pulmonary disease? A systematic review. J Fam Pract 2001; 50: Dere WH. Acute bronchitis: Results of U.S. and European trials of antibiotic therapy. Am J Med 1992; 92:S53-S57 6. Smucny J, Fahey T, Becker L, Glazier R, McIsaac W. Antibiotics for acute bronchitis (Cochrane Review). In: The Cochrane Library. Issue Oxford: Update software. 7. Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings (Cochrane Review). In: The Cochrane Library. Issue Oxford: Update software. 8. Stocks N, Fahey T. Labelling of acute respiratory illness: evidence of between practitioner variation in the UK. Fam Pract. In press van Duijn NP, Brouwer HJ, Lamberts H. Use of symptoms and signs to diagnose maxillary sinusitis in general practice: comparison with ultrasonography. BMJ 1992;305: Bridges-Webb C, Britt H, Miles DA, Neary S, Charles J, Traynor V. Morbidity and treatment in general practice in Australia Med J Aust 1992;157 (Suppl):S1- S Meza R, Bridges-Webb C, Sayer G, Miles D, Traynor V, Neary S. The management of acute bronchitis in general practice: results of the Australian Morbidity and Treatment Survey, Aust Fam Physician 1994;23: Macfarlane J, Colville A, Guion A, Macfarlance R, Rose D. Prospective study of aetiology and outcome of adult lower-respiratory-tract infections in the community. Lancet 1993;341: Macfarlane J, Holmes W, Gard P, et al. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax 2001;56: Macfarlane J, Holmes W, MacFarlane R. Reducing reconsultations for acute lower respiratory tract illness with an information leaflet: a randomised controlled study of patients in primary care. Br J Gen Pract 1997;47: Hueston W, Mainous A. Acute bronchitis. Am Fam Physician 1998;57: Macfarlane J, Holmes W, Macfarlane R. Do hospital physicians have a role in reducing antibiotic prescribing in the community? Thorax 2000;55:

14 17. Metlay J, Kapoor W, Fine M. Does this patient have community-acquired pneumonia? JAMA 1997; 278: Jonsson B, Sigurdsson JA, Kristinsson KG, Guonadottir M, Magnusson S. Acute bronchitis in adults: how close do we come to its aetiology in general practice? Scand J Prim Health Care 1997; 15: Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ 1995;311: King DE, Muncie HL. High prevalence of Mycoplasma Pneumoniae in patients with respiratory tract symptoms: a rapid detection method. J Fam Pract 1991;32: Boldy DA, Skidmore SJ, Ayres JG. Acute bronchitis in the community: clinical features, infective factors, changes in pulmonary function and bronchial reactivity to histamine. Resp Med 1990; 84: Stocks N, Fahey T. The treatment of acute bronchitis by GPs in one UK Health Authority: results of a cross-sectional survey. Aust Fam Physician. In press Todd JK, Todd N, Damato J, Todd W. Bacteriology and treatment of purulent nasopharyngitis: a double blind, placebo-controlled evaluation. Pediatric Infectious Disease Journal. 1984;3: Fine M, Auble T, Yealy D, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Eng J Med 1997;336: Little P, Williamson I, Warner G, Gould G, Gantley M, Kinmonth AL. Open randomised trial of prescribing strategies in managing sore throat. BMJ 1997;314: Macfarlane J, Holmes B, MacFarlane R, Britten N. Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: a questionnaire study. BMJ 1997; 315: Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996;43: Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations-a questionnaire study. BMJ 1997;315: Dowell J, Pitkethly M, Bain J, Martin S. A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care. Br J Gen Pract 2001; 51: Gonzales R, Steiner JF, Lum A, Barrett P. Decreasing antibiotic use in ambulatary practice: impact of uncomplicated acute bronchitis in adults. JAMA 1999;281: Virji A, Britten N. A study of the relationship between patient's attitudes and doctors prescribing. Fam Pract 1991;8:

15 Brand names Bronchodilators Salbutamol metered dose inhaler, 100 micrograms/dose, CFC-free formulation Airomir, Asmol, Epaq, Ventolin Salbutamol syrup 2 mg/5ml Ventolin Terbutaline powder for oral inhalation in breath actuated device 500 micrograms/dose Bricanyl Terbuhaler Terbutaline elixir 0.3 mg/ml, sugar-free Bricanyl Elixir Choline theophyllinate oral liquid 10 mg/ml Choline theophyllinate oral liquid 10 mg/ml (with guaiphenesin) Brondecon-PD Elixir Brondecon Expectorant Antibiotics Amoxycillin 250 mg, 500 mg Alphamox 250,500, Amohexal, Amoxil, Bgramin, Cilamox, Moxacin Amoxycillin+clavulanate 500/125 mg Augmentin Duo, Clamoxyl Duo Amoxycillin+clavulanate 875/125 mg Augmentin Duo Forte, Ausclav Duo Forte, Clamoxyl Duo Forte Cefaclor 375 mg sustained release Ceclor CD, Keflor CD Cephalexin 250 mg, 500 mg Ceflin, Cilex, Ibilex, Keflex Doxycycline 100 mg Doryx, Doxsig, Doxy-100, Doxyhexal, Doxylin 100, Vibramycin Roxithromycin 150 mg, 300 mg Biaxsig, Rulide 15

16 I VE GOT A TROUBLESOME COUGH: WILL AN ANTIBIOTIC MAKE ME BETTER? Some information to help you in the next week or so We don t always know when antibiotics help a chesty cough. For people who are normally fit and well, we do know that: most chesty illnesses get better on their own antibiotics don t help most coughs get better quicker antibiotics can have unpleasant side effects (for example thrush, rashes, tummy upsets and diarrhoea) taking antibiotics when you don t need them isn t sensible overusing antibiotics produces resistant germs, which means the medicines may not work when they are really needed. So deciding when to use antibiotics isn t always easy! Your doctor has examined you during your visit to the surgery and even though you feel unwell, he or she hasn t found any serious illness that definitely needs antibiotics today. What does a chesty cough mean? A cough is not a bad thing: it is there for a reason. It helps defend your lungs by making sure that any secretions your airways produce are coughed UP, rather than settling in the lower lungs where they would cause trouble. Phlegm or sputum is there to act as a barrier to catch the dust and germs that we breathe in. Your cough is part of your body s defence mechanisms, and is likely to be the last symptom of your current illness to go back to normal. The process of recovery, even with any prescribed treatment, is likely to take up to two or three weeks to complete. Assuming you are not getting worse, you need not worry if your cough and phlegm take this time to settle, especially if you are getting gradually better each day. So, your chesty cough will quite likely get better without antibiotics. However, your doctor may have given you a prescription to have available in case you do need antibiotics in the next few days. Use your judgement whether to get them; the prescription should only be used for this episode of illness. When should I return to my doctor? If you feel your illness is getting worse. If you feel your cough is getting worse. If you do use antibiotics, do take the FULL course. Is there anything I should look out for? Should you find that you develop any new or worrying symptoms or if you start to cough up blood, telephone the surgery and make an appointment for a further check-up. Four ways to help your chesty cough 1. Make sure you re drinking plenty of fluids so you don t get dehydrated. 2. Take paracetamol if you have fever or aches and pains. Check the package for dosing instructions. 3. Some people find sucking a lozenge or hard lolly is soothing. 4. Steam inhalations can help clear mucus and ease chest tightness. For adults: breathe in steam during a hot shower or place your head over a sink of hot (not boiling) water, using a towel to trap the steam. Do not use for young children: steam can cause burns. Practice stamp Level 1/31 Buckingham Street, Surry Hills 2010 Phone: This information sheet may be copied for patient use. Adapted from: Macfarlane J, Holmes W, Gard P, et al. BMJ 2002;324:91. April 2002.