Relevant literatures refer to those that are important in providing the in-depth knowledge needed to make changes in practice or to study a selected problem. The related literatures for this study are divided into the following categories.
2.1 Incidence, prevalence, causes and risk factors of respiratory diseases.
2.2 Effectiveness of nebulization in children with respiratory conditions.
2.3 Effectiveness of nebulization with oxygen in children with respiratory diseases.
2.1 Incidence, Prevalence, Causes and Risk factors of Respiratory Diseases in Children:
Every year ARI (including both upper and lower) accounts for an estimated 3.9 million deaths worldwide. It is estimated that India, Indonesia, Bangladesh and Nepal together account for 40% of the global mortality burden. On an average, children below 5 years of age suffer about 5 episodes of ARI per child every year, which accounts about 238 million attacks. ARI is responsible for about 30-50% of outpatient visits to health care facilities and about 20-40% of pediatric admissions to hospital. It is also a leading cause of deafness as a sequele of acute otitis media (Vashishth, 2010).
Acute respiratory infections continue to stay among the main causes of child mortality. Even in the general population, they are the leading cause of acute morbidities globally. Estimates suggest that the incidence density of ARI among under five children in developing and developed countries is 0.29 which accounts for 151 million and 5 million new episodes each year. India with 43 million bear the maximal brunt of respiratory diseases in the developing countries (Sanjay Chaturvedi,2010).
A cross sectional community based study was conducted to determine the prevalence of and the socio demographic factors that contribute bronchial asthma among children aged 6-15 years in Mangalore; India. Using random sampling technique, 559 children were selected as samples. The prevalence of bronchial asthma was found to be 10.3% with a higher prevalence in boys (12.1%).A significant inverse linear trend with increasing age, and a positive association with family history of asthma were also observed in the study (Jain.A, Bhat.V, 2010).
A prospective cohort study was conducted in Cochin, India to determine whether anemia is a risk factor for childhood asthma. Two hundred children between the age group of 2-18 years, with both anemia and upper and lower respiratory tract infections were enrolled in the study as samples. Hundred children with anemia were taken as the study group and another 100 without anemia were taken as control group. All the children were subjected to investigations like CBC estimation, CRP estimation, Mantoux test and chest X-ray. Pulmonary function test was performed on children above six years of age who showed the evidence of asthma. Peripheral smear, serum ferritin and serum iron binding capacity were estimated for all anemic children. The study found anemia is a risk factor for childhood asthma and anemic children were 5.75 times more susceptible to asthmatic attacks when compared to children without anemia (Ramakrishnan.K,2010).
An extensive survey was conducted in India to determine the time trends and overall prevalence of bronchial asthma in children. The study results showed that the variables like differences in samples, primary outcome variables, inconsistency in age category, rural-urban variation, criteria for positive diagnosis, and study instruments confounded the outcome variables. The median prevalence was 4.75%. Overall mean prevalence was found to be 2.74. Childhood asthma among children between the age group of 13 - 14 years was lower than that in the younger children between 6 - 7 years of age. The prevalence was more in urban inhabitants and in male children. A wide inter-regional variation in prevalence was also observed by the researcher. The study findings indicated that the burden of bronchial asthma in Indian children was higher than that was previously understood (Ranabir Pal, 2009).
An extensive survey was conducted in Italy with the aim of investigating the effects of automobiles on asthma symptoms and to examine the validity of self reported traffic exposure.33, 632 children of age 6-7 years and adolescents were enrolled in the study. Data was collected by distributing standardized questionnaire to the parents and also by self reporting of exposure by children. External and internal validation methods were used to evaluate the possible response bias of self reported traffic exposure. The results showed that the children living in intense traffic areas are at increased risk of respiratory diseases. As the characteristics of the population were specific, the results of validation of self reported traffic exposure were not generalized. (Migliore.E,et.al,2009).
A descriptive study was conducted to find the association between cooking fuels and the risk of respiratory disease in preschool children in Lucknow, India. Mothers of 650 children from 28 urban poor neighborhoods were selected by using random sampling technique. Respiratory disease was assessed by observing the signs and symptoms. Exposures included the types of cooking fuels and duration of their use in the previous week and other potential predictors of respiratory disease. The point prevalence of respiratory disease was 14.5%. Majority (56.0%), of the families used wood as the cooking fuel. Other fuels used included kerosene (24.2%), coal (19.2%), LPG (15.4%), and dung cakes (8.6%). Use of dung cakes, as a cooking fuel was associated with respiratory diseases in the community. Other variables like age, weight, sex, family income, and household structure were not associated with disease. Use of dung cakes as cooking fuel and overcrowding increased the risk of respiratory diseases (Shally Aswathi, et.al, 2007).
A descriptive study was conducted in Tanzania to determine the effects of biomass fuels, charcoal and kerosene on ARI in children under five years of age. Approximately 85% and 15% of children were from biomass fuels and charcoal or kerosene using homes respectively. Average ARI prevalence was 11%. The prevalence of ARI across various fuel types used in cooking did not vary much from the national prevalence. The findings suggested that to achieve meaningful reduction of ARI prevalence, it is necessary to have a shift from the use of biomass fuel, charcoal/kerosene for cooking to clean fuels such as gas and electricity (Kilabuko, 2007).
A descriptive study was conducted to assess the burden of respiratory disorders in rural India. The study showed that poverty and unhealthy environment were strongly related to respiratory disorders. Bronchitis and asthma were the leading cause of respiratory diseases; pneumonia and pulmonary tuberculosis ranked one of the five causes of deaths in rural India. Asthma and bronchitis prevalence rates in Karnataka, Gujarat, Haryana, Uttar Pradesh, Kerala and Madhya Pradesh were above national average. Prevalence of pulmonary tuberculosis was high in Madhya Pradesh, Uttar Pradesh, and Gujarat whereas Tamilnadu and Maharashtra recorded lowest prevalence. Though national wide health plans have succeeded in reducing fatality of respiratory diseases to a certain extent; there is a great need for improved and effective area-specific health programs and social and economic development in rural areas to achieve the desired health goals (Ramanakumar.V, et.al, 2005).
A prospective community based study was conducted in Greenland to identify the risk factors of acute respiratory infections in children. Open cohorts of 288 children between the age group of 0-2 years were included in the study. All the children were monitored weekly for episodes of upper and lower respiratory tract infections. Analysis of risk factors was carried out using a multivariate Poisson regression model which was adjusted for age. Attending a child-care center and sharing bedroom with adults were identified as the risk factors for upper respiratory tract infection in children. Risk factors for lower respiratory tract infections included male gender, attending a child-care center, exposure to passive smoking, and sharing a bedroom with children aged 0â€"5 years. Breastfeeding was identified to be a protective factor for lower respiratory tract infections. The population attributable risk of lower respiratory tract infections associated with passive smoking and child-care centers was 47% and 48%, respectively (Koch.A, 2003).
A hospital based case control study was undertaken in Delhi, India to determine risk factors associated with severe lower respiratory tract infection in under-five children. 512 children including 201 cases and 311 controls were enrolled in the study. Healthy children attending Pediatrics outpatient department for immunization during study period were enrolled as controls. On stepwise logistic regression analysis it was found that lack of breastfeeding, upper respiratory infection in mother and siblings, severe malnutrition, cooking fuel other than liquid petroleum gas, inappropriate immunization for age and history of lower respiratory tract infection in the family were the significant contributors of acute lower respiratory tract infection in children under five years of age. Sex of the child, age of the parents, education of the parents, number of children at home, anemia, inadequate caloric intake, type of housing were not identified to be significant risk factors of acute lower respiratory tract infection. (Broor.S, 2001).
A descriptive study conducted in United States of America found that respiratory diseases contribute seven of the top 15 reasons for visiting a physician among children under 15 years of age. The study also found environmental tobacco smoke as a wide spread environmental pollutant that has been linked with respiratory problems (Gergen.P, 2001).
2.2 Effectiveness of Nebulization in Children with Respiratory Diseases:
A descriptive study conducted to determine the issues in the management of wheezing in under 5 children at community level in India showed that wheeze are likely to disappear after 2-3 cycles of inhaled bronchodilator therapy in one third to half of the children. Nebulized beta-2 adrenergic drugs (salbutamol) were found to be the mainstay of bronchodilator therapy for the treatment of wheezing in children. These drugs can be given to young children by nebulizers with an attached mask. Delivery of bronchodilators through a nebulizer driven by an electric compressor or oxygen is an effective and well established technique. However, the need for electricity to run the compressor, lack of availability of high flow O2 cylinders and high cost of equipment limit the routine use of nebulization technique in most primary health care settings in developing countries like India. (Gupta.P, Shah.D, 2010).
A randomized clinical trial was conducted in Bangladesh to determine the effectiveness of nebulization with a combination of salbutamol and ipratropium bromide over adrenaline nebulization in children with acute bronchiolitis. A sample of 60 children with age less than 2 years was divided into two equal groups. Group I received salbutamol and ipratropium bromide nebulization and group II received adrenaline nebulization. The interventions were provided twice at 6 hours interval and post assessments were done after 30 minutes of each nebulization. The results showed a significant improvement in respiratory parameters in both groups. However, L-adrenaline was found to be more effective than a combination of salbutamol and ipratropium bromide nebulization. (Kadir. M.A, 2009).
A descriptive study was conducted in Hyderabad, South India to ascertain the pattern of nebulization among the medical practitioners in private setting in the community. A detailed questionnaire was sent to 1,000 practicing physicians comprising of 600 general practitioners, 200 pediatric specialists, 150 medical consultants and 50 chest physicians. The analysis revealed that the common drugs used for nebulization were: Salbutamol (80%); Budesonide (65%); and a combination of Salbutamol & Ipratropium (60%). Common indications for nebulization in the community were: Acute Severe Asthma, Acute Exacerbation of COPD, Acute Broncholitis, Acute Exacerbation of interstitial lung disease and unexplained acute respiratory distress. Nebulization in the home settings were mostly prescribed by chest physicians; majority (95%) of them prefer direct nebulization without oxygen and only 5% used oxygen to drive the nebulized drug . Pediatricians and chest physicians preferred to use a face mask whereas general practitioners and internists used the mouth piece directly, without using a face mask. Trained nurses or respiratory therapists were available to supervise or teach nebulization technique in less than 5% of settings. Regarding the practice of nebulization, majority (> 85%) used nebulizers for short periods and did not wait till the chamber was fully emptied of the solution. Only 10% of practitioners believed in continuous nebulization (Viggs.A, 2007).
A randomized double blind study was conducted in Thailand to assess the effectiveness of salbutamol- ipratropium bromide nebulization over salbutamol nebulization.74 children aged 3 â€"15 years were included in the study. Children in the control group were administered with 3 doses of nebulized salbutamol -ipratropium bromide mixed with normal saline and the treatment group received 3 doses of ipratropium bromide .at an interval of 20 minutes. Respiratory parameters were assessed at 40, 70,100 and 120 minutes after the treatment. The results showed that the percent change in peak expiratory flow rate was high in treatment group without statistically significant difference. The study concluded that both salbutamol -ipratropium bromide nebulization andsalbutamol nebulization has similar effect in improving peak expiratory flow rate. (Watanasomsiri.A, 2006).
A case study was done in Coimbatore regarding the nursing care of children with lower respiratory tract infections. The findings revealed that repeated respiratory infections are common in children and are likely to be among the most common ailments. Hyper reactive airway disease is one of the major causative factors for lower respiratory tract infections in children and a comprehensive nursing care is essential to prevent the complications of lower respiratory tract infections in children. (Suganthi .S, 2005).
A quasi experimental study was conducted in Haryana, India to assess the additional benefit of combined salbutamol and ipratropium bromide nebulization in acute asthma with moderate severity. Fifty asthmatic children between the age group of 6â€"14 years were taken and divided into two equal groups. Group I children were nebulized with three doses of Salbutamol alone and Group II children were given combined nebulization of Salbutamol and Ipratropium bromide nebulization at 20 minutes interval. Children were observed at 15, 30, 60,120,180 and 240 minutes interval. The study showed a significant improvement in PEFR starting from 30 minutes and lasting for the entire study period of 240 minutes in both the groups. ANOVA analysis showed a better result with second group. The study concluded that combined nebulization with Salbutamol and Ipratropium bromide was more beneficial than Salbutamol nebulization in acute asthma of moderate severity (Sharma. A, 2004).
A double blind, randomized, placebo controlled clinical trial was conducted in New York to assess the effectiveness of nebulization over metered dose inhaler therapy. Convenient sampling method was used to select 168 children aged 2 -24 months as samples. The nebulizer group received a placebo metered dose inhaler with a spacer followed by albuterol nebulization and the spacer group received albuterol by metered dose inhaler with a spacer followed by nebulization with isotonic saline solution. Pulmonary Index Score and oxygen saturation were measured initially and 10 minutes after each treatment. The result showed that the nebulizer group had a significantly high mean in initial Pulmonary Index Score compared with the spacer group and the study concluded that nebulizer therapy is as effective as metered dose inhalers with spacer for the treatment of wheezing in children aged 2 years or younger (Delgado.A,et.al,2003).
2.3 Effectiveness of Nebulization with Oxygen in Children with Respiratory Diseases:
An experimental study was conducted with the objective of measuring the FiO2 during oxygen nebulization and jet driven nebulization and to compare those values observed with those measures during standards oxygen therapy. The study was conducted in cadaver. An ET tube was inserted into the distal tracheal extremity of a cadaveric head and neck specimen and was connected to a pump which simulates different respiratory patterns. An electro chemical oxygen analyzer was used to measure FiO2 under different nebulization and oxygen delivery conditions. The study concluded that oxygen delivery through nasal device during air driven nebulization significantly increases FiO2 compared with standard oxygen therapy (Vincent Caille, Stephen Erbman, 2009).
An experimental study was conducted in Mexico to compare the effectiveness of salbutamol -ipratropium bromide nebulization with supplemental oxygen and salbutamol- ipratropium bromide administered in device of measured doses with spacer chamber in treating asthmatic crisis in children.45 asthmatic children between the age group of 1 to 12 years were included in the study. Both groups received the proposed treatment 3 times at 20 minutes interval. The study showed a significant improvement in respiratory parameters with salbutamol ipratropium bromide administered by devices of measured doses with spacer chamber. The study concluded that the administration of salbutamol ipratropium bromide with devices of measured doses was more effective than its administration via a nebulizer with supplemental oxygen for treating children with asthmatic crisis. (Castro.P, 2009)
A randomized double blind placebo controlled trial was conducted in Turkey to assess the effectiveness of salbutamol nebulization and ipratropium bromide nebulization in treating children with moderate to severe bronchiolitis.70 infants admitted in the hospital for the first time with wheezing were included in the study. The children were divided into three groups receiving salbutamol alone, ipratropium bromide alone and placebo saline solution alone via a nebulizer supplemented with oxygen at a flow rate of 6-7 liters per minute. Post assessments were done at 30 minutes, 8 hours and 24 hours. The results showed a rapid improvement in respiratory parameters in both bronchodilator groups than in the placebo group. But these drugs did not change the natural course of the disease. (Karaday.B, 2007).
A comparative prospective-retrospective cohort study was conducted in Spain to determine the effectiveness of salbutamol delivered via a metered dose inhaler with spacer and nebulization with oxygen for treating acute asthma in children.580 children below the age of 14 years were included in the study.Out of that 321 prospective cohorts were administered with salbutamol via MDI with spacer and 259 retrospective cohorts received salbutamol via an oxygen driven nebulizer at a flow rate of 7 liters per minute. The study showed that the number of doses of inhaled bronchodilator needed, the admission to the hospital and the numbers of children requiring a stay in observation unit were similar in both groups. The mean length of stay in the emergency department was slightly shorter in metered dose inhaler group. The study concluded that the administration of bronchodilators using metered dose inhaler and nebulization have similar effect in treating children with acute asthma exacerbation. (Fernandez, 2004).
A quasi experimental study was conducted to assess the effectiveness of nebulization with oxygen in 21 severe asthmatic pediatric admissions over a year period. All children received three doses of nebulized salbutamol once in every 20 minutes. Eleven of them received nebulization with oxygen and the rest received nebulization without oxygen. Oxygen saturation was measured along with clinical severity scales during treatment. 3-5% fall in oxygen saturation was observed during treatment in the control group. At the end of treatment, the respiratory rate was slightly higher in this group. No significant fall [0-1%] was observed in nebulization with oxygen group. The study concluded that hypoxemia during nebulization with air driven nebulizers can easily be prevented by simple addition of oxygen source to the air inlet of available nebulizers (Major. P. Singh Tomar, Lef Col A.R.Shurpali, Col.B.N.Biswal, 2004).
A quasi experimental study was conducted in Thailand regarding the flow rate of oxygen for nebulizer therapy. The study subjects were stable COPD patients, in whom the risk of hyperoxic induced hypercarbia is less than in the acute exacerbation stage. The study recommended that the COPD patients should receive bronchodilator drug via the nebulizer, especially in acute exacerbation stage, with oxygen flow rate of 6 liter per minute and the medical personnel must closely observe the patients for clinical signs of hypercarbia to prevent the hazard of carbon di oxide retention (Charoenratenakul.S. 1995).
In an experimental study conducted in England, ten patients with stable asthma were studied to see whether the flow rate used to drive a nebulizer was clinically important. Each patient received 1 mg of salbutamol in 2 ml of isotonic saline solution via a nebulizer driven by piped oxygen at 8, 6 and 4 liters per minute on separate randomly allocated occasions. The result showed that the time for nebulization was significantly longer as flow rate was reduced and there was no significant difference in the response with bronchodilator treatment (Hadfield .J.W, 1986).
