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Clinicians are exhorted to always place their stethoscopes directly on a patient's skin. Yet when patients are examined in hallways and prehospital settings or in locations where cultural norms prevent patients from disrobing, this rule is often violated. That is not a problem: By applying pressure on the stethoscope head, all the sounds normally heard on bare skin can be heard through up to two layers of indoor clothing—including double-layered flannel shirts. Of course, inspection and percussion cannot be done through clothing, and clothing-induced acoustic artifacts may create problems.1

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Aerosols and Spacers

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The use of aerosol spacers more than doubles the amount of medication delivered to the lungs from metered-dose inhalers (MDI); for steroid inhalers, an aerosol spacer diminishes the incidence of oral candidiasis by decreasing deposition in the oropharynx. The tube from a roll of toilet paper works well as an aerosol spacer, as does a piece of ventilator tubing.

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Dr. Lara Zibners-Lohr wrote that in remote areas of the world, she uses large Styrofoam cups. The cup lip (open end) goes over the nose and mouth. The MDI goes through a hole in the bottom end of the cup. She uses just the blue tubing from a nebulizer for older children: they close their mouth around one end and put the MDI in the other. (Personal written communication, received, June 5, 2007.)

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Dr. Karen Schneider uses a dry water bottle with a hole in the bottom for the MDI. The hole is sealed with tape, leaving a small opening to allow air movement from the outside when the child inhales. The inside of the bottle must be dry; otherwise, the aerosolized particles will stick to the water. When the MDI is activated, the child places her mouth over the drinking end and inhales a few times until the mist is cleared (Fig. 9-1). It is important that the child not exhale into the bottle because this will blow the mist out the small hole. (Written communication, received, June 5, 2007.)

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Fig. 9-1.
Graphic Jump Location

Water bottle used as spacer by Dr. Schneider in Peru. (Drawn from a photo contributed by Dr. Karen Schneider.)

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Improvised spacers have been shown to be just as effective as the expensive commercial spacers.2

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Treating Persistent Cough

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An unremitting cough may be due to airway hyperirritability caused by an upper respiratory infection, toxic inhalation, asthma (sometimes unrecognized), allergens, or the use of angiotensin-converting enzyme (ACE) inhibitors. The cough is uncomfortable for the patient and may worsen bronchospasm. For adults and children, add 0.5 mg/kg of lidocaine to 0.3 mL of albuterol solution in 3 mL of normal saline; administer the combination by aerosol nebulization. Lidocaine suppresses the cough reflex while the sympathomimetic agent relieves the bronchospasm.3

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