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This CE undertaking is accredited by course of EMS World journal, a solid accepted by using the continuing education Coordinating Board for Emergency clinical services (CECBEMS) for 1 CEU. To capture the CE verify that accompanies this article, travel to www.rapidce.com to capture the examine and immediately acquire your CE credit. Questions? electronic mail editor@EMSWorld.com.?
A wheeze is a high-pitched, musical, perennial sound that originates from oscillations in narrowed airways. Wheezing is most frequently the outcome of bronchiolitis in toddlers and bronchial asthma in older babies. this text will contend the similarities and transformations between these two childhood ailments, together with administration of the infant or baby with wheezing.
In exiguous ones beneath 1 year of age, the respiratory syncytial virus (RSV) is estimated to subsist chargeable for up to 70% of circumstances in prior to now in shape babies.1 RSV is an epidemic of the family unit Paramyxoviridae, which contains many accustomed respiratory viruses, akin to folks that trigger measles and mumps. The cognomen RSV derives from the indisputable fact that it A) is a virus that causes respiratory tract infections, and B) combines with regional viruses to figure a syncytia, or virus mass. The virus is so ubiquitous that well-nigh every bit of toddlers will absorb had an RSV infection with the aid of their 2nd birthday. After first-time publicity to RSV, 25%-40% of exiguous ones and youngsters will demonstrate signs or indicators of bronchiolitis, and 0.5%-2% would require hospitalization. Most children hospitalized for RSV an infection are beneath 6 months of age.2 Bronchiolitis brought on by RSV turned into the main judgement for hospitalization among the widely wide-spread inhabitants of infants in the united states between 1997-2000, accounting for an estimated ninety six,000 hospitalizations every bit of the course through that point.three
Mortality associated with bronchiolitis has decreased in previous decades, although younger babies can nevertheless die from bronchiolitis. these are usually the ailing ones who then enhance bronchiolitis.3,four The mortality cost is below 1%, with fewer than 500 deaths a year attributed to RSV within the united states. increased morbidity and mortality happens in high-risk sufferers,3,5,6 together with those younger than 6 weeks historic, and those with a historical past of premature delivery, hypoxia, congenital coronary heart sickness, perennial lung sickness or immune deficiency.7,eight,9 Bronchiolitis is greater regular in men, exiguous ones vital in crowded situations, and toddlers who absorb not been breast-fed.10,11,12
Bronchiolitis is predominantly a viral disease, with out a proof supporting bacterial etiologies. apart from RSV, different infectious brokers consist of parainfluenza, adenovirus, rhinovirus, mycoplasma and metapneumovirus. Viruses are spread from adult to grownup by direct contact with nasal and oral secretions, airborne droplets produced with sneezing and coughing, and fomites. A fomite is any inanimate object, comparable to a bedsheet or apparel, in a position to carrying and transferring an infectious agent.
After inoculation, viral replication starts within the epithelial cells of the upper airway, then spreads to the mucosal surfaces of the lower respiratory tract, together with the bronchioles. infection of the epithelial cells outcomes in their destruction by the exhaust of regular mobilephone lysis, courtesy of the immune equipment, or via apoptosis, genetically preprogrammed phone demise. Necrotic cells slough off and free up inflammatory mediators, leading to airway inflammation and edema. additionally, mucus production is extended. This admixture of mobile debris, edema and increased mucus construction outcomes in narrowing and obstruction of the bronchioles, multiplied resistance to air movement, lowered air flood and air trapping.
moreover exiguous ones, there's too a desultory of transmission to adults, particularly the immunocompromised or elderly. As such, every bit of medical practitioners should employ adequate personal protective device to supply protection to themselves and others.
customarily, the patient with bronchiolitis is more youthful than one year and presents every bit of over the wintry weather months. The folks of a toddler with bronchiolitis will relate a 1-5-day background of malaise, fever, irritability or negative feeding. A cough is usual, and clangorous respiration, grunting, dyspnea and improved travail of respiration may subsist obvious; fogeys may too even relate an audible wheeze. A dad or mum or caregiver could subsist capable of retain in intelligence exposure to a person with a respiratory infection inside the previous week. or not it's vital to investigate if the affected person has a historical past of untimely delivery, hypoxia, congenital coronary heart sickness, perennial lung disorder or immune deficiency, every bit of of that may complicate the course of sickness. A caregiver may additionally additionally relate periods of apnea, specially in infants younger than 6 weeks. it is essential to acquire tips in regards to the patient's hydration reputation, together with the presence of vomiting and/or diarrhea, urine output as determined via the number of diapers in a 24-hour length, and the volume and frequency of fluid intake and feedings. infants with tachypnea can too absorb issue breast-feeding or taking a bottle.
physical examination findings associated with bronchiolitis encompass fever, wheezing, tachycardia and tachypnea. signs of improved respiratory misery, including accessory muscle use, nasal flaring, retractions, cyanosis and establishing hypoxia, imply extreme ailment and airflow obstruction and require aggressive management. Pulse oximetry should subsist carried out on every bit of sufferers with suspected bronchiolitis. it's least expensive and provides short and purpose records concerning the diploma of hypoxia latest in a affected person.
The admixture of negative feeding and improved insensible fluid loss secondary to tachypnea can lead to dehydration and hypovolemic shock, additional complicating the respiratory compromise. As such, a heedful evaluation of the fontanel, dermis turgor and mucous membranes can subsist applicable.
asthma is one of the few perennial childhood ailments for which there had been raises in incidence, morbidity and mortality in recent a long time. A CDC dissect showed 34 million individuals (11.5%), or one in 9 americans, absorb been clinically determined with asthma every bit of through their lifetime. present bronchial asthma prevalence is better amongst females (eight.9%) than males (6.5%), and is larger among babies ages 17 years and more youthful (9.1%) than adults (7.three%).13 during the past 25 years, childhood asthma costs absorb more than doubled.
a regular annual 1.eight million emergency arm visits for asthma absorb been calculated for the three-12 months duration from 2001 except 2003; 1.1 million visits absorb been for adults and 696,900 visits had been for babies. greater visits had been made by manful infants (423,800) than womanish toddlers (273,100). throughout the selfsame three-year duration, a regular annual 4,210 deaths from asthma befell, with 200 of these deaths taking situation in humans below 18 years of age.14 There are particular racial disparities among exiguous ones with this disease. compared with white children, black children absorb a 60% higher incidence cost, a 260% higher ED quest recommendation from price, a 250% higher hospitalization expense and a 500% greater dying rate as a result of bronchial asthma.15 in the u.s., childhood asthma is essentially the most commonplace judgement behind childhood emergency arm visits, hospitalizations and neglected school days (10.1 million college days misplaced a 12 months).
bronchial asthma is a persistent inflammatory ailment of the airways characterised by means of variable and ordinary symptoms arising from episodic and reversible airflow obstruction. This airflow obstruction is the consequence of a great number of pathological processes, together with bronchoconstriction, airway hyperresponsiveness, irritation and edema, and expanded pulmonary secretions. bronchial asthma may well subsist labeled as atopic (extrinsic) or non-atopic (intrinsic) according to the motives of indicators. The time age atopy refers to a genetic predisposition against the construction of immediate hypersensitivity reactions to commonplace environmental allergens. Atopic asthma is brought about by course of allergens like pollen or animal dander. Non-atopic bronchial asthma, in contrast, isn't caused by using an publicity to an allergen, but is usually a response to a deadly disease or upper respiratory an infection.
An exacerbation of bronchial asthma happens in two phases: early and late. during the early part, inhalation of an allergen or different irritant consequences in immediate bronchoconstriction. every bit of over the late part, airway inflammation, edema and hyperresponsiveness extra contribute to airflow obstruction. it is value taking a closer examine these components of asthma.
In atopic bronchial asthma, allergen-prompted bronchoconstriction consequences from the IgE-dependent free up of bronchoconstrictor mediators, akin to histamine from mast cells. This occurs when IgE antibodies establish an allergen and fix to them, forming an allergen-antibody complicated. This allergen-antibody complicated is then recognized by using and certain to a mast cellphone. The mast cell degranulates and releases histamine, leading to instant bronchoconstriction. additionally, different stimuli such as recreation, gelid air, inhalation of irritants and even stress can result in acute bronchoconstriction. Bronchoconstriction is essentially the most immediate, preeminent physiological event early in an bronchial asthma assault, and airflow obstruction can subsist reversed at the flash with the administration of bronchodilators.
Airway inflammation and Edema
Cells of the immune equipment that unencumber inflammatory mediators comprehend lymphocytes, mast cells, eosinophils, and neutrophils to a lesser diploma. free up of these mediators, corresponding to histamine and cytokines, consequences in elevated capillary permeability and edema. The airflow obstruction brought about by means of airway edema may too subsist worsened by course of mucus hypersecretion and the formation of mucus plugs. Airway irritation and edema ensue later in an asthma exacerbation than does bronchoconstriction.
The term airway hyperresponsiveness is used to relate the exaggerated bronchoconstrictor response that occurs in asthma and is associated with irritation. The more irritation it truly is latest, the greater the hyperresponsiveness. a more robust diploma of hyperresponsiveness correlates with an expand within the medical severity of asthma. medicine that targets inflammation can reduce back airway hyperresponsiveness and advocate in asthma handle.
When evaluating the child with bronchial asthma, the prehospital custody issuer should still inquire as to the age of the patient, the duration and severity of the event, simultaneous medication use, and if there's a desultory of a choking episode and international body aspiration. If there had been different attacks, the folks should attempt to compare the latest ones with previous assaults. establish every bit of medication varieties and doses. Any background of problem sound asleep or eating every bit of the course through the attack suggests a reasonable to extreme exacerbation.
commonplace scientific test findings linked to asthma comprehend tachypnea, tachycardia, wheezing and desiccate cough. apart from wheezing, crackles or rhonchi could subsist auscultated over areas where mucus and inflammatory exudate absorb accumulated in the airways. A reticent chest will too subsist an ominous token up bronchial asthma, as it may too point out that air flood is extraordinarily diminished or nonexistent. another ominous token is head-bobbing or lethargy, indicating that the patient is becoming drained, hypoxic, or drawing near respiratory failure. An oxygen saturation should still subsist decided, because it can assist in settling on the diploma of illness.sixteen throughout the early levels of an exacerbation of bronchial asthma, hyperventilation outcomes in hypocapnia and a reduced end-tidal carbon dioxide (ETCO2) reading. As bronchoconstriction and edema irritate airflow, alveolar ventilation decreases and hypercapnia develops, resulting in a rise in ETCO2. No unique asthma scoring table has been universally adopted to check the degree of sickness or aid in resolution-making concerning administration, however table 1 can too subsist used as a ebook.
Measuring top expiratory movement expense (PEFR) is a straightforward and objective components of deciding on the severity of asthma in an grownup, however arguably has restricted utility in the baby and newborn with asthma, who may well subsist unable to solemnize commands essential for this testing. in a unique peek at, just two-thirds of children above age 5 had been able to comprehensive PEFR trying out right through an bronchial asthma exacerbation.17
administration of Wheezing
After prefatory comparison of airway, breathing and circulation, and the immediate remedy of life-threats recognized every bit of over the primary exam, the treatment of wheezing in the pediatric patient revolves around expanding ventilation and oxygenation during the reversal of bronchoconstriction and airway edema.
All sufferers with wheezing should still subsist administered oxygen via a suitable start machine to maintain a SpO2 above ninety%. patients with adequate respiration (fee and tidal quantity unconcerned for age) can Make the most of a nasal cannula or nonrebreather mask, whereas patients with insufficient respiratory (price and/or tidal volume outdoor of norms for age) require BVM ventilation. custody ought to subsist taken when featuring BVM or mechanical air flow, as air trapping can result in accelerated intrathoracic pressures and the risk of lowered venous return. This could lead to decreased cardiac output and barotrauma, resulting in pneumothorax. As such, ample (prolonged) expiratory time must subsist allowed for air to exit from the lungs. Permissive hypercapnia is a time age used to interpret the raise in ETCO2 that happens when a methodology of minimizing tidal volumes and respiratory expense with the objective to lower top airway and intrathoracic pressures is utilized.
Some EMS and captious custody transport features exhaust heliox in the medicine of strict asthma. Heliox is a low-density admixture (an 80:20 ratio is typical) of helium and oxygen that outcomes in much less-turbulent flood via airways narrowed through bronchoconstriction and edema. In concept, the lower in turbulent airflow should still result in decreased travail of breathing, much less respiratory muscle fatigue, and a lessen probability of respiratory failure. however, an evaluation of scientific trials assessing the exhaust of heliox means that there is insufficient facts to guide widespread use, and it's continually regarded best for exiguous ones with extreme exacerbation of bronchial asthma now not responding to widespread remedy.18
a comparatively new sort of oxygen therapy used in instances of gentle wheezing in neonates and toddlers is heated, humidified, high-move nasal cannula (HFNC) remedy. HFNC permits for the nascence of elevated gasoline flows (1-eight L/min in exiguous ones), with or without an multiplied oxygen concentration.19 HFNC offers some degree of perennial effectual airway power (CPAP), although exact fees are complicated to foretell. Neonatal studies exhibit that the volume of CPAP generated depends on the circulate delivered relative to the dimension of the affected person and on the leak around the nasal cannula.20,21,22
continual superb airway force, or greater principally, nasal continuous high-quality airway favor (NCPAP), has been shown to ameliorate scientific scores, reduce respiratory expense and enhance ventilation in children with bronchiolitis or asthma.23,24 like PEFP, however, NCPAP isn't customarily neatly tolerated via exiguous ones and children.25 toddlers and kids with greater colossal respiratory distress or with apnea require endotracheal intubation and mechanical ventilation to aid oxygenation and air flow. a hallmark of respiratory failure and impending respiratory arrest is the stressed, agitated infant in respiratory distress who suddenly becomes compliant. This may additionally attest that the affected person is drained and/or severely hypercapnic.
short-performing beta-2 agonists (SABAs), equivalent to albuterol and levalbuterol, delivered by using small-quantity nebulizer, are the medicine of alternative for exiguous ones with acute exacerbation of bronchial asthma. The facts supporting their exhaust in exiguous ones with wheezing secondary to bronchiolitis is less conclusive; youngsters, there is enough scientific overlap between asthma and bronchiolitis that both cannot subsist uncommon on actual examination findings by myself. for this reason, for the paramedic working in the prehospital ambiance, management of the child or newborn providing with wheezing of unknown etiology should comprehend the exhaust of SABAs.
Beta-agonists set off beta-2 receptors within the lungs, resulting in relaxation of bronchial light muscle, bronchodilation and more desirable airflow.
Epinephrine 1:one thousand and terbutaline, administered subcutaneously, may too subsist utilized in unconcerned to strict exacerbations of bronchial asthma. because of its profound cardiovascular consequences, epinephrine is frequently reserved for these infant and baby patients in reasonable to strict asthma; it is not advised in those pediatric sufferers with comorbidities (e.g., congenital heart disorder) that can subsist complex by the exorbitant cardiac stimulation that accompanies its use.
Anticholinergics inhibit muscarinic cholinergic receptors within the airway, decreasing the intrinsic vagal tone latest and resulting in bronchodilation. Ipratropium bromide (IB) is an anticholinergic common within the prehospital atmosphere. The onset of action of IB is long, and medical merits can subsist delayed for up to 60 minutes. regardless of the delayed onset of action, studies absorb proven that the exhaust of SABAs with IB is more beneficial in reversing bronchoconstriction than using SABAs on my own.26,27 It is not astounding to absorb prehospital protocols that allow for administration of both medicinal drugs, that are positioned into a small-quantity nebulizer and administered at the selfsame time as.
whereas corticosteroids are commonplace within the medication of reasonable to extreme bronchial asthma, their exhaust in bronchiolitis is proscribed. They don't seem to subsist regarded a typical of capture custody of the management of bronchiolitis (however they are used), and aren't counseled for exhaust in in the past vigorous toddlers with RSV.28 Corticosteroids are used to reduce back the inflammation and edema linked to both acute exacerbation and perennial asthma, and are most commonly administered by the exhaust of IV in the prehospital ambiance. like anticholinergics, there's a delayed onset of motion (as much as a yoke of hours), so the merits may additionally no longer subsist clinically obvious within the prehospital ambiance, but there is an abilities to early administration. An illustration of an intravenous corticosteroid frequently utilized by EMS is methylprednisolone (Solu-Medrol).
there is ample evidence to insinuate that IV or inhaled magnesium sulfate may additionally odds each adults and kids with extreme asthma.29,30 Magnesium acts as a antiseptic muscle relaxant and promotes bronchodilation, and the administration of magnesium has been proven to outcomes in lowered airway resistance and improved ventilation in adults. current techniques published within the national heart, Lung, and Blood Institute, national Institutes of fitness's national bronchial asthma schooling and Prevention program knowledgeable Panel record three, guidelines for the prognosis and administration of asthma attain not insinuate a selected dose or route for magnesium within the newborn or pediatric population.
table 1: asthma within the Pediatric affected person assessment devicegentleMODERATE severeFeeding commonplace less terrible SaO2 on room air >/=ninety five% 90%-ninety five% <ninety% degree of dyspnea Dyspnea only with undertaking Dyspnea interferes with or limits ordinary exercise Dyspnea at leisure, interferes with dialog Retractions None/minimalIntercostal Suprasternal accent muscle use None massive excessiveWheezing None/minimal conclusion expiratory moderate, during expiratory severe inspiratory and/or expiratory wheezing audible with out stethoscope Presence of lung sounds Full and equal breath sounds bilaterally reduced breath sounds, bilateral or localized multiple areas of reduced breath sounds mental statusAlert Alert/stressed restless/lethargic Inspiratory/expiratory ratio 1:1 1:2 Exceeds 1:2
This continuing training activity is authorised by using EMS World magazine, an organization authorised through the continuing education Coordinating Board for Emergency clinical functions (CECBEMS), for 1.5 CEUs. To earn your credits, travel to www.rapidce.com, or to print and mail a copy, down load the examine right here.
1. Henrickson KJ, Hoover S, Kehl KS, Hua W. national disease burden of respiratory viruses detected in babies by polymerase chain reaction. Pediatr Infect Dis J 23(Suppl):eleven, 2004.2. facilities for disease ply and Prevention. Respiratory Sycytial Virus an infection: infection and Incidence. www.cdc.gov/rsv/about/infection.html. up to date January 25, 2010.three. leader S, Kohlhase k. recent traits in strict respiratory syncytial virus (RSV) amongst US babies, 1997 to 2000. J Pediatr 143(suppl):S127 -S132, 2003.4. Mullins JA, Lamonte AC, Bresee JS, Anderson LJ. substantial variability in neighborhood respiratory syncytial virus season timing. Pediatr Infect Dis J 22:857-886, 2003.5. Thompson WW, Shay DK, Weintraub E, et al. Mortality linked to influenza and respiratory syncytial virus within the united states. JAMA 289(2):179-186, Jan eight 2003.6. hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus an infection in younger exiguous ones. N Engl J Med 360(6):588-598, Feb 5, 2009.7. Purcell ok, Fergie J. Driscoll babies's medical institution respiratory syncytial virus database: possibility components, treatment and health facility course in 3308 babies and younger infants, 1991 to 2002. Pediatr Infect Dis J 23:418-423, 2004.8. Welliver RC. evaluate of epidemiology and clinical desultory factors for extreme respiratory syncytial virus (RSV) an infection. J Pediatr 143:S112-S117, 2003.9. Navas L, Wang E, de Carvalho V, et al. improved outcome of respiratory syncytial virus infections in a high-chance hospitalized population of Canadian exiguous ones. J Pediatr121:348-354, 1992.10. López-Alarcón M, Villalpando S, Fajardo A. Breastfeeding lowers the frequency and duration of acute respiratory an infection and diarrhea in babies beneath six months of age. J Nutr 127(3):436 -443, 1997.11. Wright AL, Bauer M, Naylor A, et al. increasing breastfeeding prices to in the reduction of child affliction on the group stage. Pediatrics 101(5):837-844, 1998.12. centers for disorder manage and Prevention. Respiratory syncytial virus infection (RSV).13. facilities for sickness ply and Prevention. 2007 countrywide fitness Interview Survey Public exhaust data File. www.cdc.gov.14. centers for sickness control and Prevention. country wide Surveillance for bronchial asthma-united states, 1980-2004. www.cdc.gov/mmwr/preview/mmwrhtml/ss5608a1.htm.15. Akinbami L. The status of childhood asthma, u.s., 1980-2005. Adv statistics 381:1, 2006.16. Geelhoed GC, Landau LI, Le Souef PN. assessment of SaO2 as a predictor of consequence in 280 toddlers presenting with acute asthma. Ann Emerg Med 23:1236, 1994.17. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. efficiency of a novel medical ranking, the Pediatric bronchial asthma Severity rating (move), within the assessment of acute bronchial asthma. Acad Emerg Med 11:10, 200418. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute bronchial asthma sufferers. Cochrane Database Systematic reviews four:CD002884, 2006.19. de Klerk A. Humidified high-move nasal cannula: Is it the brand new and enhanced CPAP? Adv Neonatal custody 8:98-106, 2008.20. Kubicka ZJ, Limauro J, Darnell RA. Heated humidified excessive-circulate nasal cannula remedy: Yet a further technique to carry perennial high-quality airway power? Pediatrics 121: 82-88, 2008.21. Lampland AL, Plumm B, Meyers PA, et al. Observational dissect of humidified excessive-move nasal cannula in comparison with nasal continuous fine airway pressure. J Pediatr 154:177-182, 2009.22. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H. excessive-circulation nasal cannulae within the administration of apnea of prematurity: A evaluation with time-honored nasal continuous exotic airway drive. Pediatrics 107:1081-1083, 2001.23. Thia LP, McKenzie SA, Blyth TP, et al. Randomised managed trial of nasal perennial fine airway drive in bronchiolitis. Arch Dis child ninety three:637-638, 2008.24. Larrar S, Essouri S, Durand P, et al. effects of nasal continuous fine airway favor air flood in toddlers with extreme acute bronchiolitis. Archives de Pediatrie 13:1397-1403, 2006.25. Yong SC, Chen SJ, Boo ny. Incidence of nasal trauma associated with nasal prong versus nasal masks right through perennial elevated property airway favor medication in very low birthweight infants: A randomized manage analyze. Arch Dis newborn Fetal Neonatal Ed 90:F480-F483, 2005.26. Schuh S, et al. Efficacy of prevalent nebulized ipratropium bromide delivered to conventional high-dose albuterol remedy in strict childhood bronchial asthma. J Pediatr, 1995.27. Qureshi F, Pestian J, Davis P, Zaritsky A. consequence of nebulized ipratropium on the hospitalization costs of children with asthma. N Engl J Med 339:1030, 1998.28. Watts KD, Goodman DM. Wheezing, Bronchiolitis, and Bronchitis. In: Kliegman: Nelson Textbook of Pediatrics, 18th ed., Saunders, 2007.29. Rowe BH, et al. Intravenous magnesium sulfate medication for acute bronchial asthma in the emergency branch: a systematic evaluate of the literature. Ann Emerg Med 36:181, 2000.30. Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium sulphate for treating acute asthma. Arch Dis baby ninety:74, 2005.
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ACSM [4 Certification Exam(s) ]
ACT [1 Certification Exam(s) ]
Admission-Tests [13 Certification Exam(s) ]
ADOBE [93 Certification Exam(s) ]
AFP [1 Certification Exam(s) ]
AICPA [2 Certification Exam(s) ]
AIIM [1 Certification Exam(s) ]
Alcatel-Lucent [13 Certification Exam(s) ]
Alfresco [1 Certification Exam(s) ]
Altiris [3 Certification Exam(s) ]
Amazon [7 Certification Exam(s) ]
American-College [2 Certification Exam(s) ]
Android [4 Certification Exam(s) ]
APA [1 Certification Exam(s) ]
APC [2 Certification Exam(s) ]
APICS [2 Certification Exam(s) ]
Apple [71 Certification Exam(s) ]
AppSense [1 Certification Exam(s) ]
APTUSC [1 Certification Exam(s) ]
Arizona-Education [1 Certification Exam(s) ]
ARM [1 Certification Exam(s) ]
Aruba [8 Certification Exam(s) ]
ASIS [2 Certification Exam(s) ]
ASQ [3 Certification Exam(s) ]
ASTQB [11 Certification Exam(s) ]
Autodesk [2 Certification Exam(s) ]
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BICSI [2 Certification Exam(s) ]
BlackBerry [17 Certification Exam(s) ]
BlueCoat [2 Certification Exam(s) ]
Brocade [4 Certification Exam(s) ]
Business-Objects [11 Certification Exam(s) ]
Business-Tests [4 Certification Exam(s) ]
CA-Technologies [20 Certification Exam(s) ]
Certification-Board [10 Certification Exam(s) ]
Certiport [3 Certification Exam(s) ]
CheckPoint [45 Certification Exam(s) ]
CIDQ [1 Certification Exam(s) ]
CIPS [4 Certification Exam(s) ]
Cisco [325 Certification Exam(s) ]
Citrix [48 Certification Exam(s) ]
CIW [18 Certification Exam(s) ]
Cloudera [10 Certification Exam(s) ]
Cognos [19 Certification Exam(s) ]
College-Board [2 Certification Exam(s) ]
CompTIA [79 Certification Exam(s) ]
ComputerAssociates [6 Certification Exam(s) ]
Consultant [2 Certification Exam(s) ]
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CWNP [14 Certification Exam(s) ]
CyberArk [2 Certification Exam(s) ]
Dassault [2 Certification Exam(s) ]
DELL [13 Certification Exam(s) ]
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Exin [40 Certification Exam(s) ]
ExtremeNetworks [3 Certification Exam(s) ]
F5-Networks [20 Certification Exam(s) ]
FCTC [2 Certification Exam(s) ]
Filemaker [9 Certification Exam(s) ]
Financial [36 Certification Exam(s) ]
Food [4 Certification Exam(s) ]
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GIAC [15 Certification Exam(s) ]
Google [5 Certification Exam(s) ]
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HRCI [1 Certification Exam(s) ]
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McData [3 Certification Exam(s) ]
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Microsoft [393 Certification Exam(s) ]
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Military [1 Certification Exam(s) ]
Misc [2 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
mySQL [4 Certification Exam(s) ]
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NetworkAppliance [42 Certification Exam(s) ]
NetworkAppliances [1 Certification Exam(s) ]
NI [1 Certification Exam(s) ]
NIELIT [1 Certification Exam(s) ]
Nokia [7 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [37 Certification Exam(s) ]
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P&C [2 Certification Exam(s) ]
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Polycom [2 Certification Exam(s) ]
PostgreSQL-CE [1 Certification Exam(s) ]
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SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
Siemens [1 Certification Exam(s) ]
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SOA [15 Certification Exam(s) ]
Social-Work-Board [4 Certification Exam(s) ]
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Symantec [136 Certification Exam(s) ]
Teacher-Certification [4 Certification Exam(s) ]
The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [18 Certification Exam(s) ]
Trainers [3 Certification Exam(s) ]
Trend [1 Certification Exam(s) ]
TruSecure [1 Certification Exam(s) ]
USMLE [1 Certification Exam(s) ]
VCE [7 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [68 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]
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