Treatment of acute asthma: salbutamol via jet nebuliser vs spacer and metered dose inhaler

Metered-dose inhalers versus nebulization for the delivery of albuterol for acute exacerbations of wheezing or asthma in children: A systematic review with meta-analysis

OBJECTIVES

The benefits of metered-dose inhalers with a spacer (MDI+S) have increasingly been recognized as an alternative method of albuterol administration for treating pediatric asthma exacerbations. The aim of this systematic review was to compare the response to albuterol delivered through nebulization (NEB) with albuterol delivered through MDI+S in pediatric patients with asthma exacerbations.

METHODS

We conducted an electronic search in MEDLINE/PubMed, EMBASE, Ovid, and ClinicalTrials. To be included in the review, a study had to a randomized clinical trial comparing albuterol delivered via NEB versus MDI+S; and had to report the rate of hospital admission (primary outcome), or any of the following secondary outcomes: oxygen arterial saturation, heart rate (HR), respiratory rate (RR), the pulmonary index score (PIS), adverse effects, and need for additional treatment.

RESULTS

Fifteen studies (n = 2057) met inclusion criteria. No significant differences were found between the two albuterol delivery methods in terms of hospital admission (relative risk, 0.89; 95% confidence interval [CI], 0.55-1.46; I²  = 32%; p = .65). There was a significant reduction in the PIS score (mean difference [MD], -0.63; 95% CI, -0.91 to -0.35; I²  = 0%; p < .00001), and a significantly smaller increase in HR (better; MD -6.47; 95% CI, -11.69 to -1.25; I²  = 0%; p = .02) when albuterol was delivered through MDI+S than when it was delivered through NEB.

CONCLUSIONS

This review, an update of a previously-published meta-analysis, showed a significant reduction in the PIS and a significantly smaller increase in HR when albuterol was delivered through MDI+S than when it was delivered through NEB.

Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta(2)-agonists are often administered by nebuliser to relieve bronchospasm, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting.

OBJECTIVES

To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta(2)-agonists for acute asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Trial Register and reference lists of articles. We contacted the authors of studies to identify additional trials. Date of last search: February 2013.

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where spacer beta(2)-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied study inclusion criteria (one review author for the first version of the review), extracted the data and assessed risks of bias. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CIs).

MAIN RESULTS

This review includes a total of 1897 children and 729 adults in 39 trials. Thirty-three trials were conducted in the emergency room and equivalent community settings, and six trials were on inpatients with acute asthma (207 children and 28 adults). The method of delivery of beta(2)-agonist did not show a significant difference in hospital admission rates. In adults, the risk ratio (RR) of admission for spacer versus nebuliser was 0.94 (95% CI 0.61 to 1.43). The risk ratio for children was 0.71 (95% CI 0.47 to 1.08, moderate quality evidence). In children, length of stay in the emergency department was significantly shorter when the spacer was used. The mean duration in the emergency department for children given nebulised treatment was 103 minutes, and for children given treatment via spacers 33 minutes less (95% CI -43 to -24 minutes, moderate quality evidence). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -5% baseline (95% CI -8% to -2%, moderate quality evidence), as was the risk of developing tremor (RR 0.64; 95% CI 0.44 to 0.95, moderate quality evidence).

AUTHORS' CONCLUSIONS

Nebuliser delivery produced outcomes that were not significantly better than metered-dose inhalers delivered by spacer in adults or children, in trials where treatments were repeated and titrated to the response of the participant. Spacers may have some advantages compared to nebulisers for children with acute asthma.

Guidelines for aerosol devices in infants, children and adults: which to choose, why and how to achieve effective aerosol therapy

Multiple types of aerosol devices are commonly used for the administration of medical aerosol therapy to patients with pulmonary diseases. All of these devices have been shown to be effective in trials where they are used correctly. However, failure to operate any of these devices properly has been associated with poor clinical response and limited patient adherence to therapy. Therefore, the selection of the best aerosol device for the individual patient is very important for optimizing the results of medical aerosol therapy. This article presents the rationale for selecting the most appropriate aerosol device to administer inhaled drugs in specific patient populations, with emphasis on patient-, drug-, device- and environment-related factors and with a comparison between the available devices. The following recommendations for the selection of the 'best' aerosol device for each patient population are intended to help clinicians gain a clear understanding of the specific issues and challenges so that they can optimize aerosol drug delivery and its therapeutic outcomes in patients.

Comparison of the bronchodilative effects of salbutamol delivered via three mesh nebulizers in children with bronchial asthma

BACKGROUND

We compared the bronchodilative effects of salbutamol delivered via 3 different mesh nebulizers, Aeroneb-go(R)(AE), Omron-NE-U22(R)(OM) and Pari-eMotion(R)(PA).

METHODS

We enrolled 36 children with asthma who visited the Kurosaka Pediatrics and Allergy Clinic, randomly assigned to 3 groups for treatment with AE, OM or PA. The dose of salbutamol in the solution was 0.15mgx body weight (kg)(minimum 2.5mg, maximum 5mg). FEV(1), PEFR and V(50) were measured in these patients before treatment, and at 15 and 30 minutes after salbutamol inhalation using one of the 3 mesh nebulizers.

RESULTS

All groups showed a significant improvement of FEV(1), PEFR and V(50) at 30 minutes after salbutamol inhalation. The AE group did not show a significant improvement in PEFR at 15 minutes after inhalation, whereas a significant improvement in FEV(1) and V(50) was evident at the same time point. The OM group showed no significant improvement in V(50) at 15 minutes after inhalation, whereas this group clearly showed a significant improvement in PEFR and FEV(1) at the same time point.

CONCLUSIONS

Overall, all 3 mesh nebulizers were useful devices in treating bronchial asthma, although some differences in lung function improvement were evident. The limitation of this study is that subjects did not include patients with severe asthma attacks.

Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting.

OBJECTIVES

To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma.

SEARCH STRATEGY

We last searched the Cochrane Airways Group trials register in January 2006 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2005).

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI).

MAIN RESULTS

This review has been updated in January 2006 and four new trials have been added. 2066 children and 614 adults are now included in 25 trials from emergency room and community settings. In addition, six trials on in-patients with acute asthma (213 children and 28 adults) have been reviewed. Method of delivery of beta2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI 0.63 to 1.49). The relative risk for children was 0.65 (95% CI: 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of -0.47 hours (95% CI: -0.58 to -0.37). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -7.6% baseline (95% CI: -9.9 to -5.3% baseline).

AUTHORS' CONCLUSIONS

Metered-dose inhalers with spacer produced outcomes that were at least equivalent to nebuliser delivery. Spacers may have some advantages compared to nebulisers for children with acute asthma.

Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber

PURPOSE

Evidence supporting the delivery of bronchodilators with a metered-dose inhaler and a valved holding chamber (MDI+VHC) in place of a small-volume nebulizer (SVN) is discussed, and the steps taken to accomplish such a conversion program at one institution are described.

SUMMARY

Double-blind, randomized studies in patients with acute exacerbations of asthma have demonstrated that higher doses of albuterol delivered by MDI+VHC (4-10 puffs per dose) are as effective as 2.5 mg of albuterol sulfate delivered by SVN. Three double-blind studies support the conclusion that the two methods are equivalent with respect to both efficacy and adverse effects in patients with chronic obstructive pulmonary disease. MDI+VHC offers practical advantages over SVN, including the capacity for home use by the patient, portability, less setup time, and no need for daily disinfection. Pharmacists and respiratory therapists obtained approval through the pharmacy and therapeutics committee for respiratory therapists to convert orders for bronchodilators delivered by SVN to administration by MDI+VHC. The conversion policy allows physicians to override it, but none have exercised this option. On intensive care units (ICUs), the policy resulted in a 53% increase in the use of MDI+VHC during the six-month period after it went into effect. Respiratory therapists have been less thorough in implementing the policy for non-ICU patients.

CONCLUSION

Delivery of bronchodilators by MDI+VHC is as effective as delivery by SVN but offers several advantages. A policy to switch patients from SVN to MDI+VHC for bronchodilator administration met with limited success.

Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines

BACKGROUND

The proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Evidence-based guidelines for the selection of the appropriate aerosol delivery device in specific clinical settings are needed.

AIM

(1) To compare the efficacy and adverse effects of treatment using nebulizers vs pressurized metered-dose inhalers (MDIs) with or without a spacer/holding chamber vs dry powder inhalers (DPIs) as delivery systems for beta-agonists, anticholinergic agents, and corticosteroids for several commonly encountered clinical settings and patient populations, and (2) to provide recommendations to clinicians to aid them in selecting a particular aerosol delivery device for their patients.

METHODS

A systematic review of pertinent randomized, controlled clinical trials (RCTs) was undertaken using MEDLINE, EmBase, and the Cochrane Library databases. A broad search strategy was chosen, combining terms related to aerosol devices or drugs with the diseases of interest in various patient groups and clinical settings. Only RCTs in which the same drug was administered with different devices were included. RCTs (394 trials) assessing inhaled corticosteroid, beta2-agonist, and anticholinergic agents delivered by an MDI, an MDI with a spacer/holding chamber, a nebulizer, or a DPI were identified for the years 1982 to 2001. A total of 254 outcomes were tabulated. Of the 131 studies that met the eligibility criteria, only 59 (primarily those that tested beta2-agonists) proved to have useable data.

RESULTS

None of the pooled metaanalyses showed a significant difference between devices in any efficacy outcome in any patient group for each of the clinical settings that was investigated. The adverse effects that were reported were minimal and were related to the increased drug dose that was delivered. Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation.

CONCLUSIONS

Devices used for the delivery of bronchodilators and steroids can be equally efficacious. When selecting an aerosol delivery device for patients with asthma and COPD, the following should be considered: device/drug availability; clinical setting; patient age and the ability to use the selected device correctly; device use with multiple medications; cost and reimbursement; drug administration time; convenience in both outpatient and inpatient settings; and physician and patient preference.

beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis

OBJECTIVE

To compare the efficacy of beta-agonists given by metered-dose inhaler with a valved holding chamber (MDI+VHC) or nebulizer in children under 5 years of age with acute exacerbations of wheezing or asthma in the emergency department setting.

STUDY DESIGN

Published (1966 to 2003) randomized, prospective, controlled trials were retrieved through several different databases. The primary outcome measure was hospital admission.

RESULTS

Six trials (n=491) met criteria for inclusion. Patients who received beta-agonists by MDI+VHC showed a significant decrease in the admission rate compared with those by nebulizer (OR, 0.42; 95% CI, 0.24-0.72; P=.002); this decrease was even more significant among children with moderate to severe exacerbations (OR, 0.27; 95% CI, 0.13-0.54; P=.0003). Finally, measure of severity (eg, clinical score) significantly improved in the group who received beta-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, -0.44; 95% CI, -0.68 to -0.20; P=.0003).

CONCLUSIONS

The use of an MDI+VHC was more effective in terms of decreasing hospitalization and improving clinical score than the use of a nebulizer in the delivery of beta-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma.

Snapshot of acute asthma: treatment and outcome of patients with acute asthma treated in Australian emergency departments

AIMS

To characterize presentations due to acute asthma at Australian emergency departments (ED), including their severity, treatment and disposition.

METHODS

This prospective, observational study involved 38 departments of emergency medicine throughout -Australia participating in the Snapshot of Asthma Study Group project 2000 and 2001. Data were collected for patients presenting with acute asthma between 21 August 2000 and 3 September 2000, and 20 August 2001 and 2 September 2001 and included demographics, severity classification, treatment and disposition.

RESULTS

There were 1340 acute asthma presentations in the study periods. Of these presentations, 67% were for children aged <15 years. Asthma severity (according to the Australian National Asthma Guidelines classification) was 'mild' in 49% of cases; 'moderate' in 45% of cases; and 'severe' in 6% of cases. Treatment administered included: (i) salbutamol to 90%, (ii) ipratropium bromide to 59% and (iii) corticosteroids to 71%. Only six patients received aminophylline. Spacer use for salbutamol was rare (1%) in adults and only moderate (43%) in children. Sixty-five percent of patients were discharged home from the ED. Less than 1% of patients required ventilatory assistance, of which half was provided non-invasively. One percent of patients were admitted to the intensive-care unit or high-dependency unit.

CONCLUSION

Overall adherence to treatment guidelines was good. There appears to be underuse of spacers and corticosteroids in some groups and overuse of ipratropium bromide. The majority of patients are treated and discharged from the ED.

The influence of inhaler selection on efficacy of asthma therapies

Many different devices are available to aid inhalational drug delivery. Although each device is claimed to have advantages over its rivals, the evidence to support greater efficacy of a particular device is scanty. Most comparative studies are underpowered or flawed in their design. They may use inappropriate end-points, or involve healthy subjects, whose response may be very different from the patient with acute severe asthma. The dosage of drug used in a trial may be at the shallow part of the dose-response curve, masking differences in devices. Only in a few cases have clinical trials detected a significant difference between devices, and trials have rarely taken patient preference into account. The most efficacious device in practice is likely to be the one that the patient will use regularly and in accordance with a health care workers' recommendations.

Spacers and nebulisers for the delivery of beta-agonists in non-life-threatening acute asthma

BACKGROUND

In asthma exacerbations, higher doses of inhaled beta-agonists are used to overcome acute bronchoconstriction. Traditionally, wet nebulisation has been used, but metered-dose inhaler with a spacer device is an alternative delivery method.

OBJECTIVE

To compare the clinical outcomes in adults and children with acute asthma, presenting in emergency departments or in the community, who have been randomised to beta-agonists given by two different delivery.

METHODS

a metered-dose inhaler with spacer or a nebuliser.

RESULTS

A Cochrane review has found no important differences between the two delivery methods in adults. Children may suffer fewer side effects with spacer delivery.

CONCLUSIONS

Individual response to treatment cannot be predicted, but many studies overcame this problem by using frequent repeated doses of beta-agonists (one respule via nebuliser or four separate actuations of a metered-dose inhaler through a spacer) every 10-15 min, titrated against the clinical response of the patients. This approach is advocated in clinical practice.

Holding chambers versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta-2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. In the community setting nebulisers are more expensive, require a power source and need regular maintenance.

OBJECTIVES

To assess the effects of holding chambers compared to nebulisers for the delivery of beta-2-agonists for acute asthma.

SEARCH STRATEGY

We last searched the Cochrane Airways Group trials register in November 2002 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002).

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where holding chamber beta-2-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI).

MAIN RESULTS

This review has been updated in 2003 and has now analysed 1076 children and 444 adults included in 22 trials from emergency room and community settings. In addition, five trials on in-patients with acute asthma (184 children and 28 adults) have been added to the review. Method of delivery of beta-2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for holding chamber versus nebuliser was 0.88 (95% CI 0.56 to 1.38). The relative risk for children was 0.65 (95% CI 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the holding chamber was used, with a weighted mean difference of -0.47 hours, (95% CI -0.58 to -0.37 hours). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for holding chamber in children, weighted mean difference -7.6% baseline (95% CI -9.9 to -5.3% baseline).

REVIEWER'S CONCLUSIONS

Metered-dose inhalers with holding chamber produced outcomes that were at least equivalent to nebuliser delivery. Holding chambers may have some advantages compared to nebulisers for children with acute asthma.

Child and parent satisfaction with the use of spacer devices in acute asthma

OBJECTIVE

To evaluate child and parent satisfaction with the use of spacers in acute asthma.

METHODS

All parents of children presenting to the emergency department of Sydney Children's Hospital over a 3-month period with mild to moderately severe acute asthma who were treated with bronchodilators by spacer device were asked to complete an anonymous questionnaire. Children aged 8 years and older completed a separate questionnaire independently.

RESULTS

One hundred and eleven of 158 parents (70%) responded. The majority (84%) found it 'easy' or 'very easy' to use the spacer and 85% reported that they intended to use the spacer at home. Of those parents who had previously used a nebulizer (n = 73), 84% said that the spacer was easier to use, 77% said that the spacer was better tolerated by their child and 84% said that overall they preferred the spacer. Seventeen of 31 children aged 8-14 years treated with a spacer (55%) responded to the satisfaction survey. All respondents found it 'easy' or 'OK' to use the spacer and the majority (82%) 'liked it' or thought 'it was OK'. The majority of children (82%) said that they preferred using spacers because it was quicker (29%) or easier to use (53%).

CONCLUSION

The use of spacer devices in mild to moderately severe acute asthma is highly acceptable for children and parents; the majority prefer this mode of drug delivery to nebulization.

Drug delivery

What we know: In preschool children, small-volume spacers perform better than large-volume spacers. Detergent is the best antistatic agent for spacers, increasing lung delivery two- to threefold, but it must not be rinsed off. A mouthpiece should be used in children aged 2-3 years or older, as lung delivery is two- to threefold higher for oral inhalation than nasal inhalation (ie, by mask). Inhaled drug doses do not generally need to be reduced in infants and young children owing to inefficiencies of delivery in younger patients. Nebulisers are "dinosaurs" and not needed for most children with asthma. What we need to know: What is the best inhalation technique for spacers? How long should children breathe, how many breaths should they take, and at what age should they breath-hold? How should children, parents and doctors be instructed to achieve optimal levels of electrostatic charge reduction for spacers? How much should inhaled steroid dose be reduced when a spacer is used optimally? What dosing instructions should be given for beta(2)-agonists delivered by spacer?

The efficacy of metered-dose inhalers with a spacer device in the pediatric setting

PURPOSE

To systematically review the published research and report on the efficacy of using a metered-dose inhaler with a spacer (MDI-S) device in a pediatric setting to treat acute exacerbations of asthma.

DATA SOURCES

A literature search was conducted on the CINAHL, Medline, and Cochrane databases; additional searches were made by hand from the reference lists in each study retrieved from databases and from review articles written on the same topic.

CONCLUSION

This critical appraisal of the research demonstrates the MDI-S is as effective as the nebulizer, faster in the delivery of medication, and cost-effective.

IMPLICATIONS FOR PRACTICE

No significant difference between the MDI-S and nebulizer in delivering medication in an acute exacerbation of asthma was found in this analysis. The practitioner's choice of delivery methods should reflect the family's preference, the practice situation, and economic considerations.

A 500-ml plastic bottle: an effective spacer for children with asthma

Inhaled therapy using a metered-dose inhaler (MDI) with attached spacer has been increasingly recognized as the optimal method for delivering asthma medication for acute attacks and chronic prophylaxis. However, in developing countries the cost and availability of commercially produced spacers limit the use of MDI-spacer delivery systems. A 500-ml plastic bottle has been recently adapted to function as a spacer. This article reviews the current data on the efficacy of this bottle-spacer and discusses its advantages and limitations. It is concluded that a modified 500-ml plastic bottle is an effective spacer; modification and use of this device should be incorporated into international guidelines for the management of children with asthma.

Rationale for the choice of an aerosol delivery system

The choice of an aerosol delivery system depends on numerous factors such as the drug itself, the characteristics of the aerosol generator, the patient and his or her disease, the physician, and the clinical setting, notably an emergency situation or not. Some rules always apply: an ultrasonic nebulizer should not be used to aerosolize a drug suspension; whenever possible, the same type of aerosol generator should be used for all inhaled medications received by a given patient; for outpatients, education is a major factor to ensure treatment efficacy. When the deposition of the aerosolized drug is aimed at the terminal respiratory units, nebulizers that generate micronic aerosols should be chosen. When the deposition of the aerosolized drug is aimed at the conducting airways, the metered dose inhaler (MDI) is the first choice. However, the MDI is often ill-used, notably in children and elderly people. Therefore, other inhalation devices have been developed: spacers, dry-powder inhalers, breath-actuated MDIs and, more recently, piezo-electric devices. They have been shown to increase lung deposition of drugs in poor coordinators but they all have limitations, which may affect their clinical efficacy. These limitations include the cumbersome dimensions of spacers, the dependency of lung deposition of dry powders on the inspiratory flow rate, the need for reformulation of breath-actuated or not MDIs with CFC-free gases. Nebulization of drugs should be considered only when no portable device is available for the considered drug, or in case of failure of other forms of aerosol administration.