Teaching time for metered-dose inhalers in the emergency setting

Bronchodilators delivered by nebuliser versus pMDI with spacer or DPI for exacerbations of COPD

BACKGROUND

Bronchodilators are a central component for treating exacerbations of chronic obstructive pulmonary disease (COPD) all over the world. Clinicians often use nebulisers as a mode of delivery, especially in the acute setting, and many patients seem to benefit from them. However, evidence supporting this choice from systematic analysis is sparse, and available data are frequently biased by the inclusion of asthma patients. Therefore, there is little or no formal guidance regarding the mode of delivery, which has led to a wide variation in practice between and within countries and even among doctors in the same hospital. We assessed the available randomised controlled trials (RCTs) to help guide practice in a more uniform way.

OBJECTIVES

To compare the effects of nebulisers versus pressurised metered dose inhalers (pMDI) plus spacer or dry powder inhalers (DPI) in bronchodilator therapy for exacerbations of COPD.

SEARCH METHODS

We searched the Cochrane Airways Group Trial Register and reference lists of articles up to 1 July 2016.

SELECTION CRITERIA

RCTs of both parallel and cross-over designs. We included RCTs during COPD exacerbations, whether measured during hospitalisation or in an outpatient setting. We excluded RCTs involving mechanically ventilated patients due to the different condition of both patients and airways in this setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed the risk of bias. We report results with 95% confidence intervals (CIs).

MAIN RESULTS

This review includes eight studies with a total of 250 participants comparing nebuliser versus pMDI plus spacer treatment. We identified no studies comparing DPI with nebulisers. We found two studies assessing the primary outcome of 'change in forced expiratory volume in one second (FEV1) one hour after dosing'. We could not pool these studies, but both showed a non-significant difference in favour of the nebuliser group, with similar frequencies of serious adverse events. For the secondary outcome, 'change in FEV1 closest to one hour after dosing': we found a significant difference of 83 ml (95% CI 10 to 156, P = 0.03) in favour of nebuliser treatment. For the secondary outcome of adverse events, we found a non-significant odds ratio of 1.65 (95% CI 0.42 to 6.48) in favour of the pMDI plus spacer group.

AUTHORS' CONCLUSIONS

There is a lack of evidence in favour of one mode of delivery over another for bronchodilators during exacerbations of COPD. We found no difference between nebulisers versus pMDI plus spacer regarding the primary outcomes of FEV1 at one hour and safety. For the secondary outcome 'change in FEV1 closest to one hour after dosing' during an exacerbation of COPD, we found a greater improvement in FEV1 when treating with nebulisers than with pMDI plus spacers.A limited amount of data are available (eight studies involving 250 participants). These studies were difficult to pool, of low quality and did not provide enough evidence to favour one mode of delivery over another. No data of sufficient quality have been published comparing nebulisers versus DPIs in this setting. More studies are required to assess the optimal mode of delivery during exacerbations of COPD.

Asthma education delivered in an emergency department and an asthma education center: a feasibility study

Implementation of asthma education in the emergency department (ED) setting is controversial. Time constraints and patient anxiety may be potential barriers to learning. This study aimed to describe the feasibility and impact of a brief evidence-based asthma education intervention delivered in the ED and an asthma education center (AEC) on asthma knowledge and perceived control. The educational intervention was easily integrated into routine care in the ED. Participants were similar except for age and current state of anxiety. At follow-up, both groups showed a significant increase in asthma knowledge (ED, n = 3.1, SD = 2.1, p < .01; AEC, n = 2.6, SD = 2.7, p = .01). Perceived control improved significantly in the ED (n = 2.6, SD = 3.9; p = .01). Despite higher state anxiety scores in the ED setting, a brief asthma educational intervention resulted in a short-term increase in asthma knowledge and perceived control. Asthma knowledge also increased after the intervention in the AEC setting. Educational initiatives are feasible and may be beneficial in an ED, providing an additional opportunity for counseling that should not be missed.

Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma

STUDY OBJECTIVE

We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change.

METHODS

This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes.

RESULTS

At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED.

CONCLUSION

Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.

[Metered-dose inhaler with spacer vs nebulization for severe and potentially severe acute asthma treatment in the pediatric emergency department]

OBJECTIVE

To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma.

METHODS

In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later.

RESULTS

Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P<0.02). The overall length of stay in the emergency department was significantly shorter (148+/-20 vs 108+/-13 min, P<10(-9)).

CONCLUSIONS

The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.