Emergency Department Treatment of Severe Asthma: Metered-Dose Inhaler Plus Holding Chamber Is Equivalent in Effectiveness to Nebulizer

doi:10.1378/chest.103.3.665

Chest

Volume 103, Issue 3, March 1993, Pages 665-672

https://doi.org/10.1378/chest.103.3.665 Get rights and content

Study objective

To compare the effectiveness of administration of albuterol by nebulizer or by a metered-dose inhaler having a holding chamber attachment (hereafter “inhaler”) for treatment of acute asthma in an emergency department (ED).

Design

A randomized, double-blind, placebo-controlled intervention study conducted at two sites.

Setting

The EDs of a large municipal hospital and a university teaching hospital.

Patients

Thirty-five patients 10 to 45 years of age seeking treatment at an ED for acute asthma.

Interventions

Patients were randomly assigned to receive either albuterol by nebulizer plus placebo by inhaler (n = 20) or albuterol by inhaler plus placebo by nebulizer (n = 15). The dose was repeated every 30 min until the FEV₁ was at least 80 percent of predicted, the patient became asymptomatic, or 6 doses had been given.

Measurements and results

All references in this article to spirometric measurements of forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), and peak expiratory flow rate (PEFR) represent percentages of the predicted normal value. No significant (p>0.58) differences occurred in baseline mean FEV₁, FVC, or PEFR for the two groups. For both groups, significant improvement occurred in mean FEV₁ at 30 min (p<0.02) and at 60 min (p<0.02), and in maximum mean FEV₁ (p<0.001). However, no significant (p>0.6) differences occurred between groups in mean FEV₁, FVC, or PEFR at 30 and 60 min, or in maximum improvement attained. The sample size was sufficiently large to detect a 12 percent difference in improvement with a power of 90 percent. Thirty-three of 35 patients were treated successfully with the study protocol, became asymptomatic, and were discharged home. One patient from each group required further treatment.

Conclusions

There was no detectable difference in effectiveness of albuterol administered by nebulizer or the inhaler system for treatment of acute asthma. There was no detectable difference in effectiveness of albuterol administered by nebulizer or the inhaler system for the treatment of acute asthma when the dose was titrated to clinical response. When compared with nebulizer, the metered-dose inhaler with holding chamber delivers a full dose of albuterol more quickly and at no higher cost.

Section snippets

METHODS AND MATERIALS

We prospectively studied 35 patients seeking treatment for acute asthma at one of two EDs: Cook County Hospital (n = 15), an 800-bed acute care municipal teaching hospital in Chicago, and Shands Teaching Hospital (n = 20), a 568-bed acute and tertiary care hospital affiliated with the University of Florida College of Medicine in Gainesville. The review boards of both institutions approved the protocol, and all participants gave informed consent.

Patients were excluded for the following reasons:

RESULTS

Table 1 shows that patients ranged in age from 10 to 45 years old, with no significant difference in median age for the two groups; 54 percent were female, and only 9 percent of all patients smoked. Most patients in this study had chronic asthma: 66 percent had asthma for more than 8 years. None of the patients had a history of other chronic or complicating cardiac or respiratory illness.

Patients reported the following chief complaints (listed in order of decreasing frequency): cough, shortness

DISCUSSION

Albuterol delivered by metered-dose inhaler with holding chamber was as effective as albuterol delivered by nebulizer for treating patients with acute asthma. In that regard, our study agrees with other clinical trials investigating patients who presented to an ED with acute asthma. However, our study differs substantially in method.10, 13, 14, 15 We did not give a fixed number of doses to all subjects but, instead, continued treatment until preestablished criteria were met: the elimination of

CONCLUSIONS

Albuterol administered by metered-dose inhaler with holding chamber is an effective, rapid alternative to nebulizer therapy for moderate and severe acute asthma. This method helps patients master correct inhalation technique in the course of treatment in the ED. Further study is necessary to establish its role in the prehospital setting and in treatment of patients with the most severe asthma (ie, those who have an FEV₁ <30 percent of the predicted normal value).

ACKNOWLEDGMENTS

The authors thank Pauline Snider for editorial assistance, Susan Lorash for help with manuscript preparation, and Richard J. Melker, M.D., Ph.D., for thoughtful critique of the manuscript.

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Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists.
Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.
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Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma
2019, Journal of Pediatrics
Citation Excerpt :
As such, conventional jet nebulizer was chosen as the control group for this study. We appreciate that MDIs have been demonstrated as noninferior to jet nebulizers,16,17,20,22-24 and that there are EDs that use MDI albuterol regularly. It is unclear from these results how breath-enhanced nebulizers compare with MDIs and further study would be needed to address this.
To compare the efficacy of a breath-enhanced and a conventional jet nebulizer in the treatment of children with moderate to severe acute asthma.
We enrolled subjects between 6 and 18 years of age presenting to the emergency department (ED) with acute asthma and an initial forced expiratory volume in 1 second (FEV₁) <70% of predicted. We excluded patients with chronic disease, who required immediate resuscitation, or failed spirometry. Subjects were randomized to breath-enhanced or conventional jet delivery of a 5-mg albuterol treatment. Our primary outcome was change in FEV₁, and secondary outcomes included change in clinical asthma scores, ED length of stay, disposition, and side effects. Student t test and multivariable linear regression were used to evaluate the primary outcome.
In total, 497 patients were assessed for eligibility with 118 enrolled and 107 subjects available for analysis of the primary outcome. Improvement in FEV₁ was significantly greater with conventional jet nebulizer (mean ΔFEV₁ +13.8% vs +9.1%, P = .04). This difference remained significant after adjustment for baseline differences. Subgroup analysis of 57 subjects with spirometry meeting American Thoracic Society/European Respiratory Society guidelines yielded similar results (mean ΔFEV₁ +14.5% vs +8.5%, P=.03). There were no significant differences in clinical asthma scores, ED length of stay, disposition, or side effects.
Albuterol delivered via conventional jet nebulizer resulted in significantly greater improvement in FEV₁ than albuterol delivered by breath-enhanced nebulizer, without significant differences in clinical measures. Conventional jet nebulizers may deliver albuterol to children with acute asthma more effectively than breath-enhanced nebulizers.
ClinicalTrials.gov: NCT02566902.
Care of Respiratory Conditions in an Observation Unit
2017, Emergency Medicine Clinics of North America
The effect of bronchodilators administered via aerochamber or a nebulizer on inspiratory lung function parameters
2013, Respiratory Medicine
In chronic obstructive pulmonary disease (COPD) the clinical efficacy of bronchodilator therapy delivered via a nebulizer versus an aerochamber on FEV₁ is controversial. No studies comparing changes in inspiratory pulmonary function parameters (ILPs) using these inhaler devices are currently available. This information might be of interest because due to dynamic bronchial compression, the relationship between the ILPs and dyspnea is more reliable than that between FEV₁ and dyspnea. Therefore, our study aimed to investigate whether changes in ILPs after use of these inhaler devices were similar to the changes in FEV₁ and correlate with VAS (Visual Analogue Scale).
Forty-one stable COPD patients participated in a crossover trial. Spirometry was performed before and after two puffs Combivent (200 mcg salbutamol and 20 mcg ipratropium per puff) using an aerochamber or 2 mL of Combivent (2.5 mg salbutamol and 250 mcg ipratropium per mL) using a nebulizer. Differences in lung function parameters and changes in VAS were measured.
ILP values improved significantly from baseline after Combivent administration using both devices (p ≤ 0.004). With both devices, the mean percent changes were significantly greater for FEV₁ than the ILPs (p ≤ 0.003), except for IC (p = 0.19). The mean VAS score did not differ significantly between the devices (p = 0.33), but significant correlations were found between the VAS and forced inspiratory flow at 50% of the vital capacity (FIF₅₀) and peak inspiratory flow (PIF) when a nebulizer was used. With an aerochamber, no significant correlations between lung function parameters and VAS were found.
The present study demonstrates that ILPs improved significantly after using either device. Although significant correlations were found between the VAS and FIF₅₀ and PIF for the nebulizer, in stable COPD patients, the pMDI plus spacer is a better route of administration than a nebulizer.
Asthma Diagnosis and Management
2012, Emergency Medicine Clinics of North America
Citation Excerpt :
Traditionally, aerosolized bronchodilators have been administered by continuous-flow nebulization. However, multiple studies have found little difference in efficacy between MDI and nebulizer therapy.67–69 Hospital admission rates are equivalent between the 2 modalities.69
Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment
2011, Journal of Emergency Medicine
Background: Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice. Objectives: We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population. Methods: This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test. Results: Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75–180) L/min vs. 120 (80–155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5–9) vs. 7 (4–9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03–$10.28) vs. $18.26 ($9.88–$22.45) in the spacer and nebulizer groups, respectively (p < 0.001). Conclusion: There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.

View all citing articles on Scopus

Supported by a grant from Schering Laboratories.

Presented in part at the National Association of EMS Physicians, Orlando, Fla, June 1991, and at the American College of Emergency Physicians Scientific Assembly, Boston, October 1991. Manuscript reeeived April 7; revision accepted July 9

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Chest

Clinical InvestigationsEmergency Department Treatment of Severe Asthma: Metered-Dose Inhaler Plus Holding Chamber Is Equivalent in Effectiveness to Nebulizer

Study objective

Design

Setting

Patients

Interventions

Measurements and results

Conclusions

Section snippets

METHODS AND MATERIALS

RESULTS

DISCUSSION

CONCLUSIONS

ACKNOWLEDGMENTS

Chest

Chest

J Allergy Clin Immunol

Chest

Chest

Chest

Am J Med

Br J Dis Chest

Am J Med

Chest

Chest

J Emerg Med

Chest

Asthma

Emerg Med Clin North Am

Bronchial response to oral versus aerosol metaproterenol in asthma

Ann Intern Med

Aminophylline increases the toxicity but not the efficacy of an inhaled beta-adrenergic agonist in the treatment of acute exacerbations of asthma

Am Rev Respir Dis

Asthma education: a national strategy

Am Rev Respir Dis

Clinical Investigations
Emergency Department Treatment of Severe Asthma: Metered-Dose Inhaler Plus Holding Chamber Is Equivalent in Effectiveness to Nebulizer