Metered dose inhaler and nebuliser in acute asthma

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.

Nebulizer versus Inhaler with Spacer for Beta-Agonist Treatment in Acute Bronchospastic Disease

Objectives

To compare the efficacy of nebulized wet aerosol with metered-dose inhaler with a spacer (MDIS) in the management of acute bronchospasm.

Methods

It was a retrospective study by reviewing the clinical records of patients with acute exacerbation (chief complaint of shortness of breath) of asthma or chronic obstructive pulmonary disease (COPD) presenting to the Accident and Emergency Department (AED) of Tuen Mun Hospital from 1st to 30th November 2002 and 2003 respectively. All patients received beta-agonist by nebulizer, in the year 2002 (pre-SARS period) while all patients received treatment by MDIS in the year 2003 (post-SARS period). Treatment outcome measures included admission rate, length of hospitalisation for those admitted and AED re-attendance within 7 days for those discharged from the AED.

Results

Altogether 821 patients were recruited in this retrospective study, 522 belonged to the nebulizer group and 299 were of the MDIS group. The two groups had similar demographic characteristics. Concerning the admission rate (47% in the nebulizer group and 41% in the MDIS group; p=0.089) and re-attendance rate (7% in the nebulizer group and 6% in the MDIS group; p=0.607), the differences were not statistically significant. For the length of hospital stay, it was shorter in the nebulizer group than the MDIS group (3.65±SD 1.88 days vs 4.10±SD 1.94 days; p=0.035). However, the admission rate in the adult subgroup (61% in the nebulizer group and 47% in the MDIS group; p=0.002) was shown to be statistically significant. In multivariate analysis, usage of nebulizer, increase in respiratory rate and age were associated with a higher admission rate. Increase in SpO2, absence of co-morbidity and asthma patients were associated with a lower admission rate. Increase in age, respiratory rate and usage of MDIS were associated with an increase in hospital stay. Asthma was associated with a decrease in AED re-attendance rate as compared to COPD.

Conclusions

This retrospective study showed that both nebulizer and MDIS were effective for beta-agonist therapy in acute bronchospasm in AED with respect to hospital admission rate and AED re-attendance rate, but the length of hospital stay was slightly prolonged when using MDIS.

Scintigraphic Assessment of Deposition of Radiolabeled Fluticasone Delivered from a Nebulizer and Metered Dose Inhaler in 10 Healthy Dogs

Background

Aerosolized medications are increasingly being used to treat respiratory diseases in dogs. No previous studies assessing respiratory tract deposition of radiolabeled aerosols have been performed in conscious dogs.

Hypothesis/Objectives

Assess respiratory tract deposition of radiolabeled, inhalant corticosteroid (fluticasone propionate labeled with ^99mTc) delivered from a nebulizer and metered dose inhaler (MDI) to healthy dogs.

Animals

Ten healthy Foxhounds.

Methods

Prospective, randomized, cross‐over pilot study. Initial inhalation method (nebulizer or MDI) was randomly assigned. Treatments were crossed over after a 7‐day washout period. Treatments initially were performed using sedation. Dogs were imaged using 2‐dimensional planar scintigraphy, with respiratory tract deposition quantified by manual region‐of‐interest analysis. Deposition calculated as percentage of delivered dose. Six of 10 dogs were randomly selected and reassessed without sedation.

Results

Inhalation method had significant effect on respiratory tract deposition (P = 0.027). Higher deposition was achieved by nebulization with mean deposition of 4.2% (standard deviation [SD], 1.4%; range, 1.9–6.1%); whereas MDI treatment achieved a mean of 2.3% (SD, 1.4%; range, 0.2–4.2%). Nebulization achieved higher respiratory tract deposition than MDI in 7 of 10 dogs. No statistical difference (P = 0.68) was found between mean respiratory tract deposition achieved in dogs when unsedated (3.8%; SD, 1.5%) or sedated (3.6%; SD, 1.7%).

Conclusions and Clinical Importance

Study confirms respiratory tract deposition of inhalant medications delivered from a nebulizer and MDI in healthy dogs, breathing tidally with and without sedation. Respiratory tract deposition in these dogs was low compared to reported deposition in adult humans, but similar to reported deposition in children.

Spacers versus nebulizers in treatment of acute asthma - a prospective randomized study in preschool children

OBJECTIVE

To compare administration of bronchodilators by nebulizers with delivery by metered dose inhalers (MDIs) with spacers and to evaluate the clinical effect of the treatment of acute asthma in preschool children.

METHODS

A prospective randomized clinical trial in a pediatric emergency department (PED). Preschool children who were admitted for virus induced wheezing or acute asthma exacerbation were randomly allocated to receive bronchodilator treatment by nebulizer or by metered dose inhaler. The accompanying parents completed a questionnaire.

RESULTS

The length of stay in the PED and the hospitalization rate were similar and no difference was seen in the parents' view of ease of use and device acceptance. Baseline data were similar for both groups apart from the family history of asthma and atopic disease that was greater in the nebulizer group. No significant differences were seen in heart rate, respiratory rate and oxygen saturation at baseline and after the treatment. According to the parents 40% of the participants had asthma diagnosis though up to 66% had some kind of asthma medication.

CONCLUSIONS

Our data suggests that MDIs with spacers are at least as effective as nebulizers in the delivery of beta agonists to treat preschool children with virus induced wheezing or acute exacerbations of asthma in the PED. Parents may underestimate the gravity of their children's asthma. It is mandatory to provide adequate information to the staff and parents in order to treat pediatric acute asthma successfully.

Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources

Background and objectives

Metered-dose inhalers plus spacers (MDI-spacer) are as effective as, or better than, nebulizers in aerosol delivery. The selection of aerosol delivery system for hospitalized children can have a significant impact on the utilization of healthcare resources.

Design and setting

A quality improvement project to evaluate the impact of conversion to MDI-spacer to administer bronchodilators (BDs) and inhaled corticosteroids (ICSs) to hospitalized children on the utilization of hospital resources. The project was conducted in a tertiary pediatric ward from April to May 2013.

Materials and methods

The project was conducted over a six-week period. In the first two weeks, data were gathered from all hospitalized children receiving BDs and/or ICSs by nebulizers. This data collection was followed by a two-week washout period during which training of healthcare providers and operational changes were implemented to enhance the conversion to MDI-spacer. In the last two weeks, data were gathered from hospitalized children after conversion to MDI-spacer. The primary outcomes included the mean time (in minutes) of medication preparation and delivery. Secondary outcomes included the following: need for respiratory therapy assistance, estimated cost of treatment sessions, and patient/caregiver satisfaction.

Results

Five hundred seventy-five treatment sessions were enrolled (288 on nebulizers, 287 on MDI-spacer). The nebulizer group had more male predominance and were slightly older compared to the MDI-spacer group (male: 59% vs. 53% and mean age: 52 vs. 40 months respectively). The duration of treatment preparation and delivery was significantly lower in the MDI-spacer group (2 min reduction in preparation time and 5 min reduction in delivery time; p < 0.01). Caregivers mastered MDI-spacer use after an average of two observed sessions, eliminating the need for respiratory therapy assistance during the hospital stay. Medication cost analysis showed savings in favor of MDI-spacer (cost reduction per 100 doses: 50% for albuterol, 30% for ipratropium bromide, and 87% for ICSs). The patient satisfaction survey showed “very good” to “excellent” levels in both groups.

Conclusions

Conversion to MDI-spacer for BDs and ICSs administration in hospitalized children improve hospital resource utilization.

Detection and pharmacokinetics of salbutamol in thoroughbred racehorses following inhaled administration

Salbutamol sulphate (Ventolin Evohaler) was administrated via the inhalation route to six horses at a dose of 0.5 mg every 4 h during the day for 2 days (total dose 4 mg). Urine and blood samples were taken up to 92 h postadministration. Hydrolyzed plasma and urine were extracted using solid phase extraction (SPE). A sensitive tandem mass spectrometric method was developed in this study, achieving a lower limit of quantification (LLOQ) for salbutamol of 10 pg/mL in plasma and urine. The parent drug was identified using UPLC-MS/MS. Most of the determined salbutamol plasma concentrations, post last administration, lie below the LLOQ of the method and so cannot be used for plasma PK analysis. Urine PK analysis suggests a half-life consistent with the pharmacological effect duration. An estimate of the urine average concentration at steady-state was collected by averaging the concentration measurements in the dosing period from -12 to 0 h relative to the last administered dose. The value was averaged across the six horses and used to estimate an effective urine concentration as a marker of effective lung concentration. The value estimated was 9.6 ng/mL and from this a number of detection times were calculated using a range of safety factors.

Delivery of inhalation drugs to children for asthma and other respiratory diseases

Infants and children constitute a patient group that has unique requirements in pulmonary drug delivery. Since their lungs develop continuously until they reach adulthood, the airways undergo changes in dimensions and number. Computational models have been devised on the growth dynamics of the airways during childhood, as well as the particle deposition mechanisms in these growing lungs. The models indicate that total aerosol deposition in the body decreases with age, while deposition in the lungs increases with age. This has been observed on paediatric subjects in in vivo studies. Issues unique to children in pulmonary drug delivery include their lower tidal volume, highly variable breathing patterns, air leaks from facemasks, and the off-label or unlicensed use of pharmaceutical products due to lack of clinical data for this age group. The aerosol devices used are essentially those developed for adult patients that have been adapted to paediatric use. Facemasks should be used with nebulisers and spacers for infants and young children. An idealised throat that mimic the average particle deposition in paediatric throats has been designed to obtain more clinically relevant aerosol dispersion data in vitro. More effort should be spent on studying particle deposition in the paediatric lung and developing products specific for this subpopulation to meet their needs.

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.

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.

[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.

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.

Emitted doses of salbutamol pressurized metered-dose inhaler from five different plastic spacer devices

In a recent clinical study we have demonstrated that the bronchodilator effect of 200 microg salbutamol (Ventoline) was spacer device-dependent in 100 tested asthmatic children, with the Babyhaler providing greater efficacy for improving peak expiratory flow rate compared to Aeroscopic, Nebuhaler, Aerochamber and Volumatic. The aim of this present study was to correlate our clinical results to in vitro determinations of the emitted dose (ED) of Ventoline administered via these five different plastic spacer devices. ED was determined from the mean of single doses collected in unit dose sampling tubes using a constant suction flow of 28.3 L/min. Three pressurized metered-dose inhalers and three sets of spacer devices were used to obtain a total of 30 measurements per group. Inter-group results were compared by RM-ANOVA or Student-Newman-Keuls method when indicated. Babyhaler delivered significantly (P < 0.05) more salbutamol than Nebuhaler, Aerochamber and Aeroscopic (mean +/- standard deviation: 63.6 +/- 2.9 microg/100 microg actuation for Babyhaler vs. 59.4 +/- 8.6 for Nebuhaler, 50.8 +/- 5.0 for Aerochamber and 47.5 + 2.5 for Aeroscopic). The ED from Volumatic (61.5 +/- 7.9 microg/100 microg actuation) was similar to that from the Babyhaler. The variability in the ED was greatest with the large volume spacers. Despite a greater ED from the Babyhaler, in vitro results do not fully explain the in vivo results. However, the previously described clinical improvement seen with the Babyhaler may be due to the quantitatively different aerosol production in a more 'useful' size range, as well as the different breathing patterns of the children tested. The results of this present study question the relevance of mouthpiece filter collection studies using a constant sampling in predicting clinical or physiological outcomes.

Towards an integrated approach to lung health in adolescents in developing countries

The World Health Organization strategies, Integrated Management of Childhood Illness and Practical Approach to Lung health provide assessment and management guidelines for health workers in developing countries. We reviewed issues important to lung health in adolescents to highlight whether differences in factors such as adolescent behaviour have consequences for the development of case management guidelines, to form a bridge between guidelines for younger children and for adults and to make suggestions for further study. Pneumonia, asthma and tuberculosis are the leading lung health problems in adolescents. As countries industrialise, the importance of asthma mortality and morbidity increases as that of pneumonia and pulmonary tuberculosis decreases. Guidelines for managing pneumonia and asthma in children and adults in developing and developed countries should be adaptable for use in adolescents in developing countries, although more information is needed on predictors of severity such as respiratory rate cut-offs, level of fever, hypotension, malnutrition and level of consciousness. The effectiveness of low-cost treatment for asthma should be explored further. HIV and the global resurgence of tuberculosis pose significant challenges for improving adolescent lung health, and prevention of smoking initiation during adolescence is a priority goal of any integrated approach to improving lung health.

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.

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.

Emergency asthma inhalers in school

Despite there being a lack of direct evidence of the effectiveness of providing emergency inhalers to schools, the balance of evidence at present suggests the benefits outweigh any possible harm. However, unless UK prescribing law or its interpretation is changed, this will remain an action which opens teachers, nurses, and doctors to possible legal and professional sanctions, and may nullify their institutional or professional indemnity. As a consequence, provision will remain patchy and research into the value of emergency inhalers will be inhibited. A position statement from one or more responsible organisations such as the Royal College of Paediatrics and Child Health, the British Thoracic Society, or the British Paediatric Respiratory Society could persuade a reassessment from the Medicines Control Agency. This is also an issue which could be addressed in the forthcoming National Service Framework for children.

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.

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 comparison of the efficacy and tolerability of single doses of HFA 134a albuterol and CFC albuterol in mild-to-moderate asthmatic patients

BACKGROUND

After the signing of the Montreal Protocol in 1987, new propellants for use in pressurized metered-dose inhalers that are non-ozone-depleting have been developed.

OBJECTIVE

This study was designed to compare the efficacy and tolerability of single doses of albuterol/HFA 134a with albuterol/CFC and to demonstrate a dose-response among the different doses of both formulations.

METHODS

A single-center, randomized, double-blind, placebo-controlled, cross-over study. Sixty-three adolescent and adult asthmatic patients were randomized to receive at separate treatment visits single doses via a pressurized metered-dose inhaler of either placebo/hydrofluoroalkane (HFA) 134a; 100 microg, 200 microg, or 400 microg albuterol/HFA 134a; 100 microg or 200 microg albuterol/chlorofluorocarbon (CFC). Triplicate measurements of forced expiratory volume in 1 second (FEV1) were made immediately before dosing and 15 minutes, 30 minutes, 1, 2, 3, 4, 5, and 6 hours postdose. The primary efficacy variables were area under the entire 6-hour FEV1 curve, relative to baseline subtracted from the area above baseline (AUC(0-6)) and peak effect (derived from serial FEV1 measurements).

RESULTS

Analysis of AUC(0-6) and peak effect showed that all doses of albuterol had a significantly greater effect than placebo (HFA 134a propellant). Comparisons of the two formulations at 100 microg and 200 microg showed no difference in AUC(0-6) (100 microg, -0.23 Lhr, P = 0.114 and 200 microg -0.08 Lhr, P = 0.590) or in peak effect, percentage of baseline (100 microg, -1.3%, P = 0.354 and 200 microg, 0.17%, P = 0.902). There were no differences seen among formulations in the incidence of adverse events or with any of the other safety parameters, including electrocardiograms, vital signs, clinical laboratory assessments, and asthma exacerbations.

CONCLUSIONS

The study demonstrated comparability in terms of efficacy and safety between albuterol/HFA 134a and albuterol/CFC.

Patient self-management of acute asthma: adherence to national guidelines a decade later

BACKGROUND AND OBJECTIVES

Children in the emergency department (ED) with acute asthma were enrolled to assess the impact of asthma on their activities of daily living and evaluate their access to care and preventive strategies, determine the proportion who adhered to the National Heart, Lung, and Blood Institute (NHLBI) guidelines for proper steps to take at home during an acute asthma exacerbation, and compare adherence rates for those with persistent and mild intermittent asthma.

DESIGN AND METHODS

Children 2 to 18 years old who presented to the Children's Hospital of Philadelphia's ED with acute asthma exacerbations were enrolled prospectively. Parents and patients completed the 108-item Asthma Exacerbation Response Questionnaire with a focus on determining the home management steps they took both at the onset of the asthma exacerbation and just before coming to the ED.

RESULTS

Among the 433 children studied, 76% had at least 1 doctor visit, 75% had at least 1 ED visit, and 43% had at least 1 hospitalization for asthma in the preceding 12 months. Overall, 64% had persistent asthma by NHLBI criteria, yet just 4% were cared for by an allergist or pulmonologist, 38% took daily anti-inflammatory therapy, and 18% received a daily inhaled corticosteroid. Also, 48% did not use a holding chamber with their metered-dose inhalers, and 66% did not use their peak flow meters. Regarding exacerbation response, 71% did not have a written action plan, and 89% did not maintain a symptom diary. Both at the onset of wheezing and just before coming to the ED, administration of a beta2-agonist was the only step that the majority of children performed. One-third or fewer followed the other steps recommended by the NHLBI, including using a peak flow meter, beginning oral corticosteroids, calling or going to see the doctor, or going to the ED. Children with persistent asthma were not more adherent to the guidelines than those with mild intermittent disease.

CONCLUSIONS

Asthma has a significant adverse effect on the lives of these children. The NHLBI guidelines, first published a decade ago, were designed to reduce asthma's increasing morbidity and mortality, but this study uncovered a high rate of nonadherence with many aspects of the guidelines, including preventive strategies and home management of an exacerbation.

Children with asthma and nebulizer use: parental asthma self-care practices and beliefs

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.

Delivery of HFA and CFC salbutamol from spacer devices used in infancy

The aim of the study was to compare the in vitro delivery of four salbutamol pressurized metered-dose inhalers (pMDIs) via the three spacer devices commonly used in European infants: Aerochamber-Infant, Babyhaler, and metallic NES-spacer. Emitted dose (ED) and fine particle dose (FPD, particles<5.8 microm) of each combination of spacer device and pMDI (chlorofluorocarbon-based Ventoline, Eolène, Spréor, and hydrofluoroalkane-based Airomir were measured respectively using unit dose sampling tubes (n=30 per combination) and an 8-stage cascade impactor (n=6 per group). The results were compared by analysis of variance and the Student-Newman-Keuls method. ED of Airomir was always greater than for Ventoline (P<0.05). FPD obtained with Ventoline was the lowest, with Eolène>Airomir=Spréor>Ventoline (P<0.05). Only Airomir produced a similar FPD with all three spacer devices. Chlorofluorocarbon-salbutamol pMDIs are not generics when used with spacer devices. The three spacer devices may be used interchangeably with Airomir.

Relative bioavailability of salbutamol to the lung following inhalation when administration is prolonged

AIMS

Urinary salbutamol post-inhalation has been shown to be an index of lung deposition. The possibility of using the urinary method for prolonged periods of inhalation (such as nebulized therapy) has been evaluated.

METHODS

On separate study days volunteers received salbutamol 5 x 100 microg via either oral administration (ORAL), oral with 5 g oral charcoal (ORAL + C), inhaled from a metered dose inhaler (MDI) or MDI plus 5 g oral charcoal (MDI + C). Each dose was separated by 2 min, i.e. administration time of 8 min. Urine samples were provided at 0, 30, 40, 60 and 120 min postdose. Also seven subjects inhaled 5x100 microg doses from the MDI on five separate occasions and provided urine 0-30 min post dose.

RESULTS

No salbutamol was detected in urine samples following ORAL + C. The mean (s.d.) amounts of salbutamol excreted in the urine in the first 30 min post ORAL, MDI and MDI + C were 0.42 (0.55), 11.01 (3.77) and 11.60 (3.68) microg, respectively. The ratio of urinary salbutamol following MDI and MDI + C to ORAL in the 0-30 min collection period was 26.2 and 27.8, and between 30 and 40 min postdose was 5.1 and 4.7, respectively. There was no difference between urinary salbutamol over the first 30 min following MDI and MDI + C with a mean ratio (90% confidence interval) of 95.6 (84.0, 107.2). The mean (s.d.) coefficient of variation for the 30 min urinary salbutamol elimination following inhalation of 5 x 100 microg doses from the MDI by seven subjects (on 5 separate study days) was 9.4 (2.3)%.

CONCLUSIONS

The 30 min urinary salbutamol method can be used for an inhalation period of up to 8 min to identify the relative bioavailability to the lung. Samples taken after this time period are affected by excretion of the oral absorbed fraction. Most nebulisers deliver their dose within this administration time.

Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma

OBJECTIVE

To compare the costs and effectiveness of albuterol by metered dose inhaler (MDI) and spacer versus nebulizer in young children with moderate and severe acute asthma.

DESIGN

Randomized, double-blind, placebo-controlled trial in an emergency department at a children's hospital. The participants were children 1 to 4 years of age with moderate to severe acute asthma. Patients assigned to the spacer group received albuterol (600 microg) by MDI by spacer (AeroChamber) followed by placebo by nebulizer (n = 30). The nebulizer group received placebo MDI by spacer followed by 2.5 mg albuterol by nebulizer (n = 30). Treatments were repeated at 20-minute intervals until the patient was judged to need no further doses of bronchodilator, or a total of 6 treatments.

RESULTS

Clinical score, heart rate, respiratory rate, auscultatory findings, and oxygen saturation were recorded at baseline, after each treatment, and 60 minutes after the last treatment. Baseline characteristics and asthma severity were similar for the treatment groups. The spacer was as effective as the nebulizer for clinical score, respiratory rate, and oxygen saturation but produced a greater reduction in wheezing (P =.03). Heart rate increased to a greater degree in the nebulizer group (11.0/min vs 0.17/min for spacer, P <.01). Fewer children in the spacer group required admission (33% vs 60% in the nebulizer group, P =.04, adjusted for sex). No differences were seen in rates of tremor or hyperactivity. The mean cost of each emergency department presentation was NZ$825 for the spacer group and NZ$1282 for the nebulizer group (P =.03); 86% of children and 85% of parents preferred the spacer.

CONCLUSION

The MDI and spacer combination was a cost-effective alternative to a nebulizer in the delivery of albuterol to young children with moderate and severe acute asthma.

Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age

The aim of this study was to compare the efficacy of salbutamol delivered via a metered-dose inhaler with a spacer and facial mask (MDI-S) vs. a nebulizer (NEB) for the treatment of acute exacerbations of wheezing in children. In a single-blind, prospective, randomized clinical trial, 123 outpatients (1-24 months of age), presenting with "moderate to severe" wheezing, were seen in the emergency department. Children were randomly assigned to one of two salbutamol treatment groups. In the first hour, the MDI-S group received 2 puffs (100 microg/puff) every 10 min for 5 doses, and the NEB group received 0.25 mg/kg every 13 min for 3 doses. If the clinical score was >5 at the end of the first hour, the patients received another hour of the same treatment and also betamethasone (0.5 mg/kg intramuscular). On enrollment and after the first and the second hour of treatment each child had a validated clinical score assigned by a blinded investigator. There were no differences at the time of admission to the emergency department between groups in clinical score or demographic data. Success (clinical score </=5) after the first hour of treatment was 90% (56/62) in the MDI-S group and 71% (43/61) in the NEB group (odds ratio 3.9, 95% confidence interval 1.5-10.4, P = 0.01). After the second hour, the success was 100% in the MDI-S and 94% in the NEB (P > 0.05). We conclude that in this study population, children less than 2 years of age with moderate-severe exacerbations of wheezing responded faster to salbutamol delivered by MDI with a spacer and facial mask than to salbutamol delivered by nebulizer.

Aerosol therapy for asthma

Inhaled drugs play an important role in asthma management. The correct use of an appropriate delivery device is necessary to achieve the desired therapeutic effects of the drug. Currently, chlorofluorocarbon-propelled metered-dose inhalers, with or without spacers, are the most popular aerosol delivery devices. With the planned phase out of the chlorofluorocarbon metered-dose inhalers, the use of other delivery devices is being emphasized. To achieve optimal therapeutic effects, the drug and the delivery device should be considered a "couple". Aerosol delivery devices should provide an adequate "drug dose to the lung", be cost effective, simple to operate, minimize oropharyngeal deposition and systemic side effects, and match the patient's requirements. A new generation of aerosol delivery devices, incorporating the latest advances in aerosol technology, is likely to fulfill many of the goals mentioned above.

Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma

OBJECTIVE

In children with mild acute asthma, to compare treatment with a single dose of albuterol delivered by a metered dose inhaler (MDI) with a spacer in either a weight-adjusted high dose or a standard low-dose regimen with delivery by a nebulizer.

STUDY DESIGN

In this randomized double-blind trial set in an emergency department, 90 children between 5 and 17 years of age with a baseline forced expiratory volume in 1 second (FEV1 ) between 50% and 79% of predicted value were treated with a single dose of albuterol, either 6 to 10 puffs (n = 30) or 2 puffs (n = 30) with an MDI with spacer or 0.15 mg/kg with a nebulizer (n = 30).

RESULTS

No significant differences were seen between treatment groups in the degree of improvement in percent predicted FEV1 (P =.12), clinical score, respiratory rate, or O2 saturation. However, the nebulizer group had a significantly greater change in heart rate (P =.0001). Our study had 93% power to detect a mean difference in percent predicted FEV1 of 8 between the treatment groups.

CONCLUSION

In children with mild acute asthma, treatment with 2 puffs of albuterol by an MDI with spacer is just as clinically beneficial as treatment with higher doses delivered by an MDI or by a nebulizer.

Inhalation therapy in asthma: nebulizer or pressurized metered-dose inhaler with holding chamber? In vivo comparison of lung deposition in children

OBJECTIVE

To compare lung deposition from a nebulizer and a pressurized metered-dose inhaler (pMDI)/holding chamber to determine their efficiency in aerosol delivery to children.

STUDY DESIGN

Children with stable asthma (n = 17) aged 2 to 9 years inhaled in random order radiolabeled salbutamol from a nebulizer and a pMDI through a nonstatic holding chamber. Body and lung deposition of radiolabeled salbutamol was assessed with a gamma camera.

RESULTS

Mean (absolute dose) total lung deposition expressed as a percentage of the nebulized dose was 5.4% (108 microg) in younger children (<4 years) and 11.1% (222 microg) in older children (>4 years). Mean (absolute dose) total lung deposition expressed as a percentage of the metered dose was 5.4% (21.6 microg) in younger and 9.6% (38.4 microg) in older children.

CONCLUSIONS

For the same age groups we have shown equivalent percentages of total lung deposition of radiolabeled salbutamol aerosolized by either a nebulizer or a pMDI/holding chamber. However, the delivery rate per minute and the total dose of salbutamol deposited were significantly higher for the nebulizer.

Relation between pulse oximetry and clinical score in children with acute wheezing less than 24 months of age

The aim of this study was to determine the relation between transcutaneous hemoglobin oxygen saturation, measured by pulse oximetry (SpO2), and clinical score values in 138 infants (mean+/-SD, 6.6+/-5.5 months of age) with acute wheezing episodes presenting in a primary care outpatient setting. A single investigator evaluated the severity of the acute wheezing episodes by assigning a clinical score and was unaware of the SpO2 values. Another investigator measured SpO2 values on all subjects. The mean (+/-SD) SpO2 value was 98.2+/-1.1% for children with clinical scores of 2-5 (n = 32); 95.4+/-1.5% for those with scores of 6-7 (n = 82), and 92.9+/-2% for children with scores of 8-10 (n = 24), (P < 0.001 by Bonferroni's multiple comparison, when all two-way comparisons were done for each pair of results). The clinical score showed a good correlation with SpO2 (r = -0.76; 95% CI, -0.83 to -0.68). We conclude that if pulse oximetry is not available, it is advisable to include oxygen in the therapy of wheezy infants with clinical scores values >8.

A randomised controlled trial to assess the relative benefits of large volume spacers and nebulisers to treat acute asthma in hospital

OBJECTIVES

To compare the clinical effectiveness, acceptability, and cost benefit of administering beta2 agonists by means of a metered dose inhaler and large volume spacer with conventional nebulisers to children admitted to hospital with acute asthma.

METHODS

A randomised controlled trial was conducted over five months. Sixty one children older than 3 years admitted to a large teaching hospital and a district general hospital with acute asthma completed the study. Children received either 5 mg of salbutamol up to one hourly by jet nebuliser, or up to 10 puffs of salbutamol 100 microg by means of a metered dose inhaler and spacer up to one hourly.

RESULTS

Median hospital stay was 40 hours in the nebuliser group and 36.5 hours in the spacer group. Asthma disability scores at two weeks after discharge were significantly improved in the spacer group. Drug costs were pound 14.62 less for each patient in the spacer group.

CONCLUSIONS

Large volume spacers are an acceptable, cost effective alternative to nebulisers in treating children admitted with acute asthma, provided that the children can use the mouthpiece, and symptoms are not severe. Their use facilitates effective home treatment by parents, with subsequent reduction in morbidity and re-admission rates.

Comparative physicochemical and pharmacokinetic profiles of inhaled beclomethasone dipropionate and budesonide

The physicochemical and pharmacokinetic characteristics of BDP and budesonide are somewhat different, but the overall result is that both are well suited for use as inhaled corticosteroids. Both BDP and budesonide are metabolized primarily by the liver, with one of the metabolites of BDP, 17-BMP, having greater receptor affinity than either the parent compound or budesonide, which has no active metabolites. BDP has a lower water solubility than either 17-BMP or budesonide, which have similar water solubilities. Budesonide has lower oral bioavailability than BDP; however, it is generally reported to have a longer plasma half-life than either BDP or 17-BMP. The physicochemical and pharmacokinetic profiles of inhaled BDP and budesonide provide both compounds with a favourable ratio of topical to systemic effects and support their well-established role in the treatment of asthma. The device used to deliver an inhaled corticosteroid influences the lung deposition of the drug and selection of the device should be made with an understanding of the particular advantages and disadvantages of the device for each individual patient.

Efficacy of metered-dose inhaler administration of albuterol in intubated infants

STUDY OBJECTIVE

To compare the safety and efficacy of metered-dose inhaler (MDI) albuterol to nebulized (NEB) albuterol administration.

DESIGN

A randomized, triple-blinded, crossover study.

SETTING

A pediatric ICU in a tertiary care children's hospital.

PATIENTS

Eleven intubated infants with bronchiolitis.

INTERVENTIONS

Subjects received four puffs of MDI albuterol (360 microg) and 3 mL of NEB saline solution placebo or 0.3 mL of NEB albuterol (1.5 mg) and MDI saline solution placebo. Each set of albuterol and saline solution placebo was administered after direct attachment of delivery device to the endotracheal tube and bag-valve system. Subjects received the opposite sequence 4 h after the initial sequence. The second sequence was given first the next day, and the first sequence was administered 4 h later.

MEASUREMENTS AND RESULTS

Respiratory system compliance and resistance were measured at baseline and 30 min, 1 h, 2 h, and 4 h after each set of placebo and albuterol. There was an appreciable improvement in compliance and resistance for up to 2 h following both methods of administration. However, the degree of improvement was not significantly different (p>0.05) between the two methods. Neither method caused a significant change in resistance when measured at 4 h after albuterol/placebo administration. No evidence of toxicity was detected.

CONCLUSIONS

MDI-administered albuterol is as safe and efficacious as nebulized-administered albuterol in intubated infants with bronchiolitis. Generalizability of these results is limited by differences in drug delivery with different brands of nebulizers and spacers and sites of attachment.

Effects of salbutamol delivery from a metered dose inhaler versus jet nebulizer on dynamic lung mechanics in very preterm infants with chronic lung disease

Treatment of chronic lung disease of prematurity requires effective aerosol delivery of different therapeutic agents. Aerosols can be generated by a metered dose inhaler (MDI) or a jet nebulizer. An MDI combined with a spacer device is easier to use and avoids undesirable effects noted in conjunction with jet nebulization. We compared the clinical effectiveness of 200 micrograms (2 puffs) salbutamol delivered from an MDI in conjunction with a valved spacer device (Aerochamber), and 600 micrograms given via jet nebulizer (PariBaby) on 2 consecutive days, the order being randomized. Thirteen spontaneously breathing very preterm infants [mean (SD) gestational age 27.2 (1.8) weeks; birth weight 0.90 (0.34) kg] were studied at a corrected age of 37 (2.3) weeks. Mean (SD) study weight was 1.83 (0.38) kg. Dynamic lung compliance and resistance were determined from measurements of flows, volumes, and transpulmonary pressures, using a pneumotachometer and a small esophageal microtransducer catheter before and 20 min after salbutamol application. Baseline values before salbutamol administration were similar on both occasions: the mean (SD) compliance was 7.7 (3.0) mL.kPa-1.kg-1 pre-MDI plus-spacer and 8.4 (3.1) pre-jet nebulizer; the resistance was 10.4 (4.0) kPa.L-1.s pre-MDI plus-spacer and 9.7 (3.4) pre-jet nebulizer. Following salbutamol, compliance did not change significantly with either MDI plus spacer or jet nebulizer. Resistance fall significantly with MDI plus spacer (mean -2.2; 99.9% CI -0.35, -4.35) and jet nebulizer (-2.4; 99% CI -0.39, -4.42). We conclude that even in small preterm infants 200 micrograms salbutamol via MDI plus spacer improves dynamic resistance as effectively as 600 micrograms via jet nebulizer and may therefore be a preferable mode of aarosol administration.

Terbutaline nebulization and epinephrine injection in treating acute asthmatic children

Ninety children with acute asthma, equally divided into two study groups, were studied to compare the efficacy and safety of nebulized terbutaline with injected epinephrine in the treatment of acute exacerbation. The terbutaline group received 2 ml (5,0 mg) terbutaline solution diluted with 2 ml 0.9% saline for inhalation over 10 minutes; the epinephrine group received 0.01 ml/kg of 1:1000 epinephrine (maximum 0,3 ml) through subcutaneous injection at deltoid area. Spirometry, pulse oximetry, and clinical severity scoring system were evaluated at baseline and again 15 minutes after treatment. The baseline data of the two groups were not significantly different. The clinical severity score and spirometry of both groups were significantly improved after treatment. Compared with the terbutaline group, the epinephrine group had better mean oxygen saturation (SaO2; p < 0.001), frequency of oxygen desaturation (p = 0.0028) and forced expiratory flow 25-75% (FEF25-75%, p = 0.027). For those patients with initial forced expiratory volume in one second (FEV1) lower than 60% of predicted value, epinephrine treatment was more effective in the improvement of FEV1, FEF25-75%, and oxygen saturation (SaO2) (p = 0.011, 0.012, and 0.006, respectively). A Significantly higher rate of adverse effects occurred in patients given epinephrine (47% vs 11%, p = 0.0002); these included pallor, tremor, dizziness, headache, palpitation, soreness of legs, numbness of extremities, cold sweating, general weakness and nausea. Considering the general trend to noninvasive therapy in children and the more frequent adverse effects after epinephrine injection, such nebulized beta-2 agonists as terbutaline appear preferable for initial therapy of acute asthma if oxygen is supplemented to prevent possible hypoxemia. However, parenteral epinephrine still is worth trying, particularly in any severe, life-threatening attack.