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

Bushey Health Centre, Manor View Practice, London Road, Bushey, Watford, Hertfordshire, UK, WD23 2NN.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 02/2006; 2(2):CD000052. DOI: 10.1002/14651858.CD000052.pub2
Source: PubMed


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.
To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma.
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).
Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation.
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).
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).
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.

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    • "SABAs are delivered via wet nebulization or metered dose inhaler (MDI) (1). MDIs may provide better clinical outcomes and fewer adverse effects compared with nebulizers (11); however, nebulizers are useful for young children, older adults, and for patients who are unable to use an MDI. "
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    ABSTRACT: Background: Asthma remains a serious global health challenge. Poor control of asthma symptoms is due in part to incorrect use of oral inhaler devices that deliver asthma medications, such as poor inhalation technique or use of a metered dose inhaler (MDI) after the recommended number of doses is expelled. Objective: To review published research on the potential for patients to overestimate or underestimate the amount of asthma rescue medication in MDIs without integrated dose-counting mechanisms. Methods: We searched PubMed and EMBASE using search terms "dose counter and asthma" and "dose counter and metered dose inhaler" for English language publications up to July, 2012, with a manual search of references from relevant articles. Results: Up to 40% of patients believe they are taking their asthma medication when they actually are activating an empty or nearly empty MDI. Device design makes it impossible for an MDI to cease delivering drug doses at an exact point, and the number of actuations in an MDI may be twice the nominal number of recommended medication doses. Once the recommended number of medication doses is expelled, remaining actuations deliver decreasing concentrations of active medication and increasing concentrations of propellants and excipients. This phenomenon, called "tail-off," is particularly problematic when medications are formulated as suspensions, as are rescue medications to control acute bronchospasm. Reliable inhalation of rescue medication could reduce asthma-related morbidity. Conclusion: By helping ensure that patients receive accurate metered doses of asthma rescue medication to relieve bronchoconstriction, dose counters may help improve asthma management.
    Journal of Asthma 04/2013; 50(6). DOI:10.3109/02770903.2013.789056 · 1.80 Impact Factor
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    • "Nonetheless, despite the effectiveness of delivering a bronchodilator via the metered dose route [3,4], nebulized salbutamol is still very much preferred because of its convenience [5]. Most patients when visiting an emergency department expect to be given "something more" than the metered dose inhalers that they had been taking at home. "
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    ABSTRACT: Conventionally, a nebulized short-acting β-2 agonist like salbutamol is often used as the reliever in acute exacerbations of asthma. However, recent worldwide respiratory outbreaks discourage routine use of nebulization. Previous studies have shown that combined budesonide/formoterol (Symbicort®, AstraZeneca) is effective as both a maintenance and reliever anti-asthmatic medication. We performed a randomized, open-label study from March until August 2011 to compare the bronchodilatory effects of Symbicort® vs. nebulized salbutamol in acute exacerbation of mild to moderate asthmatic attack in an emergency department. Initial objective parameters measured include the oxygen saturation, peak expiratory flow rate (PEFR) and respiratory rate. During clinical reassessment, subjective parameters [i.e., Visual Analog Scale (VAS) and 5-point Likert scale of breathlessness] and the second reading of the objective parameters were measured. For the 5-point Likert scale, the patients were asked to describe their symptom relief as 1, much worse; 2, a little worse; 3, no change; 4, a little better; 5, much better. Out of the total of 32 patients enrolled, 17 patients (53%) were randomized to receive nebulized salbutamol and 15 (47%) to receive Symbicort®. For both treatment arms, by using paired t- and Wilcoxon signed rank tests, it was shown that there were statistically significant improvements in oxygen saturation, PEFR and respiratory rate within the individual treatment groups (pre- vs. post-treatment). Comparing the effects of Symbicort® vs. nebulized salbutamol, the average improvement of oxygen saturation was 1% in both treatment arms (p = 0.464), PEFR 78.67 l/min vs. 89.41 l/min, respectively (p = 0.507), and respiratory rate 2/min vs. 2/min (p = 0.890). For subjective evaluation, all patients reported improvement in the VAS (average 2.45 cm vs. 2.20 cm), respectively (p = 0.765). All patients in both treatment arms reported either "a little better" or "much better" on the 5-point Likert scale, with none reporting "no change" or getting worse. This study suggests that there is no statistical difference between using Symbicort® vs. nebulized salbutamol as the reliever for the first 15 min post-intervention.
    International Journal of Emergency Medicine 04/2012; 5(1):16. DOI:10.1186/1865-1380-5-16
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    • "Oxygen cannot be given with a pMDI and spacer, excluding this method in the most severe attacks. However, in children without initial oxygen requirements, β2-agonist administered via a pMDI and spacer was less likely to provoke hypoxia and tachycardia compared to the administration via a nebuliser [32,35]. Therefore, pMDI and spacer has been recommended as the preferred mode of administration for β2-agonist in paediatric acute asthma [31]. "
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    ABSTRACT: Acute severe asthma is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition. In this article we present a summary of the pathophysiology as well as guidelines for the treatment of acute severe asthma in children. The cornerstones of the management of acute asthma in children are rapid administration of oxygen, inhalations with bronchodilators and systemic corticosteroids. Inhaled bronchodilators may include selective b2-agonists, adrenaline and anticholinergics. Additional treatment in selected cases may involve intravenous administration of theophylline, b2-agonists and magnesium sulphate. Both non-invasive and invasive ventilation may be options when medical treatment fails to prevent respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 10/2009; 17(1):40. DOI:10.1186/1757-7241-17-40 · 2.03 Impact Factor
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