Thomas Gibson, BSc SRT, Conestoga College

Asthma is a chronic condition characterized by inflammation and hyperresponsiveness within the airways that can cause shortness of breath, chest tightness, wheezing and coughing (Kacmarek, Stoller & Heuer, 2020). In Canada, 3.8 million people live with asthma and 850,000 of these cases are found in children (Asthma Canada, 2020). Not only is asthma the most common chronic disease for Canadian children, it is also one of the most common causes for pediatric hospitalization in Canada (Canadian Institute for Health Information, 2018). During severe asthma exacerbation, the beta-2-adrenergic agonist salbutamol is commonly administered and can be delivered through multiple devices including inhalers and nebulizers with mask (Kacmarek, Stoller & Heuer, 2020; Pool & Cremonesini, 2014).

Salbutamol Delivery in Pediatric Patients with Severe Asthma Exacerbation

A study conducted by Iramain et al. (2018) examined the differences in administration of salbutamol and ipratropium via inhaler versus nebulizer. This was a randomized clinical trial and had 103 participants between the age of 2 and 14 that were being seen in an emergency room for severe asthma exacerbation. Half of the participants in this study were administered salbutamol and ipratropium via metered dose inhaler (MDI) with a valved-holding chamber and mask while simultaneously receiving oxygen therapy via nasal cannula. The other half of the participants received salbutamol and ipratropium via nebulizer with mask. It was found that patients who received treatment through MDI had significantly higher clinical scores and oxygen saturation than patients who received treatment through nebulizers. In addition, after 4 hours from arrival into the emergency room, there were significantly fewer hospital admissions in the MDI group in comparison to the nebulizer group. It should be noted that Iramain et al. (2018) found that patients who received treatment through nebulizers did display clinical improvement, however the time to clinical improvement was significantly longer than in the MDI group.

Salbutamol Delivery in Invasive Mechanically Ventilated Patients

Furthermore, a study conducted by ElHansy et al. (2016) supports the findings of Iramain et al. (2018) by looking at the pulmonary deposition and systemic absorption of salbutamol with differing delivery methods in invasive mechanically ventilated adults. In this study by ElHansy et al. (2016), multiple vibrating mesh nebulizers, jet nebulizers and MDIs with aerochamber were tested.  By measuring salbutamol concentration in the urine and within ventilator filters, this study concluded that MDIs with aerochamber had higher salbutamol delivery for any given dose when compared to every other type of nebulizer.

Additional Benefits to Using Metered Dose Inhalers

In addition to delivery effectiveness, many clinicians have also noted there is a cost benefit of using MDIs instead of nebulizers (Rodriguez-Martinez et al., 2020). On top of this, another consideration for choosing MDIs instead of nebulizers is the ease of use for patients and their caregivers. Children diagnosed with asthma at an early age should already be familiar with MDIs and valved-chamber plus mask, making emergency administration of inhaled medication more tolerable for pediatric patients (Pool & Cremonesini, 2014).

Clinical Implications

To summarize, there is evidence for clinicians to administer salbutamol via MDIs with valved-chamber and mask while simultaneously providing oxygen therapy via nasal cannula, instead of using nebulizers for pediatric patients experiencing severe asthma exacerbation (ElHansy et al., 2018; Iramain et al., 2018). The information presented promotes the opportunity for Respiratory Therapists to review the evidence and to educate fellow clinicians as well as patients and their caregivers on providing the best evidence-based care possible for pediatric patients experiencing severe asthma exacerbation.

References

Asthma Canada. (2020, July). Asthma Facts and Statistics [Fact sheet]. https://asthma.ca/wp-content/uploads/2020/07/Asthma-101.pdf

Canadian Institute for Health Information. (2018, April). Asthma Hospitalizations Among Children and Youth in Canada: Trends and Inequalities [Chartbook]. https://www.cihi.ca/sites/default/files/document/asthma-hospitalization-children-2018-chartbook-en-web.pdf

ElHansy, M. H. E., Boules, M. E., Essawy, A. F. M. E., Al-Kholy, M. B., Abdelrahman, M. M., Said, A. S. A., Hussein, R. R. S., & Abdelrahim, M. E. (2016). Inhaled salbutamol dose delivered by jet nebulizer, vibrating mesh nebulizer and metered dose inhaler with spacer during invasive mechanical ventilation. Pulmonary Pharmacology & Therapeutics, 45, 159-163. http://dx.doi.org/10.1016/j.pupt.2017.06.004

Iramain, R., Castro-Rodriguez, J. A., Jara, A., Cardozo, L., Bogado, N., Morinigo, R., & Jesus, R. D. (2018). Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial. Pediatric Pulmonology, 54(4), 372-377. https://doi.org/10.1002/ppul.24244

Kacmarek, R. M., Stoller, J. K., & Heuer A. J. (2020). Egan’s Fundamentals of Respiratory Care (12th ed.). Elsevier.

Pool, J., & Cremonesini, D. (2014). Asthma inhaler use in young children. Community Practitioner, 87(12), 44-48.

Rodriguez-Martinez, C. E., Sossa-Briceno, M. P., Castro-Rodriguez, J. A. (2020). Metered dose inhalers vs nebulization for the delivery of albuterol in pediatric asthma exacerbations: A cost effectiveness analysis in a middle income country. Pediatric Pulmonology, 55(4), 866-873. https://doi-org.eztest.ocls.ca/10.1002/ppul.24650

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