Original Articles
Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma,☆☆

Presented at the Presidential Plenary Session, 38th Annual Meeting of the Ambulatory Pediatric Association, Pediatric Academic Societies’ 1998 Annual Meeting, New Orleans, Louisiana, May 1-5, 1998.
https://doi.org/10.1016/S0022-3476(00)90013-1Get rights and content

Abstract

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 μg) 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. (J Pediatr 2000;136:497-502)

Section snippets

METHODS

Children were eligible if they were 1 to 4 years of age and presented with an acute exacerbation of asthma to the ED of the Starship Children’s Hospital in Auckland, New Zealand. Baselineobservations included heart rate, respiratory rate, chest findings on auscultation, and room air oxygen saturation (saturation measured noninvasively with Nellcor pulse oximeter). Wheezing, heart rate, and accessory muscle use were graded on a scale of 0 to 3 (Table I) and a summary asthma clinical severity

RESULTS

Sixty children entered the study: 30 in each treatment group. The treatment groups were similar with respect to age, but a higher proportion of the nebulizer group was male (80.0% vs 47%, P =.02). The groups were similar for measures of asthma severity in history, usual asthma therapy, and medication received in the 24 hours before presentation to ED (Table II); 78% of the spacer group had received inhaled bronchodilator in the previous 24 hours compared with 80% of the nebulizer group.

. Baseline

DISCUSSION

Comparisons between spacer and nebulizer treatment suggest they are equivalent methods of delivery of bronchodilator to children with mild or moderate asthma.13, 14, 15, 16, 17, 18 However, most studies specifically exclude children with severe asthma,14, 15, 16 and few include children <5 years of age.14, 26, 27, 28 Studies including young children with moderate and severe asthma have reported difficulties with valve movement in the spacer26 and a modest withdrawal rate because of lack of

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      The literature suggests that standard administration of nebulized bronchodilators takes more time than administration of these medications via MDI/VHCs even when all actuations or “puffs” of medication are not given simultaneously.9,13,14 In a study from New Zealand, the time required for administration of albuterol via MDI/VHC was 1.5 minutes compared to 10 minutes for albuterol administered via nebulizer.9 In a Saudi Arabian study, the mean time for medication preparation by clinical staff decreased by 98% (from 2.05 minutes to 0.3 minutes) and medication delivery time decreased by 48% (from 9.39 minutes to 4.38 minutes) with MDI/VHC use compared with nebulizer use.14

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    Supported by a grant from the Asthma and Respiratory Foundation of New Zealand and performed during Allen and Hanbury (Glaxo Wellcome) Paediatric Respiratory Research Fellowship (Drs Leversha and Campanella). Boehringer Ingelheim NZ Ltd supplied the AeroChambers. The analysis and article were completed during a Postgraduate Scholarship from the Health Research Council of New Zealand (Dr Leversha).

    ☆☆

    Reprint requests: A. Leversha, MBChB, MPH, General Paediatrics, Starship Children’s Hospital, Private Bag 92-024, Auckland, New Zealand.

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