Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial

Abstract

Introduction In moderate‐severe asthma exacerbation, salbutamol by inhaler (MDI) is superior to salbutamol delivered by nebulizer (NEB); however, to our knowledge, no studies in children with exclusively severe exacerbations were performed. Objective To compare the efficacy of salbutamol and ipratropium bromide by MDI versus by NEB in severe asthma exacerbations. Methods We performed a clinical trial enrolling 103 children (2‐14 years of age) with severe asthma exacerbations (defined by the Pulmonary Score ≥ 7) seen at the emergency room in Asuncion, Paraguay. One group received salbutamol and ipratropium (two puff every 10 min for 2 h and then every 30 min for 2 h more) by MDI with a valved‐holding chamber and mask along with oxygen by a cannula separately (MDI‐SIB); and the other received nebulization with oxygen (NEB‐SIB) of salbutamol and ipratropium (1 every 20 min for 2 h and then every 30 min for 2 h more). Primary outcome was the rate of hospitalization (Pulmonary Score ≥ 7) after 4 h and secondary outcome was oxygen saturation. Results Fifty two children received MDI‐SIB and 51 NEB‐SIB. After the 4th hour, children on MDI‐SIB had significantly (P = 0.003) lower rate of hospital admission than on NEB‐SIB (5.8% vs 27.5%, RR: 0.21 [0.06‐0.69], respectively). Similarly, a significant improved clinical score after 60 min and increase in oxygen saturation after 90 min of treatment was observed in MDI‐SIB versus NEB‐SIB group (4.46 ± 0.7 vs 5.76 ± 0.65, P < 0.00001; and 90.5 ± 1.7 vs 88.43 1 ± 1, P < 0.00001, respectively). Conclusion Even in severe asthma exacerbations administration of salbutamol and ipratropium by MDI with valved‐holding chamber and mask along with oxygen by a cannula separately was more effective than by a nebulizer.

Impact of COVID-19 on Pediatric Asthma: Practice Adjustments and Disease Burden

“…In addition, use of several diagnostic modalities, including lung function testing, fractional exhaled nitric oxide, or methacholine tests, is limited, along with therapeutic interventions, such as nebulized treatments. 16 However, many services have actively responded to these challenges, most often by "virtual" clinics or other telehealth appliances, which flourished in all medical specialties during the COVID-19 epidemic. 17 Clinicians consider such clinics suboptimal, nonetheless adequate for the, hopefully, short time period under lockdown.…”

Asthma and COVID-19 in children – a systematic review and call for data

“…The Global Initiative for Asthma (GINA) recommends avoiding the use of nebulizers due to the increased risk of disseminating COVID-19 to other patients and healthcare staff; they thus recommend the use of pressurized metered dose inhalers (pMDI) as the preferred delivery system during asthma attacks [43]. A recent randomized controlled trial (RCT) [44] showed that even in children with severe asthma exacerbations, administration of albuterol/salbutamol and ipratropium by MDI with valved-holding chamber and mask along with oxygen by nasal cannula was more effective than nebulized administration. GINA[43] and the British Thoracic Society[45] do not recommend stopping oral steroids in the patients already taking them for asthma management, and they do not recommend avoiding them for acute asthma attacks even if due to COVID-19.…”

A comparison of the costs of bronchodilator delivery methods in children with asthma exacerbations treated in hospital. The first Polish study in children

“…These analyses help in choosing the method of treatment of a given disease -which one is most costeffective while maintaining the highest clinical effective-ness. Research to date has shown that SABA as well as the combination of SABA and SAMA used in aerosol therapy of respiratory diseases may differ not only in the method of administration, but also in clinical effectiveness, safety and costs associated with their use in patients [3][4][5][6][7][8][9]. Research results indicate that regardless of the calculation method, the use of SABA with pMDI in combination with a valved holding chamber (VHC) instead of NEB is associated with a reduction in total costs in both the emergency department and the hospital ward [10][11][12][13][14][15].…”