Chest
Volume 112, Issue 2, August 1997, Pages 348-356
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Emergency Treatment of Acute Asthma With Albuterol Metered-Dose Inhaler Plus Holding Chamber: How Often Should Treatments Be Administered?

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Study objective

To determine the optimal treatment interval for administering albuterol metered-dose inhaler (MDI) with a holding chamber to patients presenting to the emergency department (ED) with acute asthma.

Design

Prospective, randomized, double-blind study.

Setting

EDs of two affiliated teaching hospitals in the Bronx, NY.

Patients

One hundred adult patients with acute asthma and FEV1 <60% predicted of normal.

Interventions

At entry (T=0 min), eligible patients all openly received inhaled albuterol (six puffs) via MDI with a spacer. Subsequently, in a double-blind fashion, they received six puffs of albuterol or placebo with new MDIs and spacers at 30,60, and 90 min such that group 1 (n=34) received albuterol every 30 min, group 2 (n=33) every 60 min, and group 3 (n=33) at 120 min only. FEV1 and vital signs were measured at T=0 and at 15,30,60,90, and 120 min following initial treatment. Potassium levels were measured at T=0 and 120 min. Adverse events, the use of additional inhaled β-agonists or systemic corticosteroids, and hospitalization rates were recorded.

Measurements and results

At T=0, the groups did not differ in age, FEV1, or prescribed asthma medications. All groups showed significant improvement in FEV1 (p<0.05; T=120 vs 0 min). The conditions of groups 1 and 2 improved significantly more than those of group 3, but did not differ compared to each other. The mean±SEM change in FEV1 (T=120 vs 0 min) was 0.993±0.108, 0.858±0.135, and 0.321±0.056 L, respectively, for the three groups. Separate analysis for patients with FEV1% <40% or >40% predicted showed similar results. However, patients who initially were low responders to albuterol treatment (<15 percentage point increase at 15 min) improved significantly with 30-min treatments compared to the other two treatment regimens. Patients who initially responded with > 15 percentage point increase in FEV1 at 15 min following initial albuterol inhalation benefited equally from 30- or 60-min treatments compared to 120 min. Potassium levels did not change significantly during the study. Adverse events and hospitalization rates were equivalent. After the conclusion of the study, group 3 patients required a greater number of β-agonist treatments prior to eventual discharge from the ED.

Conclusions

For acute asthma, albuterol MDI with a holding chamber can be given optimally at 60-min intervals with minimal adverse effects for the majority of patients. However, patients who initially demonstrate a low or poor bronchodilator response to albuterol should be given subsequent treatments at 30-min intervals. This will optimize care and conserve resources for patients who will benefit the most.

Section snippets

Patients

Patients presenting to the ED of Montefiore Medical Center and/or North Central Bronx Hospital, Bronx, NY, with acute exacerbations of asthma, as defined by the American Thoracic Society,12 were eligible to enter the study if they met the following criteria: (1) age between 18 and 55 years; (2) FEV1 was ≤60% of normal predicted values according to the equations of Crapo et al;13 (3) total cigarette smoking history not in excess of 10 pack-years; (4) able to perform pulmonary function tests with

Patient Characteristics

One hundred forty-three patients were screened for entry into the study, and 100 patients were found to be eligible and were randomized into the protocol. Six of our 100 subjects were unable to complete the 120-min study—none from group 1 (who received albuterol every 30 min), four from group 2 (who received albuterol every 60 min), and two from group 3 (who received only one dose of albuterol in 120 min). One subject in group 2 had no response to the initial albuterol treatment and dropped out

Discussion

Although still a subject of controversy, current literature strongly supports the use of MDIs coupled with delivery devices or holding chambers to deliver aerosolized β-agonist treatments to patients presenting to EDs with acute exacerbations of asthma.6, 7, 8, 9, 10, 11 MDIs attached to many types of holding chambers have been clearly shown to provide equal improvement in pulmonary function when compared to wet nebulizers in this clinical setting.6, 7, 8, 9, 10, 11

Previous studies have

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Presented at CHEST 1996, the 62nd Annual International Scientific Assembly of the American College of Chest Physicians, San Francisco, October 26-30, 1996.

Supported by a grant from Glaxo Wellcome Inc.

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