Chest
Volume 112, Issue 6, December 1997, Pages 1501-1505
Journal home page for Chest

Clinical Investigations: COPD
Nebulized Wet Aerosol Treatment in Emergency Department—Is It Essential?: Comparison With Large Spacer Device for Metered-Dose Inhaler

https://doi.org/10.1378/chest.112.6.1501Get rights and content

Objective

To determine the efficacy of a metered-dose inhaler (MDI) with a large spacer device as compared to nebulized wet aerosols in the treatment of an unselected population with severe airflow limitation.

Design

Randomized, double blind, placebo-controlled trial.

Setting

University Hospital Department of Emergency Medicine (DEM).

Patients

Fifty patients, referred to the DEM between October 1, 1994 and March 31, 1995 with a severe, acute obstructive pulmonary event. Thirteen patients were diagnosed as having COPD; 37 patients were diagnosed as having asthma.

Intervention and results

Patients received either placebo MDI through a 750-mL cone-shaped spacer (Glaxo) [2 puffs] and nebulized salbutamol aerosol 0.5 mL in 1.5 mL saline solution (group 1, n=25) or salbutamol MDI and 0.5 mL saline solution in 1.5 mL saline solution administered in the same manner as above (group 2, n=25). The above treatment was repeated three times every 15 min, unless side effects appeared. Upon enrollment into the study, the FEV1 in group 1 was 0.78±0.7 L (mean±SD), 32% of predicted, and in group 2, 0.74±0.51 L, 29% of predicted (p=0.83). The FEV1 values after the first, second, and third interventions were as follows: in group 1, 1.18±0.99 L, 1.40±0.8, and 1.47±0.79, respectively, and in group 2, 1.17±0.99 L, 1.46±1.01, and 1.54±0.79 (p=0.83, 0.36, and 0.48, respectively). We observed no difference in spirometric measurements between the two groups at any time.

Conclusion

Even in the setting of the unselected group of patient referrals to the DEM for episodes of severe airflow limitation, the clinical and the objective bronchodilator responses to the administration of salbutamol are independent of the method of delivery: MDI with a large spacer vs aerosol nebulization.

Section snippets

Patients

Fifty patients, referred to the DEM at the Edith Wolfson Medical Center (a university-affiliated, community-based general hospital) with severe obstructive pulmonary event between October 1, 1994 and March 31, 1995 were enrolled into the trial. To represent the actual population visiting the emergency department, we did not limit enrollment into the study by considerations of age, sex, severity of underlying illness, or primary diagnosis. We limited exclusion criteria to apparent active cardiac

Results

Of the 50 patients who entered the study, only 9 patients did not receive the last treatment because of side effects (palpitations, headache, or tremor), of whom 3 of 25 were from the salbutamol-MDI group (group 2) and 6 of 25 from the placebo-MDI group (group 1). Although the improvement in spirometric measurement was nominally slightly better in the salbutamol-MDI (test) group, no statistically significant difference was detected at any point during the study (Figure 2, Figure 3, Figure 4).

Discussion

A current consensus conference concluded that an MDI with reservoir chamber is the preferred mode of aerosol therapy for patients outside of the hospital.19

The advantages of the MDIs (smaller amount of the drug, convenient, portable, less expensive, no drug preparation required, and difficult to contaminate) in addition to the advantage of the accessory (spacer) devices (easy handling, less patient coordination needed, less pharyngeal deposition) compared favorably to the small-volume

ACKNOWLEDGMENTS

Diklah Geva of the Edith Wolfson Medical Center, Holon, advised on statistics. We are grateful also to Sally Izakov for secretarial assistance.

References (22)

  • TobinMT et al.

    Response to bronchodilator drug administration by a new reservoir aerosol delivery system and a review of other auxiliary delivery systems

    Am Rev Respir Dis

    (1982)
  • Cited by (39)

    • Characteristics of Spacer Device Use by Patients with Asthma and COPD

      2008, Journal of Emergency Medicine
      Citation Excerpt :

      Although there was no difference in rates of hospitalization, discharged patients who were instructed in MDI spacer use had significantly reduced 14- and 21-day relapse rates. Numerous other studies over the past 15 years have demonstrated improved outcomes with MDI used in conjunction with a SD, as compared to either the MDI alone or nebulizers (7–12). This is particularly apparent in the pediatric population, where multiple studies have shown equal efficacy of treatment of asthma exacerbations with MDI-SD and nebulizers, but fewer side effects and lower economic cost with the MDI-SD (13–17).

    • Life-Threatening Asthma

      2008, Critical Care Medicine: Principles of Diagnosis and Management in the Adult
    • Chronic Obstructive Pulmonary Disease

      2008, Critical Care Medicine: Principles of Diagnosis and Management in the Adult
    • Comparison of the effects of nebulised and inhaled salbutamol on breathlessness in severe COPD

      2005, Respiratory Medicine
      Citation Excerpt :

      Patients were randomised to receive three doses of 200 mcg salbutamol from an MDI and spacer (in addition to nebulised saline) or 2.5 mg salbutamol via nebuliser (plus placebo MDI) over 15 min. There was no difference in lung function between the treatments at any of the three time points up to 15 min.13 None of these studies suggest that the more rapid improvement in breathlessness seen with nebulised salbutamol is likely to be due to an effect on lung function.

    • Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology

      2005, Chest
      Citation Excerpt :

      One study38 found vomiting to be more common with nebulizer use than with use of an MDI with a spacer/holding chamber, which likely was due to the larger dose given by nebulizer in these subjects. Considering the common use of aerosolized drugs in hospitalized patients, there are surprisingly few studies that have compared aerosol delivery devices in this setting (Table 11).53585960616263 Six type 1 studies535859606163 included in the analysis compared nebulizers with MDIs having spacer/holding chambers in adult and pediatric patients.

    View all citing articles on Scopus
    View full text