Asthma Treatment: Spacer vs. Nebulizer

This assignment examines the efficacy and affordability of using metered dose inhalers (MDI) with spacers compared to nebulizers in treating childhood asthma. Students are required to analyze four provided research articles that compare these two treatment methods, considering factors such as symptom improvement and cost-effectiveness. The final conclusion should be based on the findings presented in the studies and advocate for the most suitable approach for delivering salbutamol to an asthmatic child.

Modes of salbutamol delivery 1
THE MORE EFFECTIVE MODE OF DELIVERY BETWEEN SPACER AND NEBULIZER
Name
Course
University

Modes of salbutamol delivery 2
Scenario 2:
Spacer versus nebulizer
Introduction
The asthma burden among children in Australia and the rest world is big considering lack
of a definitive cure for the condition (Xu, 2013). Management of symptoms and acute
exacerbations of the condition are therefore essential in improving the health of these patients.
The drug of choice for the management of exacerbations of asthma is salbutamol, a beta-agonist
bronchodilator, delivered by use of metered dose inhalers with spacers or, Nebulizers. A debate
has been heating up on what method of salbutamol administration is more effective in relieving
asthma symptoms. To fulfill the need for evidence-based clinical practices, the PICO model will
be utilized to assess which method is the preferred one. The ‘P’ stands for population; ‘I’ for the
intervention, ‘C’ for comparison and lastly ‘O’ for the outcome. In this case, the population is
represented by the drug Salbutamol; the nebulizer is the intervention, the spacer is the
comparison while the outcome is the management of Asthma. Several databases were browsed
for reliable articles, and reviews comparing the two devices. The Medline database, PubMed,
and the Cochrane library were the top databases where the search was conducted and results
filtered according to the years of publication, age limits of the participants and countries in which
the studies were conducted. The articles were then reviewed.
Spacer versus nebulizer
The first article in line is ‘policy change implementation: spacers to replace Nebulizers
for management asthma management in children’ from the Europe PMC in cooperation with The
National Library of Medicine (NLM). It’s an article of a study that was done in an emergency

Modes of salbutamol delivery 3
department of a pediatric ward at a certain University medical center (Breuer, 2015). Participants
were a group of children admitted for management of asthma as the diagnosis. Both the nursing
and medical staff were trained on how to use inhalers with spacers attached, and their use
monitored closely by a supervising medical practitioner when nebulizers were replaced by
spacers at a given date. The bronchodilator, salbutamol was administered through a spacer with
puff numbers determined by disease extent or severity. 2 years down the line, an analysis was
done from the approximately 93% of patients who used the metered dose inhaler attached to a
spacer. Analysis of the results after two years since the start of spacer use revealed the same
efficacy as the nebulizer and a surprising 63% reduction in cost. The study concluded that
treatment of asthma using spacer devices was just as effective Nebulizers. Given the cost
advantage of spacer devices, the researchers recommended that nebulizers be replaced by
Metered Dose Inhalers plus spacer devices in the management of symptoms resulting from acute
asthma in collaboration with the hospital staff, patients, and hospital authority.
From the Cochrane database, where many systematic reviews were discovered, the article
‘spacers versus nebulizers for beta-agonist (such as salbutamol) treatment of acute asthma’ was
reviewed (Cates, Welsh & Rowe, 2013) 39 different trials involving 1897 children between the
two methods of delivery of salbutamol. Thirty-three out of the thirty-nine trials were carried out
at the emergency department which validates the application of the results in emergency wings.
Six studies were done on 207 children with acute asthma. The first finding from the studies was
that there was no disparity in the hospital admission frequencies, at least not a significant one,
between those settings in which the nebulizer was used and those in which the spacer device was
used (Cates 2013). It was found that in fact, children’s duration of time spent in the emergency
room was drastically reduced when metered dose inhaler with a spacer attached was used

Modes of salbutamol delivery 4
compared to when the Nebulizer was used. Nebulization made children stay for 103 minutes on
average compared to approximately 33 minutes of time spent at the emergency wing when a
spacer device was employed. This article concluded that considering the costs such as power and
the length of time spent at the emergency services bay, the spacer device is a better alternative to
the nebulizer in acute asthma exacerbation management in the young population.
The third one is a comparative analysis of the efficacy of salbutamol in the treatment of
moderate and mild asthma when its administered via a spacer and when its administered by a
Nebulizer. It was a randomized multicenter study (Direkwatanachai et al. 2011). In this article, a
randomized, multicenter controlled study was performed among children aged between five and
eighteen years who presented in the emergency room with acute exacerbations of asthma. They
were randomized, and each of them either received six puffs of salbutamol through a metered
dose inhaler (MDI) with spacer device attached or Nebulizer. The outcome was the response to
the treatment which was calculated by the Wood’s asthma score. All the outcomes were
classified as either hospitalization, and hospital revisits for asthma within three days, adverse
events, and systemic corticosteroid use. The study results indicated that there was no disparity of
significance between all the groups who used either of the methods and no adverse effects were
also recorded among the groups. It was concluded that salbutamol administered via the spacer
was just as effective as the Nebulizer in the effective management of acute asthma or asthma
exacerbation in children 5 to 18 years of age.
The last article from PubMed compares the cost and efficacy of the administration of
bronchodilators such as salbutamol via either disposable spacers and via Nebulizers for the
management of acute asthma attacks (Dhuper et al. 2011). The article presents an accurate
double-blinded and placebo-controlled, prospective and randomized trial with available sixty

Modes of salbutamol delivery 5
asthma patients in two emergency departments of different hospitals (Dhuper et al. 2011). The
researchers hypothesized that salbutamol delivery to patients with a disposable plastic spacer is a
low cost and more effective alternative to the nebulizer in the management of acute asthma.
Patients were divided into two groups; one group used the nebulizer while the other used the
Spacer. The severity of the exacerbation had been ensured to be roughly similar in both groups.
Results showed the same degree of improvement in both groups. The median cost of treatment
for the spacer device use was $10.11 and $18.26 in the case of the nebulizer. The researchers,
therefore, concluded that there is absolutely no concrete evidence supporting the superiority of
the nebulizer to the disposable spacer in the delivery of a beta agonist in the emergency
department. They also found that the Metered dose inhaler(MDI) and spacer device use is more
economical than the use of the nebulizer.
Conclusion
From the reviews above, the patients or children used as participants are in the same age
bracket with the 10-year-old child in case scenario 2. All the four articles conclude that use of
metered dose inhalers with attached spacer devices is just as valid as using a nebulizer. They also
point out that use of the spacer is way more economical and reduced stay in the emergency
department. Based on these research findings, use of the spacer is the more effective method of
delivering salbutamol to the patient in question.

Modes of salbutamol delivery 6
References
Breuer, O., Shoseyov, D., Kerem, E. and Brooks, R., 2015. Implementation of a Policy Change:
Replacement of Nebulizers by Spacers for the Treatment of Asthma in Children. The
Israel Medical Association journal: IMAJ, 17(7), pp.421-424.
Cates, C.J., Welsh, E.J. and Rowe, B.H., 2013. Holding chambers (spacers) versus nebulizers for
beta‐agonist treatment of acute asthma. The Cochrane Library.
Dhuper, S., Chandra, A., Ahmed, A., Bista, S., Moghekar, A., Verma, R., Chong, C., Shim, C.,
Cohen, H. and Choksi, S., 2011. Efficacy and cost comparisons of bronchodilator
administration between metered dose inhalers with disposable spacers and nebulizers for
acute asthma treatment. Journal of Emergency Medicine, 40(3), pp.247-255
Direkwatanachai, C., Teeratakulpisarn, J., Suntornlohanakul, S., Trakultivakorn, M.,
Ngamphaiboon, J., Wongpitoon, N. and Vangveeravong, M., 2011. Comparison of
salbutamol efficacy in children-via the metered-dose inhaler (MDI) with Volumatic?
Spacer and via the dry powder inhaler, Easyhaler? With the nebulizer-in mild to moderate
asthma exacerbation: a multicenter, randomized study. Asian Pacific journal of allergy
and immunology, 29(1), p.25.
Xu, Z., Huang, C., Hu, W., Turner, L.R., Su, H. and Tong, S., 2013. Extreme temperatures and
emergency department admissions for childhood asthma in Brisbane, Australia. Occup
Environ Med, pp. Oemed-2013.