Evidence of Nursing

This article discusses the most effective method of delivering bronchodilators to children with asthma. It compares the use of spacers and nebulizers and explores the advantages of using spacers in asthma management. The article also provides a critical evaluation of research papers on this topic.

Running head: EVIDENCE OF NURSING
Evidence of nursing
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Author’s note:

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Introduction:
To find relevant research articles related to the most effective method of delivery of
bronchodilators like Salbutamol to a child with asthma, I formulated a PICO question first. The
PICO question for clinical scenario was ‘Is nebuliser a more effective method to administer or
deliver a bronchodilator compared to spacer?’. The search for article was conducted in CINAHL,
Cochrane library and PubMed by taking key search terms likes ‘nebuliser’, ‘spacer’,
‘bronchodilator delivery’, ‘bronchodilator administration’ and ‘bronchodilator delivery method’.
Other search filter that was used for retrieving articles included setting the publication date to
2013 to 2019 and selecting only journal articles in types of research. While accessing the
research articles for eligibility in relation to the PICO question, preference was given to those
evidence which had high quality research designs. For example, the as systematic review and
RCT comes under top level of evidence, studies with this research design were preferred. In
addition, other papers were taken based on consistency of outcome, research rigour and
consideration of biases.
Four best quality evidences were found by searching for articles in PubMed and
CINAHL. The first article by Cates, Welsh and Rowe (2013) retrieved from Cochrane library
‘Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma’ used
systematic review method to answer the research question and met the inclusion criteria as it
came under top level of evidence. In addition, the article by Snider et al. (2016) retrieved from
CINAHL was preferred as it used randomized trial to compare metered dose inhaler and breath
actuated inhalers. RCT research design is high quality evidence as it addressed bias and
systematic errors at different stage of research. The article by Mason et al. (2008) used
quantitative survey method of answer the research question. This article was preferred as it

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compared guidelines to compare performance of nebuliser and spacer. Another systematic
review retrieved from CINAHL was taken as it used systematic review method to describe acute
asthma treatment in childhood (Castro-Rodriguez, Rodrigo and Rodriguez-Martinez, 2015).
Main body:
The article by used Cates, Welsh and Rowe (2013) used systematic review method to
assess and compared delivery of beta agonist for systematic reviews by nebulizer (I) and spacer
(C) to children with acute asthma (P). The article had a clear focused question and right quality
paper was selected for the review which included RCT studies. The analysis of 39 such trials
revealed that delivery by nebulizer did not yield significantly better outcome compared to
inhalers delivered by spacers. No clear advantage was discussed regarding the advantage of
spacers to deliver bronchodilators to children with acute asthma. All the selected papers in the
study was judged for quality. However, statistically significant outcome was not found to clear
answer the research question regarding efficacy of nebulizer compared to inhalers in delivery of
nebulizers. Hence, the study findings cannot be applied in local populations as clear answer to
the research question has not been found. The study is not worth the harm and cost.
The second article Snider et al. (2016) compared metered dose inhalers (MDI) and breath
actuated nebulizers (BAN) in treating patients between 2 to 17 years with mild to moderate
asthma exacerbation. By randomly assigning patients to BAN and MDI group, it was found that
admission rate in the BAN group was 11.9% compared to 12.8% for the BAN group. The risk
difference was 0.9%. On adjustment for confounders and biases, the risk difference was found to
be 2%. The study was able to answer the research question as it revealed that MDI is effective in
treatment for asthma compared to BAN. The review of the research methodology indicated that

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blinding and allocation concealment was not followed, however follow up of patient was done
till 7 days to detect repeated hospitalization. Apart from the treatment, the groups were similar
by age and asthma severity. In addition, the research is considered to be moderate quality
evidence as very large treatment effect in two groups were not found and the difference was not
very precise. Instead of 2% difference, wider difference was needed to clearly apply MDI as a
treatment method for children. The study had similar patient group, however acute asthma
patients were not taken thus limiting the application of research findings.
Mason et al. (2008) used survey based quantitative method to evaluate current method of
administration of bronchodilators to asthma patients attending emergency department (ED). The
survey was done regarding the use of nebuliser or spacer in thirty five emergency departments in
Greater London. The review of results finding suggested that majority of EDs in London were
using nebulisers for adult patients and spacer was most commonly used for treatment of children.
The study revealed that according to British guideline, use of space is advantageous for both
children and adults. The advantage of using a spacer was that it took minimum time for nurses to
administer compared to nebulisers. Although the study did not directly compared effect of
nebuliser of spacer on treatment of asthma, however the study gave some hint that spacer is more
advantageous than nebuliser. The validity of the evidence is enhanced by the fact that the finding
has been supported with British guideline suggesting the quality of research outcome. However,
since the research was done in 2008, it does not reflect the practice of using spacer in current
health care system. Hence, to confirm the advantage of using spacer compared to other treatment
options, there is a need to compare current guidelines for Asthma management and review
whether spacer is still a treatment option for asthma management in children or not.

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Another high quality research that were relevant to the PICO question included the study
by Castro-Rodriguez, Rodrigo and Rodriguez-Martinez (2015). Although the study used
systematic review method to review treatment method for asthma, however the performance of
spacer and nebuliser was not the core focus of the study. The study evaluated eight types of
treatment for asthma. Although the paper included in the review is effective as all RCTs were
taken in the research, however one limitation of the paper is that it was not a direct comparison
between spacer and nebuliser alone. However, few evidence compared treatment of salbutamol
using spacer or nebuliser. From this outcome, it was found that use of spacer was associated with
less time in ED. However, the finding is not suitable to be directly applied in local setting as the
study did not directly answer the research question. Therefore, this is not suitable to be applied in
the scenario.
Conclusion:
Based on the comparison and critical evaluation of papers comparing performance of
nebulisers compared to use of spacers in the treatment of asthma, it can be concluded that only
two papers (Cates, Welsh & Rowe, 2013; Snider et al. (2016) directly compared nebulisers and
spacers in the treatment of asthma in children. In case of systematic review, clinically significant
difference in two outcomes was not found. However, the RCT trial revealed advantage of MDI
over BAN. Despite this evidence, almost all the four papers gave some hint regarding the
advantage of using spacer in asthma management in children. Hence, based on this evidence, it
can be said strong evidence regarding advantage of spacer over nebuliser has not been found in
young children. However, as moderate quality evidence has been found, there is a need to
confirm the result by conduct RCT study with high quality research design and minimizing
limitations found in the four research methods.

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References:
Castro-Rodriguez, J. A., Rodrigo, G. J., & Rodriguez-Martinez, C. E. (2015). Principal findings
of systematic reviews of acute asthma treatment in childhood. Journal of Asthma, 52(10),
1038-1045.
Cates, C. J., Welsh, E. J., & Rowe, B. H. (2013). Holding chambers (spacers) versus nebulisers
for beta‐agonist treatment of acute asthma. Cochrane database of systematic reviews, (9).
Mason, N., Roberts, N., Yard, N., & Partridge, M. R. (2008). Nebulisers or spacers for the
administration of bronchodilators to those with asthma attending emergency
departments?. Respiratory medicine, 102(7), 993-998.
Snider, M. A., Wan, J. Y., Jacobs, J., Kink, R., Gilmore, B., & Arnold, S. R. (2018). A
Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated
Nebulizers. The Journal of emergency medicine, 55(1), 7-14.

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Appendix:
Cates, C. J., Welsh, E. J., & Rowe, B. H. (2013). Holding chambers (spacers) versus nebulisers
for beta‐agonist treatment of acute asthma. Cochrane database of systematic reviews, (9).
Mason, N., Roberts, N., Yard, N., & Partridge, M. R. (2008). Nebulisers or spacers for the
administration of bronchodilators to those with asthma attending emergency
departments?. Respiratory medicine, 102(7), 993-998.

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Snider, M. A., Wan, J. Y., Jacobs, J., Kink, R., Gilmore, B., & Arnold, S. R. (2018). A
Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated
Nebulizers. The Journal of emergency medicine, 55(1), 7-14.
Cates, C. J., Welsh, E. J., & Rowe, B. H. (2013). Holding chambers (spacers) versus nebulisers
for beta‐agonist treatment of acute asthma. Cochrane database of systematic reviews, (9).

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