Clinical Decision-Making: Nebulizer vs Spacer for Asthma, Report

This report evaluates the effectiveness of nebulizers versus spacers for delivering salbutamol to children experiencing asthma exacerbations, drawing upon evidence-based practice. The introduction outlines the PICO framework used to formulate a searchable question, followed by an analysis of three research papers. The first paper examines the use of nebulizers versus pressurized metered-dose inhalers (with and without spacers) in preschool children, highlighting the benefits of spacers for children under five. The second paper compares nebulizers and spacers in emergency departments, finding that spacers are time-efficient and increasingly used, particularly in children. The third paper, a randomized study, compares the two methods, suggesting that metered dose inhalers with spacers are as effective as nebulizers. The conclusion synthesizes these findings, recommending spacers as a more effective delivery method for asthma treatment in children, emphasizing portability, cost-effectiveness, and reduced side effects. The report concludes that spacers offer a more effective method for delivering bronchodilators, supported by the evidence presented.

Using Evidence to Inform
Clinical Decision-Making
1

Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY..................................................................................................................................4
PAPER 1: Nebulizers versus pressurized metered-dose inhalers in preschool children with
wheezing......................................................................................................................................4
PAPER 2: Nebulisers or spacers for the administration of bronchodilators to those with asthma
attending emergency departments?..............................................................................................4
PAPER 3: Spacers Versus Nebulizers in Treatment of Acute Asthma - A Prospective
Randomized Study in Preschool Children...................................................................................5
CONCLUSION................................................................................................................................6
REFERENCES................................................................................................................................7
APPENDIX......................................................................................................................................8
Paper 1.............................................................................................................................................8
Paper 2.............................................................................................................................................9
Paper 3...........................................................................................................................................10
2

INTRODUCTION
Evidence- based practice plays an important role in the nursing profession. The use of
evidence in practice ensures quality care to patients and it also increases the rate of optimal
health outcomes. In this case, the use of evidence- based practice is put into practical use in real
life medical situations (Madney and et. al., 2017). The scenario chosen has several important
factors to note which are necessary for formulating a searchable question using the PICO format.
In scenario 3, a 10-year-old child has been admitted to the emergency department for
exacerbation of asthma secondary to bronchitis. The patient has been prescribed salbutamol. The
point of argument is which delivery method is most effective, the use of a spacer or nebuliser for
treatment.
To answer the following question. Firstly, I formulated a searchable question and developed
a search strategy by using the PICO format. Using credible databases to help find relevant
research in answering the question, in children are spacers or nebulisers most effective in the
treatment of exacerbation of asthma secondary to bronchitis. Databases used were Embase,
CINAHL and MEDLINE.
PICO:
Problem Exacerbation of asthma secondary to bronchitis in children of
0 to 10 years
Intervention Method of delivery- a nebuliser or a spacer
Comparison Nebuliser and Spacer methods
Outcome Improved in health condition of children
The Boolean operations like ‘AND’ and ‘OR’ are utilized by me to search information on
the topic so that it can be answered appropriately. I search many articles among which I make
use of three articles which help me in addressing the question effectively and answered it
appropriately. Among the selected articles, two articles are qualitative and one is quantitative.
The main reason behind selection of these articles is to effectively compare the treatment
delivery by nebuliser or spacer method in order to address the question appropriately.
3

MAIN BODY
PAPER 1: Nebulizers versus pressurized metered-dose inhalers in preschool children with
wheezing
According to this paper, commonly utilised delivery systems are pressurized metered dose
inhalers without or with spacers, nebulizers and dry powder inhalers. The children who are
younger than 5 years of age often cannot develop adequate flow of inspiratory to effectively
utilise dry powder inhaler devices. Use of nebulizer has a benefit as it can deliver drugs without
the cooperation of child. At the time of using it, lower than 10% of aerosolized drugs gets the
lungs. As compared to pressurised metered dose inhalers have drug pulmonary deposition of
around 10 percent to 40%. This range depicts inconsistencies in outcomes across studies owing
to complexity of measuring the deposition of drug in tissue of lung and the utilisation of distinct
spacer devices (Mitselou, Hedlin and Hederos, 2016). Young children and infants lack
coordination need to trigger and at the same time in a drug at the time of using pressurized
metered dose inhaler. The utilisation of adjuncts like spacers with face mask for mouth pieces
overcome this complexity. Spacer can reduce the requirement for coordinated activation of
pressurized metered dose inhalers as well as inhalation of aerosol. In general, 5 years’ younger
children need face masks to help with aerosol delivery by spacer. According to the study, the use
of spacer is more effective in comparison to the use of nebulizer in children younger than 5 years
in clinical setting. It has been found from the meta-analysis that the children less than 5 years
with moderate to severe wheezing exacerbation experienced less admission rates in hospital and
decline in validated severity score. It has been found from the study that inhaled therapies are
administered effectively by pressurized metered dose inhaler two children younger than age of 5
years (ElHansy, and et. al., 2017). This inhaler with spacers are better tolerated and portable in
comparison to nebulizer.
PAPER 2: Nebulisers or spacers for the administration of bronchodilators to those with asthma
attending emergency departments?
The objective of this paper is to determine the administration method of bronchodilators to
those with non-life threatening asthma attending emergency departments in United Kingdom and
to monitor the execution of new policy to provide bronchodilators by spacers. It has been found
from the study that nebulized route of provision of bronchodilators has no benefit over utilisation
4

of spacer in moderately severe asthma exacerbation. In study, it was found that majority of
emergency department in London were utilising nebulizer route of providing bronchodilators to
adult patients. In the treatment of children, spacers were more commonly utilised. The studies of
time and motion depicts that utilisation of spacer took no more time of nursing in comparison to
provision of bronchodilators through nebulizer. The setup and treatment time for spacers were
considerably low then nebulizers. The study shows that nebulised route of providing
bronchodilators is a dominant route for treatment of out of control asthma in adults. Whereas, a
shift has been there towards the utilisation of spacers in children treatment. Economic benefits of
utilisation of spacer are difficult to discern. If it is used to provide salbutamol alone, a cheaper
spacer could be use (Booth, 2016). The administration of bronchodilators through spacers to
patients with asthma attending emergency department uses less time for treatment in comparison
to the use of nebulizer. The study showed that despite guideline, little evidence is appearing of
decline in utilisation of nebulizers.
PAPER 3: Spacers Versus Nebulizers in Treatment of Acute Asthma - A Prospective
Randomized Study in Preschool Children
The purpose of this paper is to compare the bronchodilators administration by nebulizers
with delivery through metered dose inhalers along with spacers as well as to evaluate clinical
impact of acute asthma treatment in preschool children. The study was conducted on 0 to 6 years
of children who admitted to emergency department for viral infection associated acute asthma
flares or wheezing. Numerous studies were performed that have addressed the efficiency of
metered dose inhaler and nebulized medication delivery to children. In spite of the evidence that
other approaches appropriate for delivery of medication, a perception remains there that
nebulization is more effective and superior to metered dose inhaler or spacer use, specifically in
children who are young. In this paper, the author states the perception of parents in an acute
setting is that both the approaches or methods accomplish acceptance if they presented correctly
and appropriately (Reilly, Douglas and Currie, 2017). From the study, no significant differences
or differentiations were seen in oxygen saturation, respiratory rate and heart rate at this line as
well as after the treatment. It has been found from the study that metered dose inhalers with
spacers are less effective as the nebulizers in beta agonists delivery in order to treat preschool
5

children who is suffered from acute exacerbations of asthma or virus induced wheezing in pigeon
emergency department (Nelson, 2016).
CONCLUSION
As per the above mentioned report, it has been concluded that children with exacerbated
asthma requires an effective delivery method such as nebulizers or spacers. By reviewing the
above discussed papers, it can be said that pressurised metered dose inhalers are more effective
than nebulizers in administration of bronchodilators for the treatment of exacerbation of Asthma.
The use of nebulizers is done more in the emergency department in clinical setting, in case of
children spacers are more effective in comparison to nebulizer. Metered dose inhaler with
holding spacers are equivalent to nebulizer for treatment of asthma exacerbation. There are
various advantages to utilisation of metered dose inhaler over nebulizers. They are more
portable, less expensive to utilise, implications in less side effects as well as will help in
improving the health of patient. The delivery of metered dose inhaler at the time of
hospitalization must be accompanied with education of patient about appropriate administration
technique. These spacers have provided more cost effective and quicker way to deliver
bronchodilators for the treatment of asthma in children. So, it can be said that spacer is the more
effective method of delivery for the treatment of exacerbation of asthma.
6

REFERENCES
Books and Journals
Madney, Y.M., and et. al., 2017. Nebulizers and spacers for aerosol delivery through adult nasal
cannula at low oxygen flow rate: an in-vitro study. Journal of Drug Delivery Science and
Technology, 39, pp.260-265.
Mitselou, N., Hedlin, G. and Hederos, C.A., 2016. Spacers versus nebulizers in treatment of
acute asthma–a prospective randomized study in preschool children. Journal of
Asthma, 53(10), pp.1059-1062.
ElHansy, M.H. and et. al., 2017. Inhaled salbutamol dose delivered by jet nebulizer, vibrating
mesh nebulizer and metered dose inhaler with spacer during invasive mechanical
ventilation. Pulmonary pharmacology & therapeutics, 45, pp.159-163.
Booth, A., 2016. Nebulised therapy in respiratory disease management: Best practice. Nurse
Prescribing, 14(12), pp.586-592.
Reilly, M., Douglas, G. and Currie, G.P., 2017. Drug Delivery Devices. ABC of COPD, p.56.
Nelson, H.S., 2016. Inhalation devices, delivery systems, and patient technique. Annals of
Allergy, Asthma & Immunology, 117(6), pp.606-612.
Online
Nebulizers versus pressurized metered-dose inhalers in preschool children with wheezing, 2012.
[Online]. Available through:
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3352788/>
Nebulisers or spacers for the administration of bronchodilators to those with asthma attending
emergency departments? 2020. [Online]. Available through:
<https://www.sciencedirect.com/science/article/pii/S0954611108000838>
Spacers Versus Nebulizers in Treatment of Acute Asthma - A Prospective Randomized Study in
Preschool Children. 2017. [Online]. Available through:
<https://pediatrics.aappublications.org/content/140/Supplement_3/S218.1>
7

APPENDIX
Paper 1
8

Paper 2
9

Paper 3
10