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Think Twice About Nebulizers for Asthma Attacks

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WHAT’S NEW
Additional evidence that spacers are as effective as nebulizers
This meta-analysis, which included four new studies, should finally dispel the myth that nebulizers deliver β-agonists more effectively than MDIs with spacers. Additionally, in children, spacers are associated with lower rates of adverse effects, including tremor and elevated pulse rate.

CAVEATS
Most studies involving children were open label
Although most of the adult trials in this meta-analysis involved a double-dummy design, which allows for effective participant blinding, most of the studies involving children were open label. This open-label design might have been a source of reporting bias for symptom-related outcomes but should not have affected hospital admission rates or duration of hospital stay.

In the double-dummy studies, adults received both a nebulizer and a spacer, which likely explains the similar time spent in the ED by the treatment and control groups.

CHALLENGES TO IMPLEMENTATION
Old habits are hard to break
Clinicians may think that patients view nebulizers as more potent or more effective than spacers and thus be more likely to order them. Some patients may prefer nebulizers because of convenience or other factors.

REFERENCES
1. Cates CJ, Welsh EJ, Rowe BH. Holding ­chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9: CD000052.

2. Barrett ML, Wier LM, Washington R. Trends in pediatric and adult hospital stays for asthma, 2000-2010. HCUP Statistical Brief #169. www.hcup-us.ahrq.gov/reports/stat briefs/sb169-Asthma-Trends-Hospital-Stays.pdf. Accessed June 16, 2014.

3. Pfuntner A, Wier LM, Stocks C. Most frequent conditions in US hospitals, 2011. HCUP Statistical Brief #162. www.hcup-us.ahrq.gov/reports/statbriefs/sb162.pdf. Accessed June 16, 2014.

4. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2006;(2): CD000052.

5. Turner MO, Patel A, Ginsburg S, et al. Bronchodilator delivery in acute airflow obstruction: a meta-analysis. Arch Intern Med. 1997;157:1736-1744.

6. National Heart, Lung, and Blood Institute Expert Panel Report 3 (EPR3): Guidelines for the diagnosis and management of asthma. www.nhlbi.nih.gov/guidelines/asthma/asth gdln.htm. Accessed June 16, 2014.

7. British Thoracic Society. British guideline of the management of asthma: a national clinical guideline. www.brit-thoracic.org.uk/document-library/clinical-information/asth ma/btssign-guideline-on-the-management-of-asthma/. Accessed June 16, 2014.

8. Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. www.cdc.gov/nchs/data/nhsr/nhsr007.pdf. Accessed June 16, 2014.

ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

Copyright © 2014. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2014;63(6):321-322, 346.

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