The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–8, 2018
Ó 2018 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

https://doi.org/10.1016/j.jemermed.2018.03.002

Original
Contributions

A RANDOMIZED TRIAL COMPARING METERED DOSE INHALERS AND BREATH

ACTUATED NEBULIZERS

Mark A. Snider, DO,* Jim Y. Wan, PHD,† Jonathan Jacobs, MD,* Rudy Kink, MD,* Barry Gilmore, MD, MBA,* and
Sandra R. Arnold, MD, MSC‡
*Division of Emergency Services, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, †Division of
Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee,
and ‡Division of Infectious Diseases, Department of Pediatrics, University of Tennessee Health Science Center College of Medicine,
Memphis, Tennessee
Corresponding Address: Mark A. Snider, DO, Division of Emergency Services, Department of Pediatrics, Le Bonheur Children’s Hospital, 50
North Dunlap St, Memphis, TN 38103

, Abstract—Background: Despite little evidence for its 5% to 3%). After adjusting for baseline confounder
effectiveness, the breath-actuated nebulizer (BAN) is the severity, the risk difference was 2% (95% confidence inter-
default albuterol delivery method in our pediatric emer- val 4% to 7%), which met the criteria for noninferiority.
gency department. Objective: We compared the clinical Conclusions: Albuterol therapy by MDI is noninferior to
efficacy of BAN and the metered-dose inhaler (MDI) in BAN for the treatment of mild to moderate asthma exacer-
treating subjects patients 2 to 17 years of age who presented bations in children 2 to 17 years of age. Ó 2018 Elsevier
with mild to moderate asthma exacerbations. Methods: This Inc. All rights reserved.
is a randomized, nonblinded, noninferiority study conduct-
ed at a single pediatric tertiary care emergency department. , Keywords—asthma exacerbation; breath-actuated
Subjects presenting with a Pediatric Asthma Score ranging nebulizer; emergency department length of stay; intrave-
from 5 to 11 received albuterol by BAN or MDI via standard nous magnesium sulfate; metered-dose inhaler; Pediatric
weight-based and symptom severity dosing protocols. Aero- Asthma Score; respiratory therapist; small volume
solized ipratropium (via BAN) and intravenous magnesium nebulizer
sulfate were given when clinically indicated. The primary
outcome was patient disposition. The noninferiority margin
for the primary outcome was an admission rate difference
#10%. Analyses were adjusted for confounders that were INTRODUCTION
significant at p # 0.10. Results: We enrolled 890 subjects be-
tween October 2014 and April 2015. BAN and MDI groups Breath-actuated nebulizers (BANs) are a relatively new
were comparable for age, gender, and race but not for pre- method of treating pediatric asthma exacerbations
treatment symptom severity; 51% in the MDI group had a (AEs) in the emergency department (ED). Like the small
Pediatric Asthma Score of moderate severity (8–11) vs.
volume nebulizer (SVN), BANs aerosolize albuterol so-
63% in the BAN group (p < 0.003). Unadjusted admission
rates were 11.9% for MDI and 12.8% for BAN, for an unad-
lution but use an air compressor rather than a nebulizer.
justed risk difference of 0.9% (95% confidence interval Their use in the ED to treat AE may contribute to parents’
lack of confidence in their home metered-dose inhalers
(MDIs) (1). By treating acute AE with nebulized albute-
Reprints are not available from the authors. rol rather than with the MDI, we may be encouraging

RECEIVED: 25 September 2017; FINAL SUBMISSION RECEIVED: 19 February 2018;

ACCEPTED: 3 March 2018

1
2 M. A. Snider et al.

unnecessary repeat ED visits and contributing to the enor- score (Appendix). Additional therapies including ipra-
mous national cost of treating asthma (2,3). tropium, 0.5 mg via BAN, regardless of randomized
Acute AE can be effectively treated using BANs, cohort (ipratropium by MDI was too costly for routine
MDIs, or SVNs (4). Both the MDI and the BAN are use in the ED), or 50 mg/kg (max 2 g) of intravenous mag-
more effective than the SVN at reducing hospital admis- nesium sulfate (IV MgSO4) (11). Not infrequently, physi-
sion rates and reducing ED length of stays (ED LOS) cians may treat patients presenting with moderate
(5–8). To our knowledge, this is the first study severity AE with IV MgSO4, especially if they received
comparing the effectiveness of the MDI and the BAN. multiple doses of albuterol at home or have a history of
We hypothesize that the MDI is as effective as the BAN pediatric intensive care unit admissions in hopes of dis-
in treating acute pediatric AE in the ED. charging them home.
Albuterol administered via MDI was given through a
MATERIALS AND METHODS spacer device fitted with an appropriately sized mask if
needed. The RT was present for the entire treatment and
This is a randomized, controlled, nonblinded, noninfer- either administered or supervised patient- or parent-
iority trial comparing MDI to BAN conducted in children administered doses. Subjects randomized to BAN were
presenting with a first-time wheeze or a mild to moderate evaluated for proper breath actuation technique. For sub-
AE at a single, urban, pediatric ED in Memphis, Tennees- jects unable to breath actuate, the RT attached an appro-
see. The BAN, along with the MDI, became the standard priately sized mask to the device, changed the setting to
of care for treatment of AE after an internal pilot study of continuous nebulization, and returned to bedside after
100 patients showed BAN to be superior to SVN resulting treatment completion.
in fewer admissions (42% SVN vs. 28% BAN) and This study was designed to reflect treatment of AE as
shorter ED LOS (mean SVN 344 min vs. mean BAN is commonly practiced. Physicians could escalate care by
225 min). An abbreviated consent form, one that could increasing the dose of albuterol beyond the ED protocol.
be reviewed in minutes, was approved by the institutional Physicians were discouraged from changing appliances
review board so that therapy for willing participants but could do so if they felt that the child was not
would not be delayed. improving; however, all subjects remained assigned to
Subjects were identified for enrollment by respiratory their randomized cohort. Physicians could discharge a
therapists (RTs) and treating physicians. Eligible subjects subject at any time, but the ED protocol suggests admin-
ranged from 2 to 17 years of age and presented with either istering $3 treatments before admission. There were no
a first-time wheeze or an AE of mild to moderate severity strict criteria for admission, and each provider deter-
as defined by a Pediatric Asthma Score (PAS) ranging mined subject disposition. According to the intention to
from 5 to 11 (9). The PAS assigns points for respiratory treat principle, all admissions counted against the cohort
rate, oxygen saturation, retractions, work of breathing, to which the subject was initially randomized.
and findings on auscultation (Appendix). Subjects were The primary outcome was patient disposition defined
excluded if they had initiated therapy at an outside med- as hospital admission or discharge from the ED. Second-
ical facility or had a history of chronic lung disease, ary outcomes included: ED LOS, frequency of possible
congenital heart disease, tracheostomy, or were receiving albuterol dose-related adverse events measured by age-
diuretic therapy. Patients who were diagnosed with bron- adjusted tachycardia at the time of disposition, and
chiolitis or pneumonia by the treating physician were ondansetron administration for nausea or vomiting (12).
excluded, along with children who were wards of the state We also followed repeat ED visits within 7 days of pre-
or whose parents did not speak English. sentation.
One thousand numbers were generated and random- All information related to the subjects in the study was
ized using blocks of 20 to either MDI or BAN using on- extracted from their electronic medical record and trans-
line randomization software (www.randomization.com). ferred to REDCap, a secure Web-based database (13).
Numbers were printed and placed in sealed, sequentially Measures of noninferiority were determined using
ordered opaque security envelopes that were stored in a chi-square tests for categorical variables, t-tests for
secure location. Patients were enrolled in the study continuous, normally distributed variables, and the
24 hours per day, 7 days per week. Mann-Whitney U test for continuous nonparametric vari-
By protocol, all patients with a known history of ables. Depending on the validity of normality assump-
asthma received oral dexamethasone (0.6 mg/kg, 16 mg tion, Pearson or Spearman correlation was used to
maximum dose) at presentation, whereas those with describe the association between two continuous vari-
first-time wheeze were assessed by a physician before ables. To adjust for possible confounding factors, we
dosing (10). Albuterol dosing was based upon the sub- used a multivariate logistic regression analysis for patient
ject’s randomized cohort, weight, and presenting asthma disposition and a multiple linear regression analysis for
MDI vs. BAN in Pediatric Asthma Exacerbations 3

ED LOS. Analyses were adjusted for confounders that ED had attempted a study of this size, we anticipated as
were significantly associated with outcome at p # 0.10 much as a 20% data loss, and planned to enroll 1000 sub-
rather than p # 0.05 because this allowed us broader op- jects.
portunity to analyze potentially important clinical vari-
ables. The adjusted risk difference for admission (and RESULTS
95% confidence interval [CI]) was determined by
deriving the 2 adjusted probabilities (probability of We approached 1022 of 1987 eligible subjects between
admission for each treatment group) from the logistic October 2014 and April 2015. Twenty-two subjects
regression using least squares means that estimate the refused participation because they did not want to be ran-
marginal means over a balanced population. The differ- domized to MDI. Twenty envelopes were lost before data
ence between the 2 adjusted probabilities is the adjusted collection. The remaining 965 subjects were not ap-
risk difference. proached because of resource limitations. Of the 980 sub-
We estimated our admission rate to be 35% based on a jects who agreed to study participation, 90 subjects’ data
3-month retrospective chart review of ED visits for AE. were discarded because of enrollment documentation and
The consensus among our provider groups was that an ab- protocol violations, leaving 445 subjects in the MDI
solute difference in admission rates >10% was clinically group and 445 subjects in the BAN group (Figure 1).
important. We used the POWER procedure in SAS soft- There were no differences between MDI and BAN groups
ware (version 9.3; SAS Institute Inc., Cary, NC) to calcu- for race, gender, or age. The cohorts differed in presenta-
late the sample size required to detect a 10% difference in tion severity with 51% of the MDI and 63% of the BAN
admission rate if an MDI was used instead of BAN. With cohort (p = 0.003) scoring a moderate PAS (Table 1).
a power of 80%, the required sample size was 376 sub- The number of albuterol treatments administered to
jects per treatment arm. As this was the first time our each subject was independent of his/her age (Spearman

Figure 1. Consort flow diagram. *Eleven patients randomized to MDI received BAN and no patients randomized to BAN received
MDI; these patients were analyzed according to their randomized assignments. BAN = breath-actuated nebulization;
MDI = metered-dose inhaler.
4 M. A. Snider et al.

Table 1. Patient Demographics, Presentation Severity, and Table 3. Results of Unadjusted and Adjusted Analyses for
Complications Variables Associated with Patient Disposition

BAN 445 MDI 445 p Value Unadjusted OR (95% CI) p Value

Gender, n (%) 0.17 MDI vs. BAN* 0.92 (0.62–1.37) 0.68

Male (64.9%) 298 (67) 279 (63) Moderate (8–11) vs. mild 5.19 (3.00–8.99) 0.0049
Female (35.1%) 147 (33) 166 (37) (5–7) PAS
Race, n (%) 0.62 Ipratropium vs. none 4.77 (2.85–7.97) <0.0001
African American 413 (93) 405 (91) High albuterol dose vs. 0.6 (0.24–1.54) 0.29
White (non-Hispanic) 26 (6) 33 (7) protocol dose
Latino 6 (1) 7 (2) Adjusted†
Age (years) 0.98 MDI vs. BAN‡ 1.37 (0.89–2.10) 0.16
Mean 6 SD 6.38 6 4.0 6.37 6 3.9 Moderate (8–11) vs. mild 2.77 (1.43–5.37) 0.002
Presenting PAS,*n (%) <0.001 (5–7) PAS
Mild (PAS <8) 164 (37) 218 (49) Ipratropium vs. none 2.89 (1.52–5.51) 0.001
Moderate (PAS $8) 281 (63) 227 (51)
BAN = breath-actuated nebulization; CI = confidence interval;
BAN = breath-actuated nebulization; MDI = metered-dose MDI = metered-dose inhaler; OR = odds ratio; PAS = Pediatric
inhaler; PAS = Pediatric Asthma Score; SD = standard deviation. Asthma Score.
* Unadjusted risk difference in admission rate 0.9% (95% CI 5%
to 3%).
correlation 0.06, p = 0.1) and study group (p = 0.2), but † Variable of interest (MDI vs. BAN) forced into the model, con-
did correlate with PAS severity at presentation (Spearman founders with p < 0.05 included in the model.
correlation 0.39, p < 0.0001). There were no differences ‡ Adjusted risk difference in admission rate 2% (95% CI 3%
to 7%).
in posttreatment PAS scores between MDI and BAN
groups (Table 2). No subjects in the MDI cohort
compared with 62 (14%) subjects in the BAN cohort After adjusting for baseline severity, ipratropium, and
received $1 dose of albuterol above the recommended elevated vs. standard dosing of albuterol, the risk differ-
protocol dose (p < 0.0001) (Table 2). More BAN subjects ence for hospital admission was 1.8% (95% CI 3.7%
than MDI subjects received ipratropium, 69% vs. 39%, to 7.4%), meeting predefined criteria for noninferiority
respectively (p < 0.001). After adjusting for baseline (Table 3).
PAS, BAN subjects were more likely to receive ipra- The unadjusted difference in ED LOS was shorter for
tropium than MDI subjects (odds ratio 3 [95% CI 1.6– the MDI cohort by 14.8 min (95% CI 0.9–28.8,
5.8%], p < 0.001). Finally, 4 (0.9%) MDI subjects and 9 p = 0.037). The adjusted ED LOS difference between
(2%) BAN subjects received IV MgSO4 (p = 0.2). the cohorts was 9.0 min shorter for the MDI cohort
The unadjusted admission rates for the MDI and BAN (95% CI 22.9 to 4.9).
cohorts were 11.9% and 12.8%, respectively, for an unad- There were 11 subjects randomized to MDI who were
justed risk difference of 0.9% (95% CI 5% to 3%). later converted to BAN; no subjects transitioned from

Table 2. Treatment Summary (Including Adverse Events) of All Patients

BAN MDI p Value

Albuterol dose above protocol recommendation, n (%) 68 (15) 8 (2) <0.001

Ipratropium 309 (69) 173 (39) <0.001
Magnesium sulfate 9 (2) 4 (0.9) 0.2
Treatments for mild PAS* (<8), n (SD) 1.27 (0.44) 1.09 (0.28) <0.0001
Treatments for moderate PAS* ($8), n (SD) 1.97 (0.29) 1.69 (0.49) <0.0001
Score change in PAS after treatment† (SD)
After treatment 1 1.72 (1.53) 1.57 (1.42) 0.1
After treatment 2 2.48 (1.83) 2.40 (1.73) 0.7
After treatment 3 2.26 (1.95) 2.77 (2.00) 0.2
Tachycardia, n (%) 140 (32) 101 (23) <0.001
Nausea/vomiting,‡ n (%) 18 (4) 14 (3) <0.001
Return visit, n (%) 4 (0.9) 5 (1) 1.0

BAN = breath-actuated nebulization; MDI = metered-dose inhaler; PAS = Pediatric Asthma Score; SD = standard deviation.
* Number of treatments unadjusted (as shown above) and adjusted (1.62 for BAN and 1.39 for MDI) for baseline severity. Children random-
ized to the MDI group were more likely to require fewer treatments (p < 0.0001). However, after completing univariate analysis adjusting for
baseline severity, we determined that number of treatments required was not based on appliance, but rather correlated with baseline
severity at presentation (correlation = 0.61; p < 0.0001).
† Measurement obtained after administration of albuterol. Improvement after each treatment is based upon change in PAS from measured
PAS at presentation.
‡ Based on receipt of ondansetron.
MDI vs. BAN in Pediatric Asthma Exacerbations 5

BAN to MDI. Reasons for changing appliances included patients with an MDI. MDIs are more expensive than
a lack of clinical improvement and physician preference the BAN and require more active bedside time for the
(3,8). All but 1 of these patients had a known diagnosis RT. In contrast, the BAN (AeroEclipse) device is not
of asthma. Of the 8 subjects who failed to improve reusable, not compatible with a standard home nebulizer,
clinically, 7 failed to improve with either device and and requires a power source. By failing to demonstrate
were admitted to the hospital. Two of the 3 subjects the MDI’s effectiveness during the ED visit, lack of con-
changed for physician preference were admitted. fidence in the MDI may encourage unnecessary ED visits
Tachycardia was more common in the BAN group for AE that could otherwise be treated at home.
(141 [32%] of BAN vs. 101 [23%] of MDI, p = 0.002) We did not demonstrate a difference in ED LOS be-
(Table 2). The difference remained after adjusting for tween the 2 cohorts. ED LOS positively correlated with
baseline PAS (odds ratio 1.56 [95% CI 1.15–2.11], presentation symptom severity and the number of albute-
p = 0.004). There were no differences in documented rol treatments given. The BAN allows for delivery of both
nausea or vomiting measured by ondansetron administra- ipratropium and albuterol simultaneously, whereas the
tion, or repeat visits within 7 days, between treatment MDI requires 2 separate devices, administered sequen-
groups in unadjusted and adjusted analyses (Table 2). tially. This would suggest that in more severe exacerba-
tions requiring both treatments, BAN might reduce ED
DISCUSSION LOS; however, the total treatment time for each MDI
treatment is shorter than each BAN treatment. Additional
We know that many children are not using their home timed studies are needed to determine active bedside
MDIs correctly, and physicians are rarely taking time dur- treatment time to characterize the factors that are most
ing patient visits to demonstrate their proper use (14–17). responsible for determining ED LOS.
In addition, involving families in their child’s treatment The BAN group was more likely to receive ipra-
using MDIs in the ED has led to better MDI use at tropium than the MDI cohort (Table 2); this is likely
home (18). After adjusting for PAS severity using because of convenience, because both medicines could
protocol-recommended doses of albuterol, our study be simultaneously administered in the same BAN reser-
showed that subjects randomized to MDI or BAN had voir. There were 20 MDI subjects and 43 BAN subjects
similar admission rates and ED LOS, suggesting the presenting with mild severity who unnecessarily received
MDI is noninferior to the BAN. Giving equivalent doses ipratropium, as per our ED treatment protocol. It is uncer-
of albuterol via MDI is not practical (approximately 28 tain whether more BAN subjects would have needed
puffs for a 2.5-mg treatment of albuterol). We believe additional therapy had they not received ipratropium,
that the MDI should be first-line therapy for nonsevere because there are conflicting data regarding its effective-
AEs with the hope that it will encourage better MDI ness (30–33). It is worth mentioning that every child who
use at home and reduce future ED visits. was admitted in either cohort received ipratropium in
The existing literature on BAN efficacy is conflicting. the ED.
Several studies show BAN use in children and adults re-
sults in fewer hospitalizations, shorter ED LOS, and Limitations
improved patient satisfaction, while using less albuterol,
compared to SVN therapy (8,19,20). In contrast, Parone Our study does have several limitations. Our ED and pa-
et al. found that BAN resulted in slightly longer ED tient population is biased in favor of BAN, and this could
LOS (10 min), did not demonstrate significant clinical have resulted in failure to enroll selected patients for fear
improvement when compared with SVN therapy, and of possible treatment failure or of receiving low patient
ultimately concluded that its effectiveness was not satisfaction scores. The most common reason for patients
justified by the additional cost (21). refusing participation was the risk of randomizing to the
MDIs are more clinically efficacious and cost effective MDI cohort. During high patient volume surges, we were
than SVNs in treating mild, moderate, and severe unable to approach all study-eligible patients. These fac-
exacerbations in children as young as 12 months of age tors could result in our observed acuity being lower than
(4,22–27). Indeed, many pediatricians are successfully we intended. In addition, because we have variable physi-
treating asthma around the world by using MDIs with cian practice patterns and patients with unique individual
modified plastic soft drink bottles as spacers (28,29). needs, we did not maintain strict admission criteria. Our
There is robust literature supporting MDI use; high-volume ED made standardized recheck times post-
therefore, we expected it to be at least as effective as treatment impossible to control for in our study design.
the BAN. We feel that though these limitations may have affected
Our practice, adopted primarily out of convenience, our primary and secondary outcomes, they are not unique
has been to treat AE using BANs and then discharge to our institution, making our findings still relevant.
6 M. A. Snider et al.

Third, we overestimated our admission rate—compared 5. Pollock M, Sinha IP, Hartling L, Rowe BH, Schreiber S,
Fernandes RM. Inhaled short-acting bronchodilators for managing
to our chart review’s 35%, our study showed an admission emergency childhood asthma: an overview of reviews. Allergy
rate closer to 12%. This discrepancy occurred because 2017;72:183–200.
our chart review included severe exacerbations. Despite 6. Castro-Rodriguez JA, J Rodrigo G, E Rodrı́guez-Martı́nez C. Prin-
cipal findings of systematic reviews of acute asthma treatment in
this estimation difference, we were still able to show non-
childhood. J Asthma 2015;52:1038–45.
inferiority at a <5% margin. 7. Staggs L, Peek M, Southard G, et al. Evaluating the length of stay
There were more subjects in the BAN cohort than in and value of time in a pediatric emergency department with two
models by comparing two different albuterol delivery systems. J
the MDI cohort who scored within the moderate PAS Med Econ 2012;15:704–11.
severity range. This likely occurred because we did not 8. Sabato K, Ward P, Hawk W, Gildengorin V, Asselin JM. Random-
stratify subject randomization at presentation with ized controlled trial of a breath-actuated nebulizer in pediatric
asthma patients in the emergency department. Respir Care 2011;
respect to their baseline PAS. We presented both the un- 56:761–70.
adjusted and adjusted symptom severity data for the pri- 9. Liu LL, Gallaher MM, Davis RL, Rutter CM, Lewis TC,
mary and secondary outcomes and found no significant Marcuse EK. Use of a respiratory clinical score among different
providers. Pediatr Pulmonol 2004;37:243–8.
difference between the cohorts in either analysis 10. Altamimi S, Robertson G, Jastaniah W, et al. Single-dose oral dexa-
(Tables 2 and 3). Approximately 9% of our data were methasone in the emergency management of children with exacer-
lost because of study violations—most commonly bations of mild to moderate asthma. Pediatr Emerg Care 2006;22:
786–93.
failure to document assent—and this may have had an 11. Liu X, Yu T, Rower JE, Campbell SC, Sherwin CM,
adverse effect in distribution. Finally, there was no Johnson MD. Optimizing the use of intravenous magnesium sul-
difference in repeat visits despite the MDI cohort fate for acute asthma treatment in children. Pediatr Pulmonol
2016;51:1414–21.
receiving more training. This could mean that families 12. Chameides L, Ralston M, American Academy of Pediatrics, Amer-
who would have otherwise returned did not need to ican Heart Association. Pediatric advanced life support. Dallas, TX:
because they felt confident with the MDI, or that the American Heart Association; 2011.
13. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG.
additional training had no effect whatsoever as it was Research electronic data capture (REDCap)—a metadata-
essentially the same as the BAN. driven methodology and workflow process for providing transla-
tional research informatics support. J Biomed Inform 2009;42:
377–81.
CONCLUSION 14. Naar-King S, Lam P, Ellis D, Bruzzese JM, Secord E. Asthma medi-
cation device skills in high-risk African American adolescents. J
Despite our study limitations, analyses adjusting for im- Asthma 2013;50:579–82.
15. Reznik M, Silver EJ, Cao Y. Evaluation of MDI-spacer utilization
balances in baseline symptom severity support our
and technique in caregivers of urban minority children with persis-
conclusion that MDIs are noninferior to BANs for the tent asthma. J Asthma 2014;51:149–54.
treatment of mild to moderate pediatric AE in the ED. 16. Reznik M, Jaramillo Y, Wylie-Rosett J. Demonstrating and assess-
ing metered-dose inhaler-spacer technique: pediatric care pro-
Future studies involving severe AE are needed to deter- viders’ self-reported practices and perceived barriers. Clin Pediatr
mine if the MDI is noninferior to the BAN for treating pe- (Phila) 2014;53:270–6.
diatric AE of all severities. We believe that the MDI is 17. Osmond MH, Gazarian M, Henry RL, Clifford TJ, Tetzlaff J. Bar-
riers to metered-dose inhaler/spacer use in Canadian pediatric emer-
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readily available, and can be used by the patient at 1106–13.
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979–82. 2015;51:192–8.

APPENDIX

Pediatric Asthma Score

Examination Component 1 2 3

Respiratory rate (breaths/min)

1–4 years of age #34 35–39 $40
4–6 years of age #30 31–35 $36
6–12 years of age #26 27–30 $31
>12 years of age #23 24–27 $28
Oxygen saturation >95% on room air 90–95% on room air <90% on room air or
requirement requiring oxygen
Retractions None or intercostal Intercostal and substernal Intercostal, substernal, and
supraclavicular
Work of breathing (count to 10) Speaks in sentences, coos Speaks in partial sentences, short cry Speaks in single words/
and babbles short phrases, grunting
Auscultation Normal breath sounds to end- Expiratory wheezing Inspiratory and expiratory
expiratory wheezes only wheezing to diminished
breath sounds
Total PAS Mild = 5–7 Moderate = 8–11 Severe/critical$12

Institutional Asthma Treatment Protocol

Mild Moderate Severe

Albuterol MDI (spacer/mask) Albuterol MDI (spacer/mask) MDI not indicated

#20 kg (6 puffs) #20 kg (6 puffs)
>20 kg (12 puffs) >20 kg (12 puffs)
BAN albuterol 2.5 mg/0.5 mL with 0.5 mL BAN albuterol BAN albuterol
NS #20 kg (2.5 mg/0.5 mL) #20 kg (5 mg/1 mL)
>20 kg (5 mg/1 mL) >20 kg (10 mg/2 mL)
SVN albuterol SVN albuterol SVN albuterol
#20 kg (2.5 mg/3 mL) #20 kg (2.5 mg/3 mL) #20 kg (7.5 mg/9 mL)
>20 kg (5 mg/6 mL) >20 kg (5 mg/6 mL) >20 kg (15 mg/18 mL)
No ipratropium indicated Ipratropium nebulization Ipratropium nebulization
0.5 mg/2.5 mL 0.5 mg/2.5 mL

BAN = breath-actuated nebulization; MDI = metered-dose inhaler; PAS = Pediatric Asthma Score; SVN = small volume nebulizer.
8 M. A. Snider et al.

ARTICLE SUMMARY
1. Why is this topic important?
Pediatric asthma exacerbations account for >9 million
emergency department (ED) visits annually. Many of
these visits occur because families do not feel comfortable
using their home metered-dose inhaler (MDI), resulting in
unnecessary visits to the ED.
2. What does this study attempt to show?
Breath-actuated nebulization (BAN) is a relatively
newer method for delivering aerosolized albuterol for pa-
tients experiencing an asthma exacerbation. The BAN is
not yet readily available for home use; however, this study
shows that the MDI is clinically noninferior to the BAN
for treatment of mild to moderate asthma exacerbations
in pediatric patients.
3. What are the key findings?
Admission rates and ED lengths of stay for the MDI
cohort was noninferior to the BAN cohort. Subjects in
the BAN cohort were more likely to experience tachy-
cardia than subjects in the MDI cohort; however, treat-
ment of nausea with ondansetron and return ED visits
were not statistically significant between the cohorts.
4. How is patient care impacted?
MDIs are still the optimal method for treating pediatric
asthma exacerbations. ED visits are an opportunity to
show families that the MDI is readily available, effective,
and can be used at home.