Nebulizer versus Metered-Dose Inhaler: Which One in Pediatrics?


Should emergency room clinicians use a breath-actuated nebulizer (BAN) or is a metered-dose inhaler (MDI) a better choice?

With a large number of drug-device combinations available to administer medication to people who have asthma, clinicians can be somewhat confused. In addition, patients who visit the emergency room for acute exacerbations are often treated with devices that are different than that they use at home. Should emergency room clinicians use a breath-actuated nebulizer (BAN) or is a metered-dose inhaler (MDI) a better choice? BANs aerosolize albuterol solution but use an air compressor rather than a nebulizer. Some clinicians believe that using BANs in the emergency department may cause parents to think that MDIs are less effective.

This is a question that researchers from the University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee address in a new study in the Journal of Emergency Medicine. Conducted in a study population of children aged 2 to 17 years who had mild to moderate asthma exacerbations, they found that BAN is noninferior to MDI.

This randomized, nonblinded, noninferiority study enrolled 445 participants in each arm of the study. Participants received either albuterol by BAN or albuterol by MDI. When the treating clinician determined it was necessary, participants also received aerosolized ipratropium via BAN.

Participants in each arm of the study were similar except for pretreatment symptom severity. Approximately half of participants in the MDI group had a Pediatric Asthma Score of moderate severity (8—11). In the BAN, slightly more—63%—fell into that category.

The researchers calculated unadjusted admission rates of 11.9% and 12.8% for MDI and BAN, respectively. They then adjusted for baseline severity, and calculated a risk difference of just 2%. This met the noninferiority criteria.

The researchers indicate these results suggest the MDI should be first-line therapy for nonsevere asthma exacerbations, as doing a show delivers a message to parents that inhalers are effective. Patients may be more adherent at home, and less likely to have future emergency department visits. They also note, however, that MDIs are more expensive than the BAN.


Snider MA, Wan JY, Jacobs J, Kink R, Gilmore B, Arnold SR. A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med. 2018 Apr 28. pii: S0736-4679(18)30244-0. doi: 10.1016/j.jemermed.2018.03.002. [Epub ahead of print]

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