Table of Contents
When it comes to childhood illnesses, asthma is easily the most common chronic condition seen in pediatric medicine (Zal, 2014) and the leading diagnosis when it comes to pediatric emergency room (ER) visits (Alpern et al., 2014). With asthma the airways become inflamed and can result in narrowing. This narrowing decreases the amount of oxygen that is delivered to the lungs. The signs and symptoms of an acute exacerbation can include shortness of breath, tachypnea, increased work of breathing, tachycardia, accessory muscle use, diminished or absent breath sounds, hypoxia, wheezing, decreased level of alertness, and anxiety (Ortiz-Alvarez and Mikrogianakis, 2012).
Rapid assessment and evaluation of a patient’s clinical status is necessary in order to determine the proper approach to treatment. The current therapies available for treatment usually include a combination of beta-agonists, anticholinergics, steroids, magnesium sulfate, oxygen and intravenous fluids (Federico, Hoch, Anderson, Spahn, and Szefler, 2016). Which medications are administered depend on the severity of the patient’s symptoms and their clinical appearance.
The beta-agonist albuterol is inhaled into the airways either through a nebulized aerosol treatment or a metered dosed inhaler with a spacer with facemask or mouthpiece. The purpose of this paper is to compare the two delivery methods for use with pediatric patients and determine if one option offers better results than the other.
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PICOT Question
In pediatric patients ≤ 12 years of age (P) how does the use of nebulized albuterol (I) compared to albuterol delivered via metered dose inhaler (C) affect the symptoms of an acute asthma exacerbation (O) within 3 hours (T)?
P: Patient Population
The patient population identified is pediatric patients between the ages of 1 and 12 years of age who have been diagnosed with asthma and have sought treatment for an acute exacerbation in an emergency room setting. There are currently over seven million children in this country who are diagnosed with asthma (Bengtson, Marvel, White, Figliomeniand, and Buikema, 2018).
I: Intervention
In pediatric patients the first line treatment in acute asthma exacerbations is a beta-agonist bronchodilator. Bronchodilators relax the smooth muscle of the airway that normally becomes inflamed and narrow during the acute phase of an asthma exacerbation (Doan, Shefrin, and Johnson, 2011). They have been shown to have the greatest potential for quick relief of acute symptoms. The bronchodilator most often utilized in the pediatric emergency room is albuterol.
C: Comparison
Metered dose inhalers can deliver a preset amount of medication in a mist that is inhaled in a short amount of time. The inhaler is usually utilized with a holding chamber called a spacer. The medicine is held in this reservoir until ready to be inhaled. This assures that all the medication is delivered to the lungs at a slower rate. Using a spacer prevents medication from being wasted and reduces side effects related to being administered in the mouth. The spacer can be used with a face mask or mouth piece depending on the age and size of the patient. While MDIs are easy to actuate, they are difficult to use properly without the spacer.
A nebulizer vaporizes liquid medication and delivers a fine mist to the patient via a mask or mouth piece. The nebulizer utilizes compressed medical air or oxygen to create the mist. A nebulized aerosol treatment is administered over 10-20 minutes. Nebulizers are used more often than an MDI with spacer in the acute care setting, however, there has been a push to change this statistic (Prieto, Rucker, and Payne, 2018). Some research shows that a large percent of the medication given through nebulization never actually reaches the lungs (DiBlasi, 2015).
O: Outcome
Evidence suggests that an MDI with spacer used in the appropriate and prescribed manner, offers the same amount of relief of acute asthma symptoms and bronchodilation as a nebulizer in pediatric patients. While MDIs have been shown to reduce the rate of hospital admission rates and the length of inpatient stays for pediatric patients, each device resulted in the same clinical outcomes with minimal side effects for either.
T: Time Frame
From the moment a pediatric patient in respiratory distress walks in the door assessment and evaluation begins. Within minutes an action plan is put into place and interventions begin. One of the first steps is to administer albuterol by MDI or nebulizer. Within 180 minutes it is determined whether a patient needs to be admitted or meets criteria for discharge. That being said, the time frame established was 3 hours.
Processes and Outcomes of Literature Search
A literature search is guided by a central research question. After a question has been decided on, the next steps are to define the search terms, identify the databases that will be utilized for the search, determine which filters to apply for inclusion and exclusion criteria, and decide what articles to utilize from search results. Criteria may have to be changed in order to further filter the number of articles and their relevance to the research question.
The literature search was conducted utilizing the following databases: CINAHL Plus with Full-Text, MEDLINE Complete (EBSCO), and PubMed. MEDLINE Complete is a full text data base that contains articles from over 5,000 medical journals for a wide range of subjects and is an essential resource for any medical professional. CINAHL Plus is a database created for nursing and allied health journal articles. This is the database I use most often for research. PubMed is a database that is maintained by The United States National Library of Medicine at the National Institutes of Health. The database is a free search engine and can be utilized by the general public.
The key words utilized while conducting the literature search included: “nebulizers”, “inhalers”, “asthma”, “pediatric”, and “MDI”. The search resulted thousands of articles with varied sources. It was necessary to reduce this number to a manageable amount by including different combinations of the terms and additional inclusion/exclusion criteria. The exclusion/inclusion criteria added to the search was: published in the last five years, peer-reviewed, research article, ages from one to twelve, published in the United States, printed in English language, and published in an academic journal.
Synthesis of Evidenced Based Literature
In young children inhaled delivery can be limited due to many reasons. These reasons include narrow airways, an increase in the airway resistance, and decreased inspiratory effort.
Other criteria that must be considered when determining which delivery vehicle to use is patient/parent preference, cost of medication, ability of patient to tolerate, and ease of use. Studies show that nebulizers are preferred to MDIs by most parents of children with asthma (Nambiar, Rimareva, & Krata, 2018). A parent’s perception is because they can see the mist created by the nebulizer, they know that their child is getting the medication. They also feel that because a nebulizer takes substantial more time to administer than the MDI that the child is receiving a better treatment.
However, MDIs do have benefits that nebulizers do not. They are portable and do not require a power source to use. This is convenient for a parent that is traveling or for a child in daycare. While either medication delivery method can be utilized it is difficult to do so with an uncooperative child. The benefit of the MDI in this instance is that the medication can be delivered quickly and with minimal emotional trauma to a child. Wherein as nebulizers may require holding the child and the mask to their face with them fighting and screaming the whole time. Add to this the stress of having to give multiple treatments or even a continuous treatment and an MDI may be the best vehicle of delivery.
According to the National Heart, Lung, and Blood Institute (NHLBI) 2018 Clinical Practice Guidelines for Asthma, medication and delivery devices should be selected to meet patient’s need and circumstances. Since both delivery devices result in almost identical clinical outcomes for pediatric patients, it is best to defer to these criteria when choosing which one to utilize in the acute care setting.
Integration of Interest into Clinical Practice
Although nurse educators in the clinical setting can take on many roles, the most vital role is the education and development of clinical staff. In acute care settings many providers are reluctant to administer MDIs for first line treatment of asthmatics. It is important for clinicians to know that research shows that MDIs are clinically equivalent to nebulizers and to know how to administer them correctly. Clinical staff needs to ensure proper technique for optimal medication administration. If MDI treatment fails, it is usually due to improper application and not because they are inferior to nebulizers (Mudd, Leu, Sloand, and Ngo, 2015). It is imperative when teaching patients and families, that teach back demonstrations are utilized and the first few administrations be supervised. Educating both staff and patients regarding the pros and cons of both delivery method will help them to choose the best method on a case by case basis.
