22-14 PULMONARY DISORDERS

Studies comparing responses to SABAs administered by

Metered-Dose Inhaler
nebulization versus IPPB have shown no significant advan-
(MDI) tages for the IPPB method of administration.5 Furthermore,
dose-response studies that compared nebulization with IPPB
and pressurized metered-dose aerosols in stable chronic asthma
patients have shown no advantage among these methods of
administration when equivalent doses are administered.5,25,26
Each method delivers approximately 10% of the beginning
dose to the patient’s airways.27 Trials comparing metered-dose
aerosols of short-acting inhaled β 2 -agonists with the nebuliza-
tion of those same drugs in acute asthma also have shown no
significant advantage for the nebulization method of adminis-
tration when the metered-dose aerosolized administration was
carefully supervised by experienced personnel and a spacer
device was used. 28,29 However, in some younger acutely ill
children, it is difficult (even with supervision) to administer an
effective SABA with a metered-dose canister. Because many
patients and clinicians perceive that nebulizers provide more
Open Nebulizer intensive therapy, it often is important psychologically to give
at least the first dose of a SABA via a nebulizer. Thereafter,
it is more cost-effective to use the therapeutically equivalent
MDI plus spacer.30
The dose ratio for SABAs delivered by MDI plus spacer
versus nebulizer has varied in the literature. For children with
mild acute asthma, 2 puffs of albuterol MDI attached to a
spacer were not different from 6 to 10 puffs of albuterol or via
nebulizer 0.15 mg/kg.31 In one double-blind trial in children
with a severe exacerbation, investigators used a dose ratio of 1:5
(i.e., albuterol MDI-spacer 1 mg [10 puffs]: nebulized albuterol
5 mg).32 Nebulization of albuterol with compressed air or,
preferably, oxygen was the preferred method of administration
Closed Nebulizer for Q.C. initially.

DOSING
7. Starting 20 minutes after the first albuterol dose, two more
doses of 2.5 mg of albuterol were administered by nebulizer Q 20
minutes over the next 40 minutes. After three treatments, Q.C.’s
breath sounds became increasingly clear. She was no longer in
distress and could speak in complete sentences. Her PEF was now
70% of predicted, her SaO2 was 97% on room air, and discharge to
home was planned. Were the dose and dosing interval of albuterol
appropriate for Q.C.?
FIGURE 22-10 Metered-dose inhaler and nebulizer.
Schuh et al.33 demonstrated that a higher-dose albuterol reg-
imen (0.15 mg/kg vs. 0.05 mg/kg every 20 minutes) produced
Nebulized significantly greater improvement with no greater incidence of
Medication
Solution adverse effects. Schuh et al.34 subsequently reported greater ef-
Jet Orifice Baffle ficacy of albuterol in a dose of 0.3 mg/kg (up to 10 mg) hourly
over a dose of 0.15 mg/kg (up to 5 mg) hourly in children. The
Mainstream larger dose was tolerated as well as the 0.15 mg/kg dose.
Gas Flow Patient
Therefore, Q.C.’s albuterol regimen of 2.5 mg (0.13 mg/kg)
nebulized every 20 minutes for 40 minutes subsequent to her
first dose of aerosolized albuterol could have been even more
Capillary aggressive but was appropriate. Figure 22-12 and Table 22-5
Tube list the doses for inhaled β -agonists for acute asthma as well
as doses of other medications.1

COMPARISON OF SHORT-ACTING INHALED β2 -AGONISTS

Medication Solution
8. Would another SABA have been more effective in the initial
FIGURE 22-11 Air jet nebulizer. therapy of Q.C.?