Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial

Abstract

Introduction: In moderate-severe asthma exacerbation, salbutamol by inhaler (MDI) issuperior to salbutamol delivered by nebulizer (NEB); however, to our knowledge, nostudies in children with exclusively severe exacerbations were performed.Objective: To compare the efficacy of salbutamol and ipratropium bromide by MDIversus by NEB in severe asthma exacerbations.Methods: We performed a clinical trial enrolling 103 children (2-14 years of age) withsevere asthma exacerbations (defined by the Pulmonary Score ≥ 7) seen at theemergency room in Asuncion, Paraguay. One group received salbutamol andipratropium (two puff every 10 min for 2 h and then every 30 min for 2 h more) byMDI with a valved-holding chamber and mask along with oxygen by a cannulaseparately (MDI-SIB); and the other received nebulization with oxygen (NEB-SIB) ofsalbutamol and ipratropium (1 every 20 min for 2 h and then every 30 min for 2 h more).Primary outcome was the rate of hospitalization (Pulmonary Score ≥ 7) after 4 h andsecondary outcome was oxygen saturation.Results: Fifty two children received MDI-SIB and 51 NEB-SIB. After the 4th hour,children on MDI-SIB had significantly (P = 0.003) lower rate of hospital admission thanon NEB-SIB (5.8% vs 27.5%, RR: 0.21 [0.06-0.69], respectively). Similarly, a significantimproved clinical score after 60 min and increase in oxygen saturation after 90 min oftreatment was observed in MDI-SIB versus NEB-SIB group (4.46 ± 0.7 vs 5.76 ± 0.65,P < 0.00001; and 90.5 ± 1.7 vs 88.43 1 ± 1, P < 0.00001, respectively).Conclusion: Even in severe asthma exacerbations administration of salbutamol andipratropium by MDI with valved-holding chamber and mask along with oxygen by acannula separately was more effective than by a nebulizer.