MDI vs Nebulizer for Asthma Exacerbation

Oh, the sound of nebulized beta-agonists… it is like … fingers nails on a chalk board to me!

Ok, I might be a bit of a vigilante, going exam room to exam room trying to eliminate albuterol nebs… but, here’s my rationale:

MDI’s rock!

  • Studies have shown that with regards to delivery of bronchodilators, MDI with spacer and nebulizer can be equally efficacious.
  • Some studies even state that MDIs are superior as they can lead to shorter time to discharge from the ED, lead to less tachycardia, and end up being more cost-effective than nebs.
  • The “mystical smoke” seems to be inhaled by everyone else in the room more than the patient.

Commonly heard….

  • Often our patients have the notion that the nebs “work-better.”
  • The problem with MDIs is:
    • It requires more patient coordination and education to use.
    • Many of the patients who are not getting the same improvement with their home MDIs are likely not using a Spacer (with is imperative to ensure the medicine isn’t simply squirt on the tongue – making it oral albuterol, which is worthless) or their MDI is empty.
    • It does require a respiratory hold to be performed (so the patient who cannot coordinate their own respiratory hold likely can’t use a MDI … but that patient also likely needs much more aggressive therapies, i.e. Continuous Albuterol, Heliox, BiPap, Magnesium, Kitchen Sink).

The Problem with Nebs

  • Require someone to hold the “mystical smoke” near the patient’s face for ~60 minutes.
  • The “mystical smoke” is difficult to target (ends up dilating the parent’s bronchioles more).
  • Home Neb Machines are notoriously filthy and disgusting. Ask a family the last time that the neb machine was cleaned out… I would bet that it may never have been cleaned. So now they are not only nebulizing medications, but also cockroach parts, dust and dust mites, mouse poop, and fungi. Those are awesome therapies for the asthma exacerbation.
  • Home Neb Machines are not very portable and can’t go to Grandma’s house easily… or be at school… or on vacation.

The benefit of MDI use in the ED:

  • At least, if not more, as efficacious as nebs.
  • Less time to administer (less holding screaming kids down to get the neb or trying to coax them to wear a mask with tusks on it).
  • BUT the best reason: It offers an opportunity to educate the patient and the family on proper use of the MDI with the spacer and helps reduce the belief that the “mystical smoke” works better. This will help them when they have another exacerbation and will hopefully help prevent a return to the ED. It also allows them to feel comfortable using the MDI correctly and then can have multiple MDI canisters in the various places they live, work, and play so they can treat the exacerbation appropriately as quickly as possible.

Certianly, MDI’s aren’t appropriate for everyone and your therapies should always be tailored to the individual; however, for the majority of patients, MDIs are the preferred initial treatment in the ED. If your patient is getting a neb, then they likely look pretty sick and you might want to start considering the other Kitchen Sink therapies (see Heliox Morsel).

Doan Q, Shefrin A, Johnson D. Cost-effectiveness of meter-dose inhalers for asthma exacerbations in the pediatric emergency department. Pediatrics 2011; 127(5): e1105-e1111

Castro-Rodriguez JA, Rodrigo GJ. beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. J Pediatr 2004;145:172–7.

Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand R, Rau JL, Smaldone GC, Guyatt G. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest 2005 Jan;127(1):335-71.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. Hi! Not exactly MDI vs spacer question, but…. I’ve been trying for a while to find out the reason why there is such a big variation in salbutamol dosing recommendations (in acute situations) between various countries and national guidelines. E.g. in my country (somewhere in Europe) 2 puffs/dose is standard, regardless of age, weight or even severity (?!) – and people say it’s based on the GINA document (which actually advises 2 puffs/dose for mild-moderate asthma exacerbation). But all other sources (be them from the UK, US, Australia etc) recommend more than 2 puffs (ranging from 2 to 10 puffs), especially to moderate-severe cases.
    Can someone please advise on that?
    Thank you.

  2. […] problem and, therefore, a common topic for the Morsels.  We have discussed my preference for MDIs over Nebs as well as the utility of Magnesium.  In addition, we have covered mechanical ventilation for […]

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