Original Article
β-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

https://doi.org/10.1016/j.jpeds.2004.04.007Get rights and content

Abstract

Objective

To compare the efficacy of β-agonists given by metered-dose inhaler with a valved holding chamber (MDI+VHC) or nebulizer in children under 5 years of age with acute exacerbations of wheezing or asthma in the emergency department setting.

Study design

Published (1966 to 2003) randomized, prospective, controlled trials were retrieved through several different databases. The primary outcome measure was hospital admission.

Results

Six trials (n = 491) met criteria for inclusion. Patients who received β-agonists by MDI+VHC showed a significant decrease in the admission rate compared with those by nebulizer (OR, 0.42; 95% CI, 0.24-0.72; P = .002); this decrease was even more significant among children with moderate to severe exacerbations (OR, 0.27; 95% CI, 0.13-0.54; P = .0003). Finally, measure of severity (eg, clinical score) significantly improved in the group who received β-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, −0.44; 95% CI, −0.68 to −0.20; P = .0003).

Conclusions

The use of an MDI+VHC was more effective in terms of decreasing hospitalization and improving clinical score than the use of a nebulizer in the delivery of β-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma.

Section snippets

Methods

A search was carried out by using three search strategies to identify potentially relevant trials without language restriction. First, we searched Medline (1966-2003) and Embase (1980-2003) databases by using the following MeSH, full text, and key word terms: (1) emergency or acute asthma or status asthmaticus or severe asthma or wheeze, (2) spacer or holding chamber or volumatic or nebuhaler or aerochamber or fisonair or extension or spacing device or inspirease, and (3) nebulizer. Second, an

Results

Seventy-nine articles were identified in the initial search. Of these, reviewers found that 25 papers were potentially eligible. Reasons for subsequent exclusion were studies on children >5 years old (n = 12)11., 12., 13., 14., 15., 16., 26., 27., 28., 29., 30., 31.; studies on nonacute patients (n = 4)32., 33., 34., 35.; and studies on hospitalized patients (n = 3).36., 37., 38. Finally, 6 articles were selected for inclusion in the meta-analysis.39., 40., 41., 42., 43., 44. One study was from Spain,

Discussion

The purpose of this systematic review was to compare the efficacy of β-agonists given by two different delivery methods (MDI+VHC or nebulizer) in infants or preschool children younger than 5 years of age with acute exacerbation of wheezing or asthma in the ED setting. Overall, the use of the MDI+VHC was more effective, in terms of hospitalizations and clinical score, than the use of a nebulizer. Our analysis strongly demonstrates that the administration of β-agonists by MDI+VHC significantly

Acknowledgements

We thank Dr Mark A. Brown (from the Pediatric Pulmonary Section, Arizona Respiratory Center, University of Arizona) for his advice and critical review of the manuscript.

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