Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler.

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

Inhaler usability of a pressurized metered dose inhaler and a soft mist inhaler in patients with COPD: A simulated-use study.

The objective of this study was to evaluate task performance and handling errors with soft mist inhalers (SMIs) or pressurized metered-dose inhalers (pMDIs) among patients with chronic obstructive pulmonary disease (COPD) experienced with, but not recently trained in, using these devices. This exploratory, noninterventional, simulated-use study (D5970R00004) assessed handling/usability of SMIs and pMDIs in inhaler-experienced patients with COPD (40-78 years; diagnosis ≥6 months). Patients received a device and instruction-for-use leaflet but no training and were recorded while performing tasks required for checking the device, priming, and dosing. Errors that could substantially affect the lung-delivered dose were considered critical. Sixteen of 61 patients (52% male) had used SMIs and 55 had used pMDIs. Thirty-one patients received an SMI and 30 a pMDI. Overall, 79% made ≥5 performance errors (SMI 94%; pMDI 63%) and 49% made ≥5 critical errors (SMI 68%; pMDI 30%). All patients made ≥1 error; three (all pMDI) made no critical errors. Regardless of the device used and previous inhaler experience, patient-centered training, education, and continuous retraining on correct inhaler use should be key aspects of routine patient care in COPD.

Performance of the Population Bioequivalence (PBE) Statistical Test with Impactor Sized Mass Data.

This article extends previous work studying performance characteristics of the population bioequivalence (PBE) statistical test recommended by the US Food and Drug Administration (FDA) for orally inhaled and nasal drug products. Based on analysis of a metered dose inhaler database for impactor sized mass, a simulation study was designed to compare performance of the recommended PBE approach with several modified or alternative approaches. These included an extended PBE that separately modeled within-batch (can) and between-batch (batch) variability and average bioequivalence (ABE) tests that modeled with or without between-batch variability and with or without log-transformation. This work showed that separately modeling within- and between-batch variability while increasing the number of sampled batches addressed previously identified issues of the PBE approach when between-batch variability was present, namely, (a) increased risk for falsely concluding equivalence and (b) low probability of correctly concluding equivalence. The same modifications were also required of the ABE to achieve expected performance. However, these modifications did not successfully address the issue of equivalence conclusions that depended on the direction of product mean differences (asymmetric performance). This work highlights the importance of understanding decision-making error rates in developing regulatory recommendations to standardize bioequivalence outcomes across products.

Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization.

STUDY OBJECTIVE: We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma. METHODS: This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit. RESULTS: A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit. CONCLUSION: Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort.

Are children with asthma overconfident that they are using their inhalers correctly?

OBJECTIVE: The objectives of this study were to quantify the extent to which children with asthma are overconfident that they are using their inhalers correctly and determine whether demographic and clinical characteristics are associated with children being overconfident. METHODS: Children (n = 91) ages 7-17 with persistent asthma were recruited at two pediatric practices in North Carolina and demonstrated their inhaler technique for metered dose inhalers during an office visit. Children were dichotomized into two groups based on how confident they were that they were using their inhalers correctly: "completely confident" or "not completely confident". The mean number of inhaler steps (out of 8) children performed incorrectly was examined. We applied linear regression models for children in the "completely confident" group to determine whether demographic and clinical factors predicted their overconfidence, defined as the number of inhaler steps performed incorrectly. RESULTS: Children were primarily male (56%) and non-Hispanic White (60%). Sixty-eight (75%) children were "completely confident" that they were using their inhalers correctly. The "completely confident" group missed an average of 1.5 steps. In the "completely confident" group, males (p < 0.04) missed significantly more steps than females. The two most common errors were forgetting to shake the inhaler and holding their breath for 10 s. CONCLUSION: Regardless of their confidence level, children in our sample missed an average of 1-2 steps on an inhaler technique assessment. Findings from this study provide new evidence that it is insufficient to ask children if they are using their inhalers correctly. Therefore, it is vital that providers ask children to demonstrate their inhaler technique during health encounters.

Energy Efficient Monitoring of Metered Dose Inhaler Usage.

Life-long chronic inflammatory diseases of the airways, such as asthma and Chronic Obstructive Pulmonary Disease, are very common worldwide, affecting people of all ages, race and gender. One of the most important aspects for the effective management of asthma is medication adherence which is defined as the extent to which patients follow their prescribed action plan and use their inhaler correctly. Wireless telemonitoring of the medication adherence can facilitate early diagnosis and management of these diseases through the use of an accurate and energy efficient mHealth system. Therefore, low complexity audio compression schemes need to be integrated with high accuracy classification approaches for the assessment of adherence of patients that use of pressurized Metered Dose Inhalers (pMDIs). To this end, we propose a novel solution that enables the energy efficient monitoring of metered dose inhaler usage, by exploiting the specific characteristics of the reconstructed audio features at the receiver. Simulation studies, carried out with a large dataset of indoor & outdoor measurements have led to high levels of accuracy (98 %) utilizing only 2 % of the recorded audio samples at the receiver, demonstrating the potential of this method for the development of novel energy efficient inhalers and medical devices in the area of respiratory medicine.

Metered dose inhaler-spacer use education effects on achieve asthma control in children.

INTRODUCTION: Improper Metered Dose Inhaler (MDI)-spacer use technique can result in less than optimal delivery of medicine to the lungs and poor asthma outcomes. The aim of this study was to evaluate the influence of standardized education on proper MDI- spacer use and asthma control in children with asthma and to identify the factors associated with these results. MATERIALS AND METHODS: This is a cohort study that evaluated the influence of standardized education about MDI-Spacer device use on asthma control in children. Asthmatic children using MDI-Spacer device and their parents were enrolled in this study. Children were followed up for two months after standardized education and the change in asthma control was recorded. RESULT: Thirty eight children (14 females and 24 males) aged between 2.5 and 13 years were enrolled in the study. Mean age of the children was 7.5 ± 2.8 years. Six patients were lost to follow up and thirty two patients completed the study. Mean inhalation technique score was 4.9 ± 1.3 before education and increased significantly to 7.8 ± 0.4 after education (p< 0.001). Mean Asthma Control Questionnaire (ACQ) score decreased significantly with education (0.77 ± 0.9 vs 0.1 ± 0.1 respectively, p< 0.001). Similarly, mean asthma symptom score (ASS) decreased significantly from 4.3 ± 3.6 to 0.2 ± 0.7 with education (p< 0.001). Most common mistake in use of MDI-Spacer device use was detected to be lack of mouth rinsing after use before education in 78.9% of the patients. CONCLUSIONS: Providing standardized education about MDI-Spacer device use to children and parents leads to correct MDI-Spacer device use and is associated with improvement in asthma symptom score and asthma control.

Using videos to teach children inhaler technique: a pilot randomized controlled trial.

OBJECTIVE: This primary objective of this pilot randomized, controlled trial was to determine whether a brief video intervention delivered after a pediatric office visit could improve inhaler technique in children with asthma immediately and one month later. The intervention's effect on children's inhaler self-efficacy and asthma control was also evaluated. METHODS: Children (n=91) ages 7-17 years with persistent asthma were recruited at two pediatric practices in North Carolina. Eligible children demonstrated their inhaler technique for metered dose inhalers (MDIs) either with or without a spacer. A trained research assistant used a validated inhaler technique checklist to record which steps children performed correctly. After a regularly scheduled office visit, children were randomized to watch either a 3-min MDI video (intervention group) or a nutrition video (control group) in English or Spanish. Children's technique was assessed again after watching the video and one month later. RESULTS: Children were primarily male (56%) and non-White (60%). When compared with the control group, children in the intervention group demonstrated a significant improvement in MDI technique post-intervention [mean=1.12 steps, 95% CI (0.73, 1.50)] but the improvement was not sustained at 1-month follow-up. The intervention did not lead to significant improvements in inhaler self-efficacy or asthma control. CONCLUSIONS: A brief video intervention offered during pediatric clinic visits can lead to immediate improvements in children's inhaler technique. Future studies should evaluate whether booster training videos can help maintain improvements in children's inhaler technique over time.

Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers.

OBJECTIVE: To address the problems about correct use of inhaler devices, adherence to inhaler corticosteroid treatment and the effects of these problems on the control of asthma. METHODS: Children with asthma were evaluated for the correct use of inhaler devices and adherence to therapy using a questionnaire. Effect of these on control of asthma was defined. RESULTS: A hundred and seventy-one patients and/or their families were interviewed. The mean age was 8.29 ± 4.65 years (1-19) and 62.6% were male. Metered dose inhaler (MDI) with spacer was used by 119 (69.5%) patients and 52 (30.5%) used dry powder inhalers (DPIs). The devices were used correctly by 68.1% of patients using MDI and 34.6% of patients using DPI (p < 0.001). The most common improper step was "breathe in from the spacer 5-6 times or 10 s" for MDI (24.4%) and "exhale to residual volume" for DPI (51.9%). Frequency of correct use was higher in patients trained 3 times (p < 0.001). Asthma was controlled more frequently among correct users (p < 0.001). Partial or poor adherence was showed 22.8% of patients. Patients with mothers who had lower educational status had higher frequency of incorrect use of inhaler device (p = 0.007). CONCLUSION: It was found that asthma control was better among correct users. Repetitive training about using devices may contribute improving inhaler technique. Especially children whose mothers had low education level and patients using DPI should be evaluated more carefully.

Evaluating the effect of an asthma self-management intervention for rural families.

OBJECTIVE: To present outcomes of an asthma self-management educational intervention delivered to children (grades 2-5) at school and to parents in a home visit. METHODS: The intervention effectiveness was tested in a 12-month longitudinal study with randomization by elementary schools into treatment and attention-control groups with 183 children who had a diagnosis of asthma. Data were collected at four time points. Change over time was examined with linear mixed models. RESULTS: Quality of life (QOL), hospitalizations, and emergency department visits improved significantly for all the children. African American and Mexican American children had worse asthma-related QOL than did White children. Asthma management behaviors, asthma self-efficacy, and coping likewise improved with girls improving significantly more than the boys. Significant improvements in inhaler skill and asthma severity were seen in the treatment group children when compared to the control group. Treatment group parents showed significant improvements in home asthma management and self-efficacy. CONCLUSIONS: The improvement in inhaler skill is an important finding for practitioners as this is a behavior that can be addressed in the clinical setting. The reduction in the treatment group's asthma severity scores may reflect the improvement in medication delivery as their inhaler skill improved. The differential improvement between boys and girls points to the need for testing other formats in asthma education that can address different learning styles. The individualized parent asthma education enabled the intervener to incorporate neighborhood and home environmental information thereby allowing for tailoring of parental instruction.

[Inhalation therapy, patient's perspective]. / Patientenpräferenz von Inhalern.

The cornerstone of drug application in obstructive pulmonary diseases is by inhalation as advocated by all treatment guidelines. Today, there exists an extensive choice of inhalers and new models. Numerous inhaler types are constantly being developed and introduced into the market making the "correct" selection a wearying task for the physician as well as for the patient. Improvement in the management of this aspect, which is often neglected in its importance in daily practice as well as in guidelines, is therefore reliant not only on the medications themselves but also on their effective delivery. Complicated inhaler mechanics and poor inhaler technique which do not meet the patient requirements and desires contribute to poor compliance eventually leading to poor disease control. In this review, the importance of inhaler acceptance and the degree of satisfaction with different inhaler types are discussed. This paper focuses on the behavioral and attitudinal evidence that the acceptance of the inhaler is linked to patient compliance, and its linkage on health and patient-reported outcomes.

The Tiotropium Safety and Performance in Respimat Trial (TIOSPIR), a large scale, randomized, controlled, parallel-group trial-design and rationale.

BACKGROUND: Tiotropium bromide is an effective therapy for COPD patients. Comparing across programs tiotropium Respimat Soft Mist inhaler was at least as efficacious as tiotropium HandiHaler, however, concerns have been raised about tiotropium's safety when given via Respimat. METHODS: The TIOSPIR trial (NCT01126437) compares the safety and efficacy of tiotropium Respimat 5 µg once daily (marketed) and 2.5 µg once daily (investigational) with tiotropium HandiHaler 18 µ once daily (marketed). The hypotheses to be tested are 1). that tiotropium Respimat 5 µg once daily and Respimat 2.5 µg once daily are non-inferior to HandiHaler in terms of all-cause mortality, and 2). that tiotropium Respimat 5 µg once daily is superior to HandiHaler in terms of time to first exacerbation. A spirometry substudy evaluates the bronchodilator efficacy. The trial is a randomized, double-blind, double dummy, event-driven, parallel group study. Participants can use any background treatment for COPD except inhaled anticholinergic agents. The study encompasses a wide range of COPD patients, e.g. patients with stable cardiac diseases including arrhythmia can be included. Clinical sites are international and include both primary care as well as specialists. RESULTS: To date, over 17,000 participants have been randomized from over 1200 sites in 50 countries with an anticipated treatment duration of 2-3 years. CONCLUSION: TIOSPIR will provide precise estimates of the relative safety and efficacy of the Respimat and HandiHaler formulations of tiotropium, assess potential dose-dependence of important outcomes and provide information on the clinical epidemiology of COPD in a large international patient cohort.

Growth of preschool age children receiving daily inhaled corticosteroids.

Data on the effects of inhaled corticosteroid (ICS) on linear growth in children <5 years old are limited with conflicting results from existing studies. This study was designed to investigate growth effects of inhaled corticosteroid use in children <5 years of age treated for asthma with ICS administered through a valved holding chamber (VHC). A retrospective cohort study was performed of 145 children in three treatment groups: (1) metered-dose inhaler (MDI) containing ultrafine beclomethasone dipropionate (n = 62), (2) MDI containing fluticasone propionate (n = 32), and (3) oral montelukast sodium (n = 51). Children <5 years of age between 2000 and 2009 treated for asthma with one of the three drugs were included in the study. Linear mixed model analysis was used to examine and compare growth during sustained treatment with each of the three medications. The three treatment groups did not differ significantly in their effect on growth rates (p = 0.64). However, female subjects had significantly slower growth than male subjects (p = 0.017), and the addition of intranasal corticosteroids (INS; p = 0.013) and the presence of atopy (p = 0.015) had a significant negative effect on growth. In children <5 years of age receiving maintenance therapy for chronic asthma, low-to-medium doses of ultrafine beclomethasone or fluticasone administered through a VHC were not associated with growth inhibition compared with children receiving oral montelukast. A small but statistically significant decrease in growth was seen in subjects with positive skin testing to inhalant allergens in female subjects and in subjects receiving INS.

Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial.

BACKGROUND: Hospitalized patients frequently misuse their respiratory inhalers, yet it is unclear what the most effective hospital-based educational intervention is for this population. OBJECTIVE: To compare two strategies for teaching inhaler use to hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD). DESIGN: A Phase-II randomized controlled clinical trial enrolled hospitalized adults with physician diagnosed asthma or COPD. PARTICIPANTS: Hospitalized adults (age 18 years or older) with asthma or COPD. INTERVENTIONS: Participants were randomized to brief intervention [BI]: single-set of verbal and written step-by-step instructions, or, teach-to-goal [TTG]: BI plus repeated demonstrations of inhaler use and participant comprehension assessments (teach-back). MAIN MEASURES: The primary outcome was metered-dose inhaler (MDI) misuse post-intervention (<75% steps correct). Secondary outcomes included Diskus® misuse, self-reported inhaler technique confidence and prevalence of 30-day health-related events. KEY RESULTS: Of 80 eligible participants, fifty (63%) were enrolled (BI n=26, TTG n=24). While the majority of participants reported being confident with their inhaler technique (MDI 70%, Diskus® 94%), most misused their inhalers pre-intervention (MDI 62%, Diskus® 78%). Post-intervention MDI misuse was significantly lower after TTG vs. BI (12.5 vs. 46%, p=0.01). The results for Diskus® were similar and approached significance (25 vs. 80%, p=0.05). Participants with 30-day acute health-related events were less common in the group receiving TTG vs. BI (1 vs. 8, p=0.02). CONCLUSIONS: TTG appears to be more effective compared with BI. Patients over-estimate their inhaler technique, emphasizing the need for hospital-based interventions to correct inhaler misuse. Although TTG was associated with fewer post-hospitalization health-related events, larger, multi-centered studies are needed to evaluate the durability and clinical outcomes associated with this hospital-based education.

A randomized controlled trial of a literacy-sensitive self-management intervention for chronic obstructive pulmonary disease patients.

BACKGROUND: Low literacy skills are common and associated with a variety of poor health outcomes. This may be particularly important in patients with chronic illnesses such as chronic obstructive pulmonary disease (COPD) that require appropriate inhaler technique to maintain quality of life and avoid exacerbations. OBJECTIVE: To explore the impact of a literacy-sensitive self-management intervention on inhaler technique scores in COPD patients and to determine if effects differ by literacy. DESIGN: Randomized controlled trial. PARTICIPANTS: Ninety-nine patients with COPD. INTERVENTION: Patients were randomly assigned to a one-on-one self-management educational intervention or usual care. The intervention focused on inhaler technique, smoking cessation, and using a COPD action plan. MAIN MEASURES: At baseline, an inhaler technique assessment, literacy assessment, health-related quality of life questionnaires, and pulmonary function tests were completed. Inhaler technique was re-evaluated after two to eight weeks. KEY RESULTS: Mean age 63, 65% female, 69% Caucasian, moderate COPD severity on average, 36% with low literacy, moderately impaired health-related quality of life, and similar baseline metered dose inhaler technique scores. Patients in the intervention group had greater mean improvement from baseline in metered dose inhaler technique score compared to those in the usual care group (difference in mean change 2.1, 95% CI 1.1, 3.0). The patients in the intervention group also had greater mean improvements in metered dose inhaler technique score than those in the usual care group whether they had low health literacy (difference in mean change 2.8, 95% CI 0.6, 4.9) or higher health literacy (1.8, 95% CI 0.7, 2.9). CONCLUSIONS: A literacy-sensitive self-management intervention can lead to improvements in inhaler technique, with benefits for patients with both low and higher health literacy.

Comparison of the bronchodilating effects of albuterol delivered by valved vs. non-valved spacers in pediatric asthma.

INTRODUCTION: Inhaled therapy using a metered-dose inhaler (MDI) with attached valved holding chamber has been increasingly recognized as the optimal method for delivering bronchodilators for asthma treatment. However, mainly due to the high cost of these valved holding chambers in many developing countries, the use of non-valved spacers is frequent, despite the scarce evidence that supports their efficacy. The aim of this study was to compare the bronchodilator response to albuterol administered by MDI with and without a valved spacer. METHODS: In a randomized, two-period, two-sequence crossover clinical trial, we analyzed 31 stable asthmatic children (6-18 yrs of age) on two consecutive days, who were randomly assigned to receive 100 µg of albuterol MDI through either a locally produced valved spacer or a non-valved spacer. The next day, a crossover treatment was employed through the use of the other spacer. Spirometry was recorded before and after each albuterol administration. RESULTS: As we were not able to identify any sequence or carryover effect, we tested for treatment effects in both periods. No significant differences in the absolute change in FEV(1) (0.20 ± 0.17 vs. 0.18 ± 0.16, p = 0.63), FVC (0.07 ± 0.13 vs. 0.07 ± 0.16, p = 0.88), or MMEF (0.49 ± 0.31 vs. 0.43 ± 0.39, p = 0.53) after bronchodilator administration were found between the use of valved and non-valved spacers. CONCLUSIONS: In stable asthmatic children, albuterol administered through MDI using a non-valved spacer produces a bronchodilator response similar to that of a spacer with a valve that requires an inhalatory opening pressure (with flows between 2 and 32 l/min) that even toddlers with bronchial obstruction can easily generate.

Review: clinical inertia in the management of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death in the United States. Despite clinical practice guidelines endorsed by national organizations, the management of COPD deviates from guideline recommendations. Patients with COPD are frequently underdiagnosed and misdiagnosed, due in large part to the lack of spirometry testing. When diagnosed, about one third of patients are not receiving any COPD-related drug therapy. Factors that contribute to suboptimal management include provider, patient, and system factors. Physician factors such as understanding and attitude toward the disease, and awareness of guidelines, may affect appropriate management of COPD. Patient factors include medication non-adherence, understanding of the disease, severity of their symptoms, and access to medications. System factors such as insurance coverage may limit aspects of COPD care. To overcome clinical inertia, a multifaceted approach is required. Provider and patient education, the use of health informatics, changes in provider work-flow and the recent development of performance measures, such as the use of spirometry in patients with COPD, can improve the delivery of recommended care for COPD patients.

Relative bioavailability of terbutaline to the lung following inhalation, using urinary excretion.

AIMS: The aim of the study was to determine the relative lung and systemic bioavailability of terbutaline. METHODS: On separate days healthy volunteers received 500 µg terbutaline study doses either inhaled from a metered dose inhaler or swallowed as a solution with and without oral charcoal. Urine samples were provided at timed intervals post dosing. RESULTS: Mean (SD) urinary terbutaline 0.5 h post inhalation, in 12 volunteers, with (IC) and without (I) oral charcoal and oral (O) dosing was 7.4 (2.2), 6.5 (2.1) and 0.2 (0.2) µg. I and IC were similar and both significantly greater than O (P<0.001). Urinary 24 h terbutaline post I was similar to IC + O. The method was linear and reproducible, similar to that of the urinary salbutamol method. CONCLUSIONS: The urinary salbutamol pharmacokinetic method post inhalation applies to terbutaline. Terbutaline study doses can replace routine salbutamol during these studies when patients are studied.

Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment.

BACKGROUND: Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice. OBJECTIVES: We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population. METHODS: This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test. RESULTS: Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03-$10.28) vs. $18.26 ($9.88-$22.45) in the spacer and nebulizer groups, respectively (p < 0.001). CONCLUSION: There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.