RESUMO
Aerosol delivery is a vital therapeutic strategy for both adult and pediatric patients presenting to the emergency department with respiratory distress. Aerosolized bronchodilators are frequently used as rescue medications for patients with diagnoses of asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. Historically, emergency department providers utilized jet nebulizers (JNs) for medication delivery, but were challenged by a need for increasingly higher bronchodilator doses to elicit the desired response. Advancements in technology have led to the development of newer specialized aerosol delivery devices and treatment strategies which provide clinicians with improved options for aerosol delivery but may also cause some uncertainty regarding appropriate device selection. Initial investigations comparing these devices presented valuable evidence of in vitro benefit but were unable to demonstrate corresponding improvement in clinical results. More recently there has been an influx of clinical evidence that suggests improved clinical outcomes associated with more efficient aerosol delivery devices such as vibrating mesh nebulizers (VMN) compared to the standard JN device. VMN will likely become an increasingly important tool in emergency department treatment of patients with respiratory distress. Additional controlled studies are needed both to examine the effects of VMN on patient outcomes, as well as to analyze how performance differences between aerosol devices may affect dosing strategies. Future efforts should also focus on applying new evidence in the form of updated consensus guidelines and standardized treatment strategies.
RESUMO
BACKGROUND: Nebulizers are commonly used in emergency departments to deliver bronchodilators to children with asthma exacerbations. However, no clinical study comparing a vibrating mesh nebulizer with a jet nebulizer is available in this patient population. The purpose of this study was to compare the clinical efficacy of a vibrating mesh nebulizer to a jet nebulizer combined with a mouthpiece or mask in children with asthma exacerbations admitted to the emergency department. METHODS: We conducted a single-blinded randomized clinical trial of 217 children (2-18 y old) with a moderate to severe asthma exacerbation in the emergency department. Assessment of severity was defined by our acute asthma score, adapted from the Pediatric Asthma Score. Subjects were randomized to receive bronchodilator treatment via vibrating mesh nebulizer (n = 108) or jet nebulizer (n = 109) and were treated until they achieved a mild asthma score and were discharged or until a decision to admit was made. All subjects were treated per our acute asthma clinical pathway algorithm for the emergency department with modifications to allow for blinding, assessment of treatment, and data collection. Outcome variables included hospital admission rate, number of treatments, and time to mild asthma score. RESULTS: There was a significant difference in baseline asthma score between subjects treated with the vibrating mesh nebulizer and those treated with the jet nebulizer (P = .042), but no other significant differences in demographics existed between groups. To adjust for effect of baseline asthma score, a multiple logistic regression model was used to model admission. The vibrating mesh nebulizer group had a lower probability of being admitted to the hospital (P = .062), and they required significantly fewer treatments (P < .001) and less time to reach a mild asthma score (P = .004) than those in the jet nebulizer group. In subjects with a mask interface, the vibrating mesh nebulizer significantly reduced the probability of admission (P = .032). CONCLUSIONS: Subjects treated with a vibrating mesh nebulizer required significantly fewer treatments and less time to achieve a mild asthma score. In subjects with a mask interface, the vibrating mesh nebulizer significantly reduced the probability of admission compared to jet nebulizer. (ClinicalTrials.gov registration NCT02774941.).