Continuous vs intermittent nebulized albuterol for emergency management of asthma. Continuous versus intermittent albuterol nebulization in the treatment of acute asthma. Continuous vs intermittent albuterol, at high and low doses, in the treatment of severe acute asthma in adults. Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department. Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial. Randomised pragmatic comparison of UK and US treatment of acute asthma presenting to hospital. Continuous nebulization of albuterol (salbutamol) in acute asthma. Continuous versus frequent intermittent nebulization of albuterol in acute asthma: a randomized, prospective study.
To compare the efficacy and safety of continuous nebulized (CN) albuterol therapy with those of intermittent nebulized (IN) albuterol therapy in the ED treatment of children with moderate to severe asthma exacerbations.
                A prospective, randomized, single-blind study was conducted at a children's hospital ED. Patients aged 2 to 18 years with a moderate to severe asthma exacerbation (asthma score > or = 8) were enrolled. Patients were randomized to receive either IN albuterol (0.15 mg/kg/dose every 30 min) or CN albuterol (0.3 mg/kg/hr) for a maximum of 2 hours. All patients received prednisone at entry. All released patients were evaluated by telephone, 48 hours after the ED visit. Estimates of respiratory therapist (RT) time commitments for the 2 delivery systems were calculated.
                There were 35 patients assigned to IN therapy and 35 to CN therapy. Nine of the 35 patients (26%) in the IN group and 8 of the 35 patients (22%) in the CN group were hospitalized (p = NS). Although the durations of ED therapy were comparable in the 2 groups, the time spent by the RTs in delivering asthma therapy was significantly less for the CN group than it was for the IN group (30.3 min vs 51.9 min per patient; p < 0.001). There was no major adverse effect in either study group.
                There was no difference in efficacy or safety between CN therapy and IN therapy in the ED management of moderate to severe asthma exacerbations in children. Moreover, CN therapy provided a significant time savings in the delivery of asthma therapy to patients in a busy ED. To compare bronchodilation, chronotropic effects, and side effects of the same dose of nebulized albuterol when given by either intermittent or continuous administration.
                A randomized assignment of patients to one of the two methods of albuterol nebulization.
                Adult emergency department in an urban public hospital.
                Adult patients with acute exacerbations of asthma.
                Administration of 30 mg albuterol given over 110 minutes by either continuous or intermittent aerosolization.
                FEV1, forced vital capacity, heart rate, and systolic and diastolic blood pressures were measured immediately before treatment and then hourly for two hours. Side effects, symptoms, subsequent admission, and discharge also were noted.
                An overall significant decrease in heart rate was observed, indicating the lack of significant chronotropic effects with this dose of albuterol. Both treatments resulted in significant spirometric improvement without a significant treatment difference for the entire group. A difference, however, was found in the relative rates of FEV1 improvement with the two treatments depending on whether patients had an initial FEV1 less than or more than 50% predicted (P = .05). A secondary analysis on patients with an initial FEV1 less than percent predicted demonstrated a higher rate of percent predicted FEV1 increase with the continuously nebulized albuterol group (P = .03).
                This study demonstrates that albuterol can be given safely at this dose by either intermittent or continuous nebulization. Future studies should examine whether continuous nebulization has a reproducible advantage over intermittent nebulization in patients with more severe obstruction. Adult patients suffering from acute asthma presenting to the Emergency Department with an FEV1 of less than 40% of predicted were randomized into four treatment groups. They were treated with nebulized albuterol at a high (7.5 mg) or standard (2.5 mg) dose given either continuously through 1 h, or intermittently every hour, for 2 h. When the FEV1 improvements for the different groups at 2 h were compared, the groups treated with continuous nebulization had the greatest improvement. The improvements (1.07 L for the high-dose group, and 1.02 L for the standard-dose group) were significantly greater than the improvement seen with standard-dose intermittent treatment (0.72 L; p < 0.05). The improvement in FEV1 of the high-dose, hourly treated group was intermediate in magnitude between these (0.09 L). There was no difference in the improvement seen between the two groups treated with continuous nebulization. The potassium fall, present in all groups, was more pronounced in the groups treated with high doses of albuterol. Only one person (high dose, continuous treatment group) developed hypokalemia of less than 3.0 mmol/L. The high-dose hourly treated group had the highest incidence of side effects, and the standard-dose continuously treated group had the lowest. The standard-dose continuous-treatment regimen had the greatest improvement in FEV1 with the least number of side effects. To compare continuously nebulized albuterol with intermittent bolus nebulization of albuterol.
                Consecutive block enrollment in groups of ten to continuous or intermittent therapy.
                Urban emergency department.
                Patients who presented to the ED with moderate to severe asthma and did not improve after one treatment with nebulized albuterol.
                All patients received an initial nebulized treatment with 2.5 mg albuterol followed by 125 mg solumedrol. Patients in the intermittent group received 2.5 mg nebulized albuterol at 30, 60, 90, and 120 minutes after the initial treatment. Patients in the continuous group received 10 mg albuterol nebulized in 70 mL over two hours.
                There was no difference between groups in age, sex, or initial peak expiratory flow rate (PEFR). Ninety-nine patients were included in the study (47 continuous and 52 intermittent). There was no statistically significant difference in PEFRs or admission rate between groups over the two-hour study period. One subgroup analysis was performed on patients with PEFRs on presentation to the ED of 200 L/min or less. Mean +/- SD baseline PEFR at presentation to the ED was 135 +/- 35 in the 35 patients in the continuous group and 137 +/- 45 in the 34 patients in the intermittent group). At 120 minutes, PEFR was 296 +/- 98 in the continuous group and 244 +/- 81 in the intermittent group (P = .01). Admission: discharge ratios for this subgroup analysis were 11:24 in the continuous group and 19:14 in the intermittent group (P = .03). Mean +/- SD heart rate in the subgroup analysis was 102 +/- 21 at baseline for the continuous group and 109 +/- 22 at baseline in the intermittent group. At 120 minutes, heart rate was 90 +/- 18 in the continuous group and 104 +/- 16 in the intermittent group (P = .002).
                Continuous nebulization offers no benefit over intermittent therapy in patients with an initial PEFR of more than 200 L/min. In PEFRs of 200 or less, continuous nebulization may decrease admission rate and improve PEFRs when compared with standard therapy. This study was conducted to compare the clinical and spirometric effects of continuous and intermittent nebulization of salbutamol in acute severe asthma.
                Forty-two consecutive patients presenting to the emergency department for acute severe asthma (peak expiratory flow [PEF] mean+/-SD, 24%+/-12% predicted) were prospectively randomly assigned to receive 27.5 mg of salbutamol by either continuous or intermittent nebulization over a 6-hour period. The continuous nebulization group received 15 mg of salbutamol during the first hour and 12.5 mg over the next 5 hours. The intermittent nebulization group received 5 mg of salbutamol every 20 minutes during the first hour and 2.5 mg hourly over the next 5 hours. All participants received oxygen and intravenous hydrocortisone. Clinical and spirometric assessment was performed at baseline, 40 minutes, 60 minutes, and at 3 and 6 hours after the start of the nebulization. Secondary endpoints were the respective rates of hospitalization and treatment failure.
                A significant clinical and spirometric improvement was observed in both groups over baseline as soon as the 40th minute and was sustained thereafter (absolute PEF increase at the sixth hour 30%+/-18% and 32%+/-22% in the continuous and intermittent nebulization groups, respectively; P <.01 over baseline). PEF and the clinical score evolved similarly in both groups. There was no difference between the groups regarding the failure rate of the initial bronchodilator treatment to terminate the asthma attack (3 [14%] in the continuous nebulization group and 2 [9.5%] in the intermittent nebulization group, absolute difference 4.5% [95% confidence interval -14% to 23%]). Eight (38%) patients and 9 (43%) patients from the continuous and intermittent nebulization groups, respectively, required hospitalization according to predefined criteria (absolute difference 4.8% [95% confidence interval -24% to 34%]).
                We did not observe an appreciable difference between continuous and intermittent nebulization of salbutamol in acute severe asthma. The decision to use one of these nebulization methods should be based on logistical considerations. Systemic corticosteroids and inhaled beta(2) agonists are accepted first line treatments for acute severe asthma, but there is no consensus on their optimum dosage and frequency of administration. American regimens include higher initial dosages of beta(2) agonists and corticosteroids than UK regimens.
                In a prospective, pragmatic, randomised, parallel group study, 170 patients of mean (SD) age 37 (12) years with acute asthma (peak expiratory flow (PEF) 212 (80) l/min) presenting to hospital received treatment with either high dose prednisolone and continuous nebulised salbutamol as recommended in the US or lower dose prednisolone and bolus nebulised salbutamol as recommended in the UK by the BTS.
                Outcome measures were: deltaPEF at 1 hour (BTS 89 l/min, US 106 l/min, p=0.2, CI -8 to 41) and at 2 hours (BTS 49 l/min, US 101 l/min, p<0.0001, CI 28 to 77); time to discharge if admitted (BTS 4 days, US 4 days); rates of achieving discharge PEF (>60%) at 2 hours (BTS 64%, US 78%, p=0.04); time to regain control of asthma as measured by PEF >/=80% best with </=20% variability (BTS 3 days, US 4 days, p=0.6); PEF at 24 hours in patients admitted (BTS 293 l/min, US 288 l/min, p=0.8); and control of asthma in the subsequent month (no significant differences).
                Treatment with higher doses of continuous nebulised salbutamol leads to a greater immediate improvement in PEF but the degree of recovery at 24 hours and speed of recovery thereafter is achieved as effectively with lower corticosteroid doses as recommended in the British guidelines. We studied the safety and efficacy of albuterol (salbutamol) delivered by continuous nebulization (CN) in the initial emergency department treatment of asthma. In a randomized fashion 21 patients received 5 mg of albuterol by bolus nebulization (BN) at time 0 and again 60 minutes later. Twenty-one others received albuterol (0.2 mg/ml) by CN using a calibrated nebulizer with a known output of 25 ml/h. Thus, each patient had received 10 mg of albuterol over two hours. FEV1, blood pressure (BP), heart rate (HR), respiratory rate (RR), and hand tremor were recorded at 30-minute intervals. The FEV1 was 1.48 +/- 0.64 L prior to BN and increased to a maximum of 2.20 +/- 0.94 L (p less than 0.05) 90 minutes later. The FEV1 prior to CN was 1.13 +/- 0.51 L and improved to 2.20 +/- 1.02 L (p less than 0.05) at 120 minutes. The FEV1 did not differ significantly between regimens over the 2-hour period. Both modes of therapy were well tolerated. There was a slight but significant increase in HR at 30 and 90 minutes in the BN group when compared with CN. There was no significant difference in BP, RR, or tremor between the groups. Thus, albuterol by CN was found to be equally effective as the same medication by BN in the early treatment of asthma in patients seen in the emergency department. In acute severe asthma the optimal dose, frequency, duration and method of administration of beta-2 agonists is unknown. No study to date has evaluated the efficacy of high dose beta-2 agonists beyond the initial two hours.
                (1) To determine whether high-dose continuous nebulization of albuterol (7.5 mg/h) is as safe and as efficacious as high-dose intermittent nebulization of albuterol (2.5 mg every 20 minutes) for four hours. (2) To evaluate whether there is a continual improvement using high dose therapy beyond two hours.
                We devised a simple means of continuous nebulization calibrated to deliver 7.5 mg albuterol per hour. Twenty-two nonsmoking, patients with acute, severe asthma who presented to the emergency department with less than 60% predicted normal PEFR were randomized to either the continuous or intermittent group. All patients received intravenously 125 mg methyl prednisolone on initiation of the study. No theophylline was administered. Spirometry and vital signs were measured at baseline and every 30 minutes thereafter. Electrocardiograms were obtained on all patients and all patients had continuous cardiac monitoring.
                Both groups doubled their baseline spirometric values over the four-hour period (P < .0001). The FEV1 did not differ significantly between regimens at any time interval. Improvement from 120 minutes to 240 minutes was statistically significant (P < .0001). There was no significant difference in vital signs at the end of the study compared with baseline in either group, nor between the two groups at any time interval.
                High-dose continuous nebulization of albuterol is as safe and as efficacious as intermittent nebulization of albuterol in the early treatment of asthma in an emergency department. To our knowledge, this is the first study showing continued significant improvement beyond the initial two hours of therapy using high dose nebulized beta-2 agonists.
Current evidence supports the use of CBA in patients with severe acute asthma who present to the emergency department to increase their pulmonary functions and reduce hospitalisation. Moreover, CBA treatment appears to be safe and well tolerated in patients who receive it.