Running head: METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

Metered-Dose Inhalers versus Nebulizers in Pediatrics

Lori Huneau
State University of New York Polytechnic Institute

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

Abstract
The efficacy of bronchodilator (Beta2-agonist) treatment in children with asthma depends on the
proper use of inhaled devices. The aim of this study is to compare the efficacy of inhaled
bronchodilator treatment with a metered-dose inhaler (MDI) and a nebulizer in children during
an acute asthma exacerbation. Participants in the study will include children ages 2 to 18 years
old admitted to a general pediatric floor at Albany Medical Center with the diagnosis of asthma
admitted within a 6 month period. The Symptoms Management Theory will be used as a
theoretical framework for the study. The research design that will be utilized is an experimental
design in which the control group will receive their bronchodilator via the traditional nebulized
modality while the experimental group receives the medication via MDI with spacer.
Physiological data will be collected using a clinical survey to quantify the severity of acute
asthma symptoms among both groups including respiratory rate, work of breathing, pulse
oximetry reading, and degree of wheezing. Additional quantitative data will be collected to
determine the effect that each modality had on frequency of required treatments, duration of
treatments, and overall length of hospital stay. Analysis of the data will be conducted using
inferential analysis and a t-test to determine if there is a statistically significant difference
between the two modalities of bronchodilator delivery on the duration of acute asthma
symptoms.
Keywords: acute asthma, bronchodilator, metered-dose inhaler, nebulizer, children

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

Metered Dose Inhalers versus Nebulizers in Pediatrics

Introduction
"Reactive Airway Disease is a major cause of morbidity in infants and young children and is
a common reason for emergency department visits and hospital admissions" (Delgado, Chou,
Silver, & Crain, 2003, p. 80). Appropriate delivery of medication directly into the lungs
increases the effectiveness of treatment of acute asthma symptoms and decreases the potential
side effects. Treatment of asthma in the pediatric setting can be difficult due to many factors.
These factors can include the childs age, ability to cooperate, the familys ability to administer
the medication, as well as the characteristics of the delivery device (Yilmaz, Sogut, Kose,
Sakinsi, & Yuksel, 2009). Nebulizers and metered-dose inhalers (MDI) with the use of a spacer
have been proven as the treatment of choice in children who are too young or unable to
cooperate with the rapid, deep sustained breaths required for the effective use of the dry
powdered inhalers (National Asthma Education and Prevention Program, 2007).
Many studies have proven that the inhalation of bronchodilating beta2-agonists by
nebulization has been effective in relief of symptoms in an acute asthma exacerbation in an
emergency room setting (Buxtan, Baldwin, Berry, & Mandleco, 2002). While many providers
are still using nebulizers for pediatric asthma exacerbations in the emergency room and critical
care setting, there are some providers that are pushing towards the use of MDIs with spacers in
the less acute patients on the general pediatric floors.
Bronchodilators such as Albuterol are frequently used as management for an acute asthma
exacerbation. Frequent and repetitive treatments are often required. Respiratory therapists and
others providing the treatments can become overwhelmed and struggle to keep up with their
nebulized treatments. MDIs are quicker, more cost effective, more easily portable, and better

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

tolerated by pediatric patients. Therefore, if there is minimal or no difference in the efficacy of

modalities of bronchodilator administration than it would be more practical to provide the
medication via MDI.
Statement of the Problem and Purpose
The purpose of this research is to determine if MDIs are as effective as the use of nebulizers
in the delivery of a bronchodilator (Albuterol) in the treatment of an acute asthma exacerbation
in the pediatric population. This study would be an observational study in a general pediatric
floor setting, done over a 6 month period. It would compare the frequency of necessary
treatments, the severity acute asthma symptoms, and length of hospital stay between children
who received the Albuterol for the treatment of their symptoms via nebulizer and those who
received the medication via MDI. Prior to the study, the children would need to be educated on
the appropriate technique of both modalities to ensure that they were getting the medication
intended.
Review of the Relevant Literature
Theoretical Background
The theory utilized to conduct this research would be the Symptom Management Theory.
Three dimensions underlie this theorys foundation. These dimensions include the symptom
experience, the symptom management strategies, and the symptom status outcomes (Newcomb,
2010). The symptom experience would include both subjective and objective data. The patient
(if old enough) could rate the severity of their asthma symptoms from 0-5 via a clinical score or
survey which could include respiratory rate, work of breathing, pulse oximetry reading, and
degree of wheezing. The childs bedside nurse could provide this information for children too

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

young to report. The symptom management strategies could include both the frequency of
treatments necessary and the delivery device used. Based on the different management strategies
the symptom status outcomes can be determined in terms of duration of severe asthma
symptoms, frequency of treatments necessary to control symptoms, and length of hospital stay.
The Symptom Management Theory seems to fit this particular research proposal because it
investigates different symptom management strategies (metered-dose inhaler vs nebulizer) and
their relationship to overall patient outcomes (duration of asthma symptoms, frequency of
treatments, and length of hospital stay). This theory is an appropriate framework for
understanding and evaluating nursing interventions and is applicable to a variety of nursing care
settings as well as patients (Newcomb, 2010).
Review of Related Literature
A critical review of the literature was completed regarding the use of metered-dose inhalers
in children on the CINAHL and Medline databases using the keywords; asthma, children,
metered-dose inhaler, and nebulizer. Many of the clinical trials conducted found that the
administration of bronchodilators via a metered-dose inhaler with spacer is a least, if not more
effective to, the delivery of the medication by nebulizer in the resolution of asthma symptoms in
infants and children (Delgado, et al, 2003).
Many of the studies were conducted on older children and adults and were proven to provide
a quicker, more cost-effective way to deliver bronchodilators for asthma treatment (Delgado et
al, 2003). However, younger patients lacked the correct coordination of activation and
inspiration to adequately receive a full dose of the medication. A study using a double-blind,
randomized, placebo controlled clinical trial studied admission rates in children ages 2 to 24

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

months in a pediatric emergency room who received either a nebulizer or metered-dose inhaler
with use of a spacer for their medication administration. The results of this study suggested that
an MDI with the use of a spacer is as efficacious as nebulizers for the emergency room treatment
of wheezing in this age group (Delgado et al, 2003).
An observational study conducted by Yilmaz et al (2009), compared the duration of acute
asthma findings between children who received their bronchodilator via MDI and those that
received the medication via nebulizer in an ambulatory setting. The children in this study were
instructed on the use of their inhaled device from a pulmonary nurse prior to the initiation of the
study to ensure that they were using the appropriate technique and receiving a full dose of the
medication. . These children returned to the pulmonary clinic every 2 days to be examined for
acute asthma findings. The results of this study found that the duration of acute asthma findings
in the group that used the nebulizer were not significantly different from that in the MDI group
(Yilmaz et al, 2009).
In a study by Fugstang and Pederson (1986), the participants in the study were asked to
choose a preference for using both methods of delivery. The participants reported greater
bronchodilation and preferred the use of the MDI over the nebulizer due to its shorter duration of
treatment time. The results of this study demonstrated that the MDI was just as effective as the
nebulizer in children with asthma as well as the preferred route by the participants and their
parents (Fugstang & Pederson, 1986).
While some studies supported the ease of use of the MDI, others considered the costeffectiveness as well. Several researchers not only concluded that MDIs were effective in acute
asthma, but they were significantly less expensive than a nebulizer. (Dewar, Stewart, Cogswell,
& Connett, 1999).

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

Research Question/Hypothesis
The research question I am planning to investigate is Are metered-dose inhalers as effective
in the treatment of an acute asthma exacerbation as nebulizers in the pediatric population?
Many of the studies I have read that were conducted in the emergency room setting state that
they are equally effective, but I was unable to locate many studies that were done on the inpatient pediatric population. My thought in doing this research, as stated previously, is that if
there is minimal or no difference in the efficacy of modalities of bronchodilator administration in
the pediatric population, than it would be more practical and more beneficial to the child to
provide the medication via MDI.
Definition of Terms
The terms that would need to be described for this study would include asthma
exacerbation, asthma symptoms (increased work of breathing, wheezing, increased respiratory
rate, and decreased oxygen saturation), frequency of respiratory treatments, and what is
considered effective.

Effective: success in producing resolution of asthma symptoms

Asthma exacerbation: characterized by wheezing (airway spasm), tightness in the chest,

breathlessness (dyspnea), and cough (Dunphy, Winland-Brown, Porter, & Thomas, 2011).

Asthma symptoms:

1. Work of breathing: accessory muscle use, subcostal retractions, nasal flaring

(Dunphy et al, 2011).

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

2. Wheezing: continuous, coarse, whistling sound produced by the lungs during

breathing as the result of narrowing of the respiratory passages (Dunphy et al,
2011).
3. Respiratory rate: number of breaths taken per minute (Dunphy et al, 2011).
4. Pulse oximetry: procedure used to measure oxygen saturation in the blood, noninvasive and painless (Dunphy et al, 2011)
The severity of the asthma symptoms would be measured via a clinical score or survey
which could include respiratory rate, work of breathing, pulse oximetry reading, and degree of
wheezing.
Methods and Procedures
Research Design
The type of design I plan to use is an experimental design for this particular research
question. The experimental design would be the best fit for my research question because it
allows me to manipulate a variable and measure the effect that it has on the participants in the
study. The independent variable would be the use of an MDI instead of the traditional nebulizer
for the delivery of the bronchodilator during an acute asthma exacerbation. The dependent
variables would be the duration of severe asthma symptoms as measured by the frequency of
treatments required, the duration of hospital stay, and the severity of the asthma symptoms as
measured by a clinical score or survey which could include respiratory rate, work of breathing,
pulse oximetry reading, and degree of wheezing.

METERED-DOSE INHALERS VERSUS NEBULIZERS IN PEDIATRICS

Setting
This would be a single-site study conducted on a general pediatric floor in The Childrens
Hospital at Albany Medical Center. This is a childrens hospital that provides comprehensive
care to children in northeastern New York and western New England. The particular floor I
would use is a 40 bed unit that admits pediatric patients ages 1 month to 21 years with a variety
of diagnoses including asthma exacerbation. About half of the rooms on the floor are private, the
other half have the capacity to have 2 patients in them. Each of the nurses on this floor has 4-5
patients to care for depending on their acuity.
Sampling Procedures and Characteristics
The total population that I am planning on studying would include pediatric patients ages 218 years old admitted to the general pediatric floor at Albany Medical Center with the diagnosis
of asthma admitted between the 6 month period of September 1st and February 28th. None of the
children could have a secondary diagnosis or additional disease that could influence the duration
of acute asthma findings. The target population would be the same as the total population in this
case.
The sample for this study would be a nonprobability sample. The probability of individuals
being included in the study are not known to the researcher (Wood & Ross-Kerr, 2011). There is
not a determined list of participants to choose from for this study. It will consist of a
convenience sample. A convenience sample (sometimes called an available sample) is a
nonprobability sample that happens to be available at the time of the data collection (Wood &
Ross-Kerr, 2011, p. 161). The sample will consist of children who just happened to be to be

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admitted to the general pediatric floor at Albany Medical Center with the diagnosis of asthma
during the predetermined dates of the study who have no confounding factors as described that
would influence the duration of their acute asthma symptoms. Recruitment for the study will
begin once ethical and administrative approval have been obtained. A formal letter will be
provided to the parents of the potential participants who meet the eligibility criteria explaining
the intended study and its purpose, requesting their participation.
Ethical Considerations
Prior to conducting the research I will obtain ethics approval from the institutional board
from Albany Medical Center, where I will be conducting my research. The study involves a
sample from a vulnerable population. These subjects are those who, for cognitive, custodial, or
environmental factors, might easily have their rights or preferences overridden by those to whom
they are in a subordinate position (OLonergan & Milgrom, 2005). Although this is the case,
children have unique needs that need to be studied separately from adults (Wood & Kerr, 2011).
The most important issues to consider when conducting research on children are the assessment
of risk to the child compared with benefit, the long term interests of the child, and parental
permission and pediatric assent if developmentally able. Participants would be allowed to
withdraw from the study at any time.
Selection of Measurement Instruments
Physiological data must be collected to quantify the severity of acute asthma symptoms
among the group receiving the traditional modality of nebulized treatments and those in the
experimental group receiving their medication via MDI. The data collected would include
respiratory rate, work of breathing, pulse oximetry reading, and degree of wheezing. To

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collect the physiologic data necessary to determine the severity of the asthma symptoms a
clinical score or survey could be used and include questions regarding the childs respiratory
rate, work of breathing, pulse oximetry reading, and degree of wheezing to be filled out every
4 hours throughout the hospital stay by the bedside nurse. The survey questions would have
a close-ended approach in which the respondents were asked to select from a range of
predetermined answers. Each answer would be awarded a number of points ranging from 15. A lower number of the answers to the questions added together, indicates more severe the
asthma symptoms being experienced by the child at that interval. A sample question could
include:
What is the childs pulse oximetry reading on room air?

1- < 85%

2- 85-88%

3- 89-92%

4- 93-96%

5- 97-100%

Additional quantitative data that would need to be collected to determine the difference in
efficacy of the two modalities of medication delivery would include the frequency of beta2agonist treatments required and for how long, as well as the overall length of hospital stay. The
frequency of treatments required at a given time and for how long could be obtained from the
medication administration record in the Electronic Health Record (EHR) at the hospital. The
childs overall length of stay could be obtained there as well.
Validity and Reliability of Instruments
A level III study requires the highest level of validity and reliability testing (Wood & Kerr,
2011). The instruments would require a series of pilot-tests prior to use in the study. Content
validity is the extent that an instrument accurately assesses what you want to know (Wood &

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Kerr, 2011). For this particular study, the instrument being used is a survey which gives each
variable a clinical score from 1-5. Each of the variables represents an asthma symptom (work of
breathing, degree of wheeze, respiratory rate and pulse oximetry reading). The study aims to
explore the difference that the method of bronchodilator administration has on these reported
asthma symptoms. The asthma symptoms have physiological explanatory base so the use of the
intended instrument has construct validity.
The reliability of the instrument would be tested prior to initiating the study. The test for
equivalence would be used to test the reliability of this instrument because the characteristics
being measured are changeable and not expected to remain stable over time (Wood & Kerr,
2011).
Interrater reliability testing would be utilized for the observation portion of the survey to
determine if different bedside nurses would interpret the childs degree of wheezing and work of
breathing the same. This is the most common method of testing observation tools because it can
be used in situations that are changeable (Wood & Kerr, 2011). The childs frequency of
treatments, duration of those treatments, and overall length of hospital stay could be obtained in
the hospitals EMR in a numerical form. Human error could potentially occur during the process
of imputing the information or navigating the EMR for the data.
Plan for Analysis
My proposed level III research question requires an experimental design. This type of
design provides at least 2 groups of subjects, and the hypotheses predicts how these groups will
respond in the experimental situation (Wood & Kerr, 2011). The analysis of the data collected
among these groups must test if there is a difference between these groups. In order to do this, I

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would use inferential analysis. For this type of design it is not enough to collect and describe the
data, but there you must also draw conclusions from those data (Wood & Kerr, 2011).
To begin my analysis, I would set up a sample data table describing the variables in the
experiment. I would use a summary data table to summarize the raw data collected using
measures of central tendency (average of the scores obtained on the survey). The first column
would list the different values of the independent variable the use of metered-dose inhaler and
nebulizer. The top portion of the table would describe the physiological data collected using the
survey including; respiratory rate, work of breathing, pulse oximetry reading, and degree of
wheezing. The average scores for each of the independent variables in regards to each category
of the dependent variables would be placed in the appropriate columns. A separate table would
be made in a similar fashion to describe the independent variables of those who used a metereddose inhaler or a nebulizer in relation to the dependent variables including frequency of
Albuterol treatments, for how long at each frequency, and the duration in days of their hospital
stay. I would also display the data on a bar graph to see trends and patterns in the data.
Once all of the average values are organized in a table, I would then use a t-test to determine
whether there was a difference in effectiveness between the group that received their treatment
via MDI and those who received their treatment via nebulizer. For this I would need to state the
hypothesis of: Metered-dose inhalers are as effective in the treatment of an acute asthma
exacerbation as nebulizers in the pediatric population. This would need to be tested against an
alternative or null hypothesis which could be: Metered-dose inhalers are not as effective in the
treatment of an acute asthma exacerbation as nebulizers in the pediatric population. I would then

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use the t-test to determine whether the averages of the scores of the independent variables were
reliably different to answer my research question.
Limitations
One of the limitations of the study is that there could be a small population if there are few
subjects that meet the eligibility criteria admitted during the 6 month study duration or choose to
not participate in the study. There could also be inherent limitations in the instrument if the pulse
oximeter was broken or reading inaccurately or if there were differences in the bedside nurses
interpretation of the childs objective asthma findings.
Dissemination of Findings
The researcher will contact the attending physicians, resident physicians, and nursing staff to
provide information on the outcome of the study. Any publications from this study will be
targeted at pediatric providers including pulmonary clinics. Potential examples of targeted
journals would include; The Journal of Pediatrics, Pediatric Research, Pediatrics and Child
Health, and Pediatric Pulmonology. In addition, a research abstract presentation at pertinent
pediatric conferences will be sought, such as the Cleveland Clinic Childrens Pediatric
Innovation Summit, the Celebration of Pediatric Pulmonology conference, or the Hot Topics in
Pediatrics conference.

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References
Buxton, L, Baldwin, J., Berry, J., & Mandleco, B. (2002). The efficacy of metered-dose inhalers
with a spacer device in the pediatric setting. Journal of the American Academy of Nurse
Practitioners, 14(9), p. 390-397.
Delgado, A., Chou, K., Silver, E., & Crain, E. (2003). Nebulizers vs Metered dose inhalers with
spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 month
in a pediatric emergency department. Archives of Pediatric & Adolescent Medicine,
157(1), p.76-80.
Dewar, A., Stewart, A., Cogswell, J., & Connett, G. (1999). A randomized controlled trial
to assess the relative benefits of large volume spacers and nebulizers to treat acute asthma
in hospital. Archives of Disease in Children, 80, p. 421-423.
Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2011). Primary care: The art and
science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A. Davis Company.
Fugstang, G. & Pedersen, S. (1986). Comparison of nebuhaler and nebulizer treatment of
acute asthma in children. European Journal of Respiratory Disease, 69, p. 109-113.
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3):
Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.
Journal of Allergy & Clinical Immunology 2007; 120:S94-138.

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Newcomb, P. (2010). Using symptom management theory in to explain how nurse practitioners
care for children with asthma. The Journal of Theory Construction & Testing, 14(2),
p. 40-44.
OLonergan, M. & Milgrom, H. (2005). Ethical considerations in research involving children.
Pediatric Allergy and Immunology, 5, p. 451-458.
Yilmaz, O., Sogut, A., Kose, U., Sakinci, O., & Yuksel, H. (2009). Influence of ambulatory
inhaled treatment with different devices in the duration of acute asthma findings in children.
Journal of Asthma, 46(2), 191-193.