The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:

• There is NO significant difference in efficacy outcome.
• Nebs are associated with greater increase in tachycardia and tremors.
• Nebs are more costly overall.
• MDI's were associated with shorter ED stays and fewer hospital admissions for pediatric patients.

Albuterol:  2.5 mg nebulizer solution = 3-5 MDI puffs

Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs

Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs

Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs

 

References

1. Alhaider SA, Alshehri HA, Al-Eid K. Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources. Int J of Pediatr and Adolesc Med.2014;1(1):26-30.
2. Castro?Rodriguez JA, Rodrigo GJ. Beta?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. J Pediatr. 2004;145(2):172–177.
3. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta?agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.
4. Delgado A, Chou KJ, Silver EJ, Crain EF. Nebulizers vs metered?dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a pediatric emergency department. Arch Pediatr Adolesc Med. 2003;157(1):76–80.
5. Turner MO, Gafni A, Swan D, FitzGerald JM. A review and economic evaluation of bronchodilator delivery methods in hospitalized patients. Arch Intern Med. 1996;156(18):2113–2118.