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Question 6:

In the child hospitalized with an asthma exacerbation, should albuterol be administered by nebulizer or metered-dose inhaler (MDI) and spacer to improve pulmonary function?

Inpatient asthma team recommendation: 
EPR-3 (2007) makes no statement of preference of using a nebulizer over an MDI with a valved spacer for the administration of inhaled medications. In addition, they conclude “it is important to assess inhaler techniques for all prescribed medications and reinforce correct technique before patients are discharged home.” Thus, based on studies conducted in Emergency Departments for children with mild-to-moderate exacerbations, administration of inhaled medications via an MDI plus valved holding chamber is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel. A mask should be used for children < 4 years of age. Nebulized albuterol should be reserved for children with moderate-to-severe symptoms. We placed high value on prompt resolution of symptoms and the ability to evaluate the patient’s technique when using an MDI and spacer. 

Literature: Literature was not found to support using MDI with spacer versus nebulizer for the delivery of albuterol for children hospitalized with asthma exacerbation. 

Search strategy: 
(("Asthma"[Mesh] AND ("Emergency Service, Hospital"[Mesh] OR "Emergency Nursing"[Mesh] OR "Emergency Medical Services"[Mesh] OR "Emergency Medicine"[Mesh] OR "Acute Disease"[Mesh] OR exacerbation[All Fields] OR attack[All Fields])) AND ("Magnesium Sulfate"[Mesh] 

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.