The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–8, 2018
Ó 2018 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

https://doi.org/10.1016/j.jemermed.2018.03.002

Original
Contributions

A RANDOMIZED TRIAL COMPARING METERED DOSE INHALERS AND BREATH

ACTUATED NEBULIZERS

Mark A. Snider, DO,* Jim Y. Wan, PHD,† Jonathan Jacobs, MD,* Rudy Kink, MD,* Barry Gilmore, MD, MBA,* and
Sandra R. Arnold, MD, MSC‡
*Division of Emergency Services, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, †Division of
Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee,
and ‡Division of Infectious Diseases, Department of Pediatrics, University of Tennessee Health Science Center College of Medicine,
Memphis, Tennessee
Corresponding Address: Mark A. Snider, DO, Division of Emergency Services, Department of Pediatrics, Le Bonheur Children’s Hospital, 50
North Dunlap St, Memphis, TN 38103

, Abstract—Background: Despite little evidence for its
effectiveness, the breath-actuated nebulizer (BAN) is the
default albuterol delivery method in our pediatric emer-
gency department. Objective: We compared the clinical
efficacy of BAN and the metered-dose inhaler (MDI) in
treating subjects patients 2 to 17 years of age who presented
with mild to moderate asthma exacerbations. Methods: This
is a randomized, nonblinded, noninferiority study conduct-
ed at a single pediatric tertiary care emergency department.
Subjects presenting with a Pediatric Asthma Score ranging
from 5 to 11 received albuterol by BAN or MDI via standard
weight-based and symptom severity dosing protocols. Aero-
solized ipratropium (via BAN) and intravenous magnesium
sulfate were given when clinically indicated. The primary
outcome was patient disposition. The noninferiority margin
for the primary outcome was an admission rate difference
#10%. Analyses were adjusted for confounders that were
significant at p # 0.10. Results: We enrolled 890 subjects be-
tween October 2014 and April 2015. BAN and MDI groups
were comparable for age, gender, and race but not for pre-
treatment symptom severity; 51% in the MDI group had a
Pediatric Asthma Score of moderate severity (8–11) vs.
63% in the BAN group (p < 0.003). Unadjusted admission
rates were 11.9% for MDI and 12.8% for BAN, for an unad-
justed risk difference of 0.9% (95% confidence interval
Reprints are not available from the authors.
5% to 3%). After adjusting for baseline confounder
severity, the risk difference was 2% (95% confidence inter-
val 4% to 7%), which met the criteria for noninferiority.
Conclusions: Albuterol therapy by MDI is noninferior to
BAN for the treatment of mild to moderate asthma exacer-
bations in children 2 to 17 years of age. Ó 2018 Elsevier
Inc. All rights reserved.
, Keywords—asthma exacerbation; breath-actuated
nebulizer; emergency department length of stay; intrave-
nous magnesium sulfate; metered-dose inhaler; Pediatric
Asthma Score; respiratory therapist; small volume
nebulizer
INTRODUCTION
Breath-actuated nebulizers (BANs) are a relatively new
method of treating pediatric asthma exacerbations
(AEs) in the emergency department (ED). Like the small
volume nebulizer (SVN), BANs aerosolize albuterol so-
lution but use an air compressor rather than a nebulizer.
Their use in the ED to treat AE may contribute to parents’
lack of confidence in their home metered-dose inhalers
(MDIs) (1). By treating acute AE with nebulized albute-
rol rather than with the MDI, we may be encouraging

RECEIVED: 25 September 2017; FINAL SUBMISSION RECEIVED: 19 February 2018;

ACCEPTED: 3 March 2018

1
2 M. A. Snider et al.
unnecessary repeat ED visits and contributing to the enor-
mous national cost of treating asthma (2,3).
Acute AE can be effectively treated using BANs,
MDIs, or SVNs (4). Both the MDI and the BAN are
more effective than the SVN at reducing hospital admis-
sion rates and reducing ED length of stays (ED LOS)
(5–8). To our knowledge, this is the first study
comparing the effectiveness of the MDI and the BAN.
We hypothesize that the MDI is as effective as the BAN
in treating acute pediatric AE in the ED.
MATERIALS AND METHODS
This is a randomized, controlled, nonblinded, noninfer-
iority trial comparing MDI to BAN conducted in children
presenting with a first-time wheeze or a mild to moderate
AE at a single, urban, pediatric ED in Memphis, Tennees-
see. The BAN, along with the MDI, became the standard
of care for treatment of AE after an internal pilot study of
100 patients showed BAN to be superior to SVN resulting
in fewer admissions (42% SVN vs. 28% BAN) and
shorter ED LOS (mean SVN 344 min vs. mean BAN
225 min). An abbreviated consent form, one that could
be reviewed in minutes, was approved by the institutional
review board so that therapy for willing participants
would not be delayed.
Subjects were identified for enrollment by respiratory
therapists (RTs) and treating physicians. Eligible subjects
ranged from 2 to 17 years of age and presented with either
a first-time wheeze or an AE of mild to moderate severity
as defined by a Pediatric Asthma Score (PAS) ranging
from 5 to 11 (9). The PAS assigns points for respiratory
rate, oxygen saturation, retractions, work of breathing,
and findings on auscultation (Appendix). Subjects were
excluded if they had initiated therapy at an outside med-
ical facility or had a history of chronic lung disease,
congenital heart disease, tracheostomy, or were receiving
diuretic therapy. Patients who were diagnosed with bron-
chiolitis or pneumonia by the treating physician were
excluded, along with children who were wards of the state
or whose parents did not speak English.
One thousand numbers were generated and random-
ized using blocks of 20 to either MDI or BAN using on-
line randomization software (www.randomization.com).
Numbers were printed and placed in sealed, sequentially
ordered opaque security envelopes that were stored in a
secure location. Patients were enrolled in the study
24 hours per day, 7 days per week.
By protocol, all patients with a known history of
asthma received oral dexamethasone (0.6 mg/kg, 16 mg
maximum dose) at presentation, whereas those with
first-time wheeze were assessed by a physician before
dosing (10). Albuterol dosing was based upon the sub-
ject’s randomized cohort, weight, and presenting asthma
score (Appendix). Additional therapies including ipra-
tropium, 0.5 mg via BAN, regardless of randomized
cohort (ipratropium by MDI was too costly for routine
use in the ED), or 50 mg/kg (max 2 g) of intravenous mag-
nesium sulfate (IV MgSO4) (11). Not infrequently, physi-
cians may treat patients presenting with moderate
severity AE with IV MgSO4, especially if they received
multiple doses of albuterol at home or have a history of
pediatric intensive care unit admissions in hopes of dis-
charging them home.
Albuterol administered via MDI was given through a
spacer device fitted with an appropriately sized mask if
needed. The RT was present for the entire treatment and
either administered or supervised patient- or parent-
administered doses. Subjects randomized to BAN were
evaluated for proper breath actuation technique. For sub-
jects unable to breath actuate, the RT attached an appro-
priately sized mask to the device, changed the setting to
continuous nebulization, and returned to bedside after
treatment completion.
This study was designed to reflect treatment of AE as
is commonly practiced. Physicians could escalate care by
increasing the dose of albuterol beyond the ED protocol.
Physicians were discouraged from changing appliances
but could do so if they felt that the child was not
improving; however, all subjects remained assigned to
their randomized cohort. Physicians could discharge a
subject at any time, but the ED protocol suggests admin-
istering $3 treatments before admission. There were no
strict criteria for admission, and each provider deter-
mined subject disposition. According to the intention to
treat principle, all admissions counted against the cohort
to which the subject was initially randomized.
The primary outcome was patient disposition defined
as hospital admission or discharge from the ED. Second-
ary outcomes included: ED LOS, frequency of possible
albuterol dose-related adverse events measured by age-
adjusted tachycardia at the time of disposition, and
ondansetron administration for nausea or vomiting (12).
We also followed repeat ED visits within 7 days of pre-
sentation.
All information related to the subjects in the study was
extracted from their electronic medical record and trans-
ferred to REDCap, a secure Web-based database (13).
Measures of noninferiority were determined using
chi-square tests for categorical variables, t-tests for
continuous, normally distributed variables, and the
Mann-Whitney U test for continuous nonparametric vari-
ables. Depending on the validity of normality assump-
tion, Pearson or Spearman correlation was used to
describe the association between two continuous vari-
ables. To adjust for possible confounding factors, we
used a multivariate logistic regression analysis for patient
disposition and a multiple linear regression analysis for
MDI vs. BAN in Pediatric Asthma Exacerbations
ED LOS. Analyses were adjusted for confounders that
were significantly associated with outcome at p # 0.10
rather than p # 0.05 because this allowed us broader op-
portunity to analyze potentially important clinical vari-
ables. The adjusted risk difference for admission (and
95% confidence interval [CI]) was determined by
deriving the 2 adjusted probabilities (probability of
admission for each treatment group) from the logistic
regression using least squares means that estimate the
marginal means over a balanced population. The differ-
ence between the 2 adjusted probabilities is the adjusted
risk difference.
We estimated our admission rate to be 35% based on a
3-month retrospective chart review of ED visits for AE.
The consensus among our provider groups was that an ab-
solute difference in admission rates >10% was clinically
important. We used the POWER procedure in SAS soft-
ware (version 9.3; SAS Institute Inc., Cary, NC) to calcu-
late the sample size required to detect a 10% difference in
admission rate if an MDI was used instead of BAN. With
a power of 80%, the required sample size was 376 sub-
jects per treatment arm. As this was the first time our
Figure 1. Consort flow diagram. *Eleven patients randomized to MDI received BAN and no patients randomized to BAN received
MDI; these patients were analyzed according to their randomized assignments. BAN = breath-actuated nebulization;
MDI = metered-dose inhaler.
3
ED had attempted a study of this size, we anticipated as
much as a 20% data loss, and planned to enroll 1000 sub-
jects.
RESULTS
We approached 1022 of 1987 eligible subjects between
October 2014 and April 2015. Twenty-two subjects
refused participation because they did not want to be ran-
domized to MDI. Twenty envelopes were lost before data
collection. The remaining 965 subjects were not ap-
proached because of resource limitations. Of the 980 sub-
jects who agreed to study participation, 90 subjects’ data
were discarded because of enrollment documentation and
protocol violations, leaving 445 subjects in the MDI
group and 445 subjects in the BAN group (Figure 1).
There were no differences between MDI and BAN groups
for race, gender, or age. The cohorts differed in presenta-
tion severity with 51% of the MDI and 63% of the BAN
cohort (p = 0.003) scoring a moderate PAS (Table 1).
The number of albuterol treatments administered to
each subject was independent of his/her age (Spearman
4 M. A. Snider et al.

Table 1. Patient Demographics, Presentation Severity, and Table 3. Results of Unadjusted and Adjusted Analyses for
Complications Variables Associated with Patient Disposition

BAN 445 MDI 445 p Value Unadjusted OR (95% CI) p Value

Gender, n (%) 0.17 MDI vs. BAN* 0.92 (0.62–1.37) 0.68

Male (64.9%) 298 (67) 279 (63) Moderate (8–11) vs. mild 5.19 (3.00–8.99) 0.0049
Female (35.1%) 147 (33) 166 (37) (5–7) PAS
Race, n (%) 0.62 Ipratropium vs. none 4.77 (2.85–7.97) <0.0001
African American 413 (93) 405 (91) High albuterol dose vs. 0.6 (0.24–1.54) 0.29
White (non-Hispanic) 26 (6) 33 (7) protocol dose
Latino 6 (1) 7 (2) Adjusted†
Age (years) 0.98 MDI vs. BAN‡ 1.37 (0.89–2.10) 0.16
Mean 6 SD 6.38 6 4.0 6.37 6 3.9 Moderate (8–11) vs. mild 2.77 (1.43–5.37) 0.002
Presenting PAS,*n (%) <0.001 (5–7) PAS
Mild (PAS <8) 164 (37) 218 (49) Ipratropium vs. none 2.89 (1.52–5.51) 0.001
Moderate (PAS $8) 281 (63) 227 (51)
BAN = breath-actuated nebulization; CI = confidence interval;
BAN = breath-actuated nebulization; MDI = metered-dose MDI = metered-dose inhaler; OR = odds ratio; PAS = Pediatric
inhaler; PAS = Pediatric Asthma Score; SD = standard deviation. Asthma Score.
* Unadjusted risk difference in admission rate 0.9% (95% CI 5%
to 3%).
correlation 0.06, p = 0.1) and study group (p = 0.2), but † Variable of interest (MDI vs. BAN) forced into the model, con-
did correlate with PAS severity at presentation (Spearman founders with p < 0.05 included in the model.
correlation 0.39, p < 0.0001). There were no differences ‡ Adjusted risk difference in admission rate 2% (95% CI 3%
to 7%).
in posttreatment PAS scores between MDI and BAN
groups (Table 2). No subjects in the MDI cohort
compared with 62 (14%) subjects in the BAN cohort After adjusting for baseline severity, ipratropium, and
received $1 dose of albuterol above the recommended elevated vs. standard dosing of albuterol, the risk differ-
protocol dose (p < 0.0001) (Table 2). More BAN subjects ence for hospital admission was 1.8% (95% CI 3.7%
than MDI subjects received ipratropium, 69% vs. 39%, to 7.4%), meeting predefined criteria for noninferiority
respectively (p < 0.001). After adjusting for baseline (Table 3).
PAS, BAN subjects were more likely to receive ipra- The unadjusted difference in ED LOS was shorter for
tropium than MDI subjects (odds ratio 3 [95% CI 1.6– the MDI cohort by 14.8 min (95% CI 0.9–28.8,
5.8%], p < 0.001). Finally, 4 (0.9%) MDI subjects and 9 p = 0.037). The adjusted ED LOS difference between
(2%) BAN subjects received IV MgSO4 (p = 0.2). the cohorts was 9.0 min shorter for the MDI cohort
The unadjusted admission rates for the MDI and BAN (95% CI 22.9 to 4.9).
cohorts were 11.9% and 12.8%, respectively, for an unad- There were 11 subjects randomized to MDI who were
justed risk difference of 0.9% (95% CI 5% to 3%). later converted to BAN; no subjects transitioned from

Table 2. Treatment Summary (Including Adverse Events) of All Patients

BAN MDI p Value

Albuterol dose above protocol recommendation, n (%) 68 (15) 8 (2) <0.001

Ipratropium 309 (69) 173 (39) <0.001
Magnesium sulfate 9 (2) 4 (0.9) 0.2
Treatments for mild PAS* (<8), n (SD) 1.27 (0.44) 1.09 (0.28) <0.0001
Treatments for moderate PAS* ($8), n (SD) 1.97 (0.29) 1.69 (0.49) <0.0001
Score change in PAS after treatment† (SD)
After treatment 1 1.72 (1.53) 1.57 (1.42) 0.1
After treatment 2 2.48 (1.83) 2.40 (1.73) 0.7
After treatment 3 2.26 (1.95) 2.77 (2.00) 0.2
Tachycardia, n (%) 140 (32) 101 (23) <0.001
Nausea/vomiting,‡ n (%) 18 (4) 14 (3) <0.001
Return visit, n (%) 4 (0.9) 5 (1) 1.0

BAN = breath-actuated nebulization; MDI = metered-dose inhaler; PAS = Pediatric Asthma Score; SD = standard deviation.
* Number of treatments unadjusted (as shown above) and adjusted (1.62 for BAN and 1.39 for MDI) for baseline severity. Children random-
ized to the MDI group were more likely to require fewer treatments (p < 0.0001). However, after completing univariate analysis adjusting for
baseline severity, we determined that number of treatments required was not based on appliance, but rather correlated with baseline
severity at presentation (correlation = 0.61; p < 0.0001).
† Measurement obtained after administration of albuterol. Improvement after each treatment is based upon change in PAS from measured
PAS at presentation.
‡ Based on receipt of ondansetron.
MDI vs. BAN in Pediatric Asthma Exacerbations
BAN to MDI. Reasons for changing appliances included
a lack of clinical improvement and physician preference
(3,8). All but 1 of these patients had a known diagnosis
of asthma. Of the 8 subjects who failed to improve
clinically, 7 failed to improve with either device and
were admitted to the hospital. Two of the 3 subjects
changed for physician preference were admitted.
Tachycardia was more common in the BAN group
(141 [32%] of BAN vs. 101 [23%] of MDI, p = 0.002)
(Table 2). The difference remained after adjusting for
baseline PAS (odds ratio 1.56 [95% CI 1.15–2.11],
p = 0.004). There were no differences in documented
nausea or vomiting measured by ondansetron administra-
tion, or repeat visits within 7 days, between treatment
groups in unadjusted and adjusted analyses (Table 2).
DISCUSSION
We know that many children are not using their home
MDIs correctly, and physicians are rarely taking time dur-
ing patient visits to demonstrate their proper use (14–17).
In addition, involving families in their child’s treatment
using MDIs in the ED has led to better MDI use at
home (18). After adjusting for PAS severity using
protocol-recommended doses of albuterol, our study
showed that subjects randomized to MDI or BAN had
similar admission rates and ED LOS, suggesting the
MDI is noninferior to the BAN. Giving equivalent doses
of albuterol via MDI is not practical (approximately 28
puffs for a 2.5-mg treatment of albuterol). We believe
that the MDI should be first-line therapy for nonsevere
AEs with the hope that it will encourage better MDI
use at home and reduce future ED visits.
The existing literature on BAN efficacy is conflicting.
Several studies show BAN use in children and adults re-
sults in fewer hospitalizations, shorter ED LOS, and
improved patient satisfaction, while using less albuterol,
compared to SVN therapy (8,19,20). In contrast, Parone
et al. found that BAN resulted in slightly longer ED
LOS (10 min), did not demonstrate significant clinical
improvement when compared with SVN therapy, and
ultimately concluded that its effectiveness was not
justified by the additional cost (21).
MDIs are more clinically efficacious and cost effective
than SVNs in treating mild, moderate, and severe
exacerbations in children as young as 12 months of age
(4,22–27). Indeed, many pediatricians are successfully
treating asthma around the world by using MDIs with
modified plastic soft drink bottles as spacers (28,29).
There is robust literature supporting MDI use;
therefore, we expected it to be at least as effective as
the BAN.
Our practice, adopted primarily out of convenience,
has been to treat AE using BANs and then discharge
5
patients with an MDI. MDIs are more expensive than
the BAN and require more active bedside time for the
RT. In contrast, the BAN (AeroEclipse) device is not
reusable, not compatible with a standard home nebulizer,
and requires a power source. By failing to demonstrate
the MDI’s effectiveness during the ED visit, lack of con-
fidence in the MDI may encourage unnecessary ED visits
for AE that could otherwise be treated at home.
We did not demonstrate a difference in ED LOS be-
tween the 2 cohorts. ED LOS positively correlated with
presentation symptom severity and the number of albute-
rol treatments given. The BAN allows for delivery of both
ipratropium and albuterol simultaneously, whereas the
MDI requires 2 separate devices, administered sequen-
tially. This would suggest that in more severe exacerba-
tions requiring both treatments, BAN might reduce ED
LOS; however, the total treatment time for each MDI
treatment is shorter than each BAN treatment. Additional
timed studies are needed to determine active bedside
treatment time to characterize the factors that are most
responsible for determining ED LOS.
The BAN group was more likely to receive ipra-
tropium than the MDI cohort (Table 2); this is likely
because of convenience, because both medicines could
be simultaneously administered in the same BAN reser-
voir. There were 20 MDI subjects and 43 BAN subjects
presenting with mild severity who unnecessarily received
ipratropium, as per our ED treatment protocol. It is uncer-
tain whether more BAN subjects would have needed
additional therapy had they not received ipratropium,
because there are conflicting data regarding its effective-
ness (30–33). It is worth mentioning that every child who
was admitted in either cohort received ipratropium in
the ED.
Limitations
Our study does have several limitations. Our ED and pa-
tient population is biased in favor of BAN, and this could
have resulted in failure to enroll selected patients for fear
of possible treatment failure or of receiving low patient
satisfaction scores. The most common reason for patients
refusing participation was the risk of randomizing to the
MDI cohort. During high patient volume surges, we were
unable to approach all study-eligible patients. These fac-
tors could result in our observed acuity being lower than
we intended. In addition, because we have variable physi-
cian practice patterns and patients with unique individual
needs, we did not maintain strict admission criteria. Our
high-volume ED made standardized recheck times post-
treatment impossible to control for in our study design.
We feel that though these limitations may have affected
our primary and secondary outcomes, they are not unique
to our institution, making our findings still relevant.
6 M. A. Snider et al.
Third, we overestimated our admission rate—compared
to our chart review’s 35%, our study showed an admission
rate closer to 12%. This discrepancy occurred because
our chart review included severe exacerbations. Despite
this estimation difference, we were still able to show non-
inferiority at a <5% margin.
There were more subjects in the BAN cohort than in
the MDI cohort who scored within the moderate PAS
severity range. This likely occurred because we did not
stratify subject randomization at presentation with
respect to their baseline PAS. We presented both the un-
adjusted and adjusted symptom severity data for the pri-
mary and secondary outcomes and found no significant
difference between the cohorts in either analysis
(Tables 2 and 3). Approximately 9% of our data were
lost because of study violations—most commonly
failure to document assent—and this may have had an
adverse effect in distribution. Finally, there was no
difference in repeat visits despite the MDI cohort
receiving more training. This could mean that families
who would have otherwise returned did not need to
because they felt confident with the MDI, or that the
additional training had no effect whatsoever as it was
essentially the same as the BAN.
CONCLUSION
Despite our study limitations, analyses adjusting for im-
balances in baseline symptom severity support our
conclusion that MDIs are noninferior to BANs for the
treatment of mild to moderate pediatric AE in the ED.
Future studies involving severe AE are needed to deter-
mine if the MDI is noninferior to the BAN for treating pe-
diatric AE of all severities. We believe that the MDI is
still the best way to treat AE because it is effective,
readily available, and can be used by the patient at
home to manage exacerbations without visiting the ED.
Acknowledgments—Clinicaltrials.gov Trial Registration Num-
ber: NCT02777125.
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APPENDIX

Pediatric Asthma Score

Examination Component 1 2 3

Respiratory rate (breaths/min)

1–4 years of age #34 35–39 $40
4–6 years of age #30 31–35 $36
6–12 years of age #26 27–30 $31
>12 years of age #23 24–27 $28
Oxygen saturation >95% on room air 90–95% on room air <90% on room air or
requirement requiring oxygen
Retractions None or intercostal Intercostal and substernal Intercostal, substernal, and
supraclavicular
Work of breathing (count to 10) Speaks in sentences, coos Speaks in partial sentences, short cry Speaks in single words/
and babbles short phrases, grunting
Auscultation Normal breath sounds to end- Expiratory wheezing Inspiratory and expiratory
expiratory wheezes only wheezing to diminished
breath sounds
Total PAS Mild = 5–7 Moderate = 8–11 Severe/critical$12

Institutional Asthma Treatment Protocol

Mild Moderate Severe

Albuterol MDI (spacer/mask) Albuterol MDI (spacer/mask) MDI not indicated

#20 kg (6 puffs) #20 kg (6 puffs)
>20 kg (12 puffs) >20 kg (12 puffs)
BAN albuterol 2.5 mg/0.5 mL with 0.5 mL BAN albuterol BAN albuterol
NS #20 kg (2.5 mg/0.5 mL) #20 kg (5 mg/1 mL)
>20 kg (5 mg/1 mL) >20 kg (10 mg/2 mL)
SVN albuterol SVN albuterol SVN albuterol
#20 kg (2.5 mg/3 mL) #20 kg (2.5 mg/3 mL) #20 kg (7.5 mg/9 mL)
>20 kg (5 mg/6 mL) >20 kg (5 mg/6 mL) >20 kg (15 mg/18 mL)
No ipratropium indicated Ipratropium nebulization Ipratropium nebulization
0.5 mg/2.5 mL 0.5 mg/2.5 mL

BAN = breath-actuated nebulization; MDI = metered-dose inhaler; PAS = Pediatric Asthma Score; SVN = small volume nebulizer.
8 M. A. Snider et al.

ARTICLE SUMMARY
1. Why is this topic important?
Pediatric asthma exacerbations account for >9 million
emergency department (ED) visits annually. Many of
these visits occur because families do not feel comfortable
using their home metered-dose inhaler (MDI), resulting in
unnecessary visits to the ED.
2. What does this study attempt to show?
Breath-actuated nebulization (BAN) is a relatively
newer method for delivering aerosolized albuterol for pa-
tients experiencing an asthma exacerbation. The BAN is
not yet readily available for home use; however, this study
shows that the MDI is clinically noninferior to the BAN
for treatment of mild to moderate asthma exacerbations
in pediatric patients.
3. What are the key findings?
Admission rates and ED lengths of stay for the MDI
cohort was noninferior to the BAN cohort. Subjects in
the BAN cohort were more likely to experience tachy-
cardia than subjects in the MDI cohort; however, treat-
ment of nausea with ondansetron and return ED visits
were not statistically significant between the cohorts.
4. How is patient care impacted?
MDIs are still the optimal method for treating pediatric
asthma exacerbations. ED visits are an opportunity to
show families that the MDI is readily available, effective,
and can be used at home.