Best Evidence Topics
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Bronchodilator delivery in acute severe asthma in adults

Three Part Question

In [an adult with acute severe asthma] is [delivery of bronchodilator therapy via nebuliser or spacer] better at [improving airflow and decreasing need for admission]?

Clinical Scenario

A 24 year old known asthmatic is brought into the emergency department by friends. She has been in a smokey bar and has become very wheezy. You assess her asthma as severe. You wonder whether a nebuliser is necessary, or whether a spacer device will suffice.

Search Strategy

Medline 1966-12/01 using the OVID interface.
([exp asthma OR] AND [exp bronchodilator agents OR bronchodilator$.mp] AND [exp nebulizers and vaporizers OR nebulise$.mp OR nebulize$.mp OR spacer$.mp]) LIMIT to human AND English language.

Search Outcome

1734 papers found of which two were meta-analyses that included all other relevant papers.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Turner MO et al,
12 of 18 randomised trials (507 patients)Meta-analysisEffect size -0.02 (-0.2 to 0.16)Includes 102 patients with COPD
Cates C and Rowe BH,
7 of 44 randomised trials (375 patients)Systematic reviewFEV1No significant difference
PEFRNo significant difference
Length of stayNo significant difference


The two meta-analyses have 4 studies (199 patients) in common.

Clinical Bottom Line

Spacer devices can be used in place of nebulisers in patients with acute severe asthma.


  1. Turner MO, Patel A, Ginsburg S, et al. Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Arch Int Med 1997;157(15):1736-44.
  2. Cates C J, Rowe BH. Holding chambers versus nebulisers for beta-agonist treatment of acute asthma (Cochrane Review). The Cochrane Library Issue 4, 2001. Oxford: Update Software.