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Three Part Question

IN [known asthmatics who present to the ED with and acute attack] IS [continuous nebuliser therapy better than intermittent nebulisers] AT [relieving the bronchospasm and terminating the attack]

Clinical Scenario

A 27yr old women who suffers with asthma presents to the ED with an acute attack of asthma that is not responding to her inhalers. She is very short of breath and is unable to talk in full sentences but is still making good respiratory effort. Your first line of management is so start her on nebulised bronchodilators and you wonder if continuous nebulisers therapy v/s intermittent nebulisers are more effective in improving pulmonary function and reducing hospital admission without increasing side effects.

Search Strategy

MEDLINE 1966 to June 2005 using OVID
COCHRANE Database
[{ASTHMA, EXERCISE-INDUCED/ or exp ASTHMA/ or asthma.mp. or bronchospasm.mp. or exp Bronchial Spasm/ or hyperactive airway disease.mp. or exp Bronchial Hyperreactivity/} AND {exp "Nebulizers and Vaporizers"/ or nebuliser.mp.}AND {intermittent.mp.} AND {continuous.mp.}Limit to (humans and english language)]

Search Outcome

81 articles were found out of which 9 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
van Schayck CP. Dompeling E. van Herwaarden CL. Folgering H. Akkermans RP. van den Broek PJ. van Wee			0.15mg/kg dex worked as well as 0.3 and 0.6mg/kg in decreasing croup score and need for adrenaline	Rates of hospital stay, intubation, need for adrenaline, readmission were all similar between groups

References

1. Camargo CA Jr. Spooner CH. Rowe BH Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database of Systematic Reviews. (4):CD001115, 2003
2. Rodrigo GJ. Rodrigo C Continuous vs intermittent beta-agonists in the treatment of acute adult asthma: a systematic review with meta-analysis
3. Besbes-Ouanes L. Nouira S. Elatrous S. Knani J. Boussarsar M. Abroug F Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial.
4. Khine H. Fuchs SM. Saville AL Continuous vs intermittent nebulized albuterol for emergency management of asthma
5. van Schayck CP. Dompeling E. van Herwaarden CL. Folgering H. Akkermans RP. van den Broek PJ. van Weel C. Continuous and on demand use of bronchodilators in patients with non-steroid dependent asthma and chronic bronchitis: four-year follow-up randomized controlled study.
6. Moler FW. Johnson CE. Van Laanen C. Palmisano JM. Nasr SZ. Akingbola O Continuous versus intermittent nebulized terbutaline: plasma levels and effects. American Journal of Respiratory & Critical Care Medicine. 151(3 Pt 1):602-6, 1995 Mar.
7. Lin RY. Sauter D. Newman T. Sirleaf J. Walters J. Tavakol M Continuous versus intermittent albuterol nebulization in the treatment of acute asthma Annals of Emergency Medicine. 22(12):1847-53, 1993 Dec.
8. Rudnitsky GS. Eberlein RS. Schoffstall JM. Mazur JE. Spivey WH. Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department Annals of Emergency Medicine. 22(12):1842-6, 1993 Dec.
9. Papo MC. Frank J. Thompson AE. A prospective, randomized study of continuous versus intermittent nebulized albuterol for severe status asthmaticus in children Critical Care Medicine. 21(10):1479-86, 1993 Oct