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Emergency Treatment of Acute Asthma With Albuterol Metered-Dose Inhaler Plus Holding Chamber : How Often Should Treatments Be Administered?

Jill P. Karpel; Thomas K. Aldrich; David J. Prezant; Katia Guguchev; Alberto Gaitan-Salas; Raja Pathiparti
Author and Funding Information

Affiliations: From the Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center and North Central Bronx Hospital, Bronx, NY.,  From the Albert Einstein College of Medicine, Montefiore Medical Center, North Central Bronx Hospital, Bronx, NY.

Affiliations: From the Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center and North Central Bronx Hospital, Bronx, NY.,  From the Albert Einstein College of Medicine, Montefiore Medical Center, North Central Bronx Hospital, Bronx, NY.


1997 by the American College of Chest Physicians


Chest. 1997;112(2):348-356. doi:10.1378/chest.112.2.348
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Abstract

Study objective: To determine the optimal treatment interval for administering albuterol metered-dose inhaler (MDI) with a holding chamber to patients presenting to the emergency department (ED) with acute asthma.

Design: Prospective, randomized, double-blind study.

Setting: EDs of two affiliated teaching hospitals in the Bronx, NY.

Patients: One hundred adult patients with acute asthma and FEV1 <60% predicted of normal.

Interventions: At entry (T=0 min), eligible patients all openly received inhaled albuterol (six puffs) via MDI with a spacer. Subsequently, in a double-blind fashion, they received six puffs of albuterol or placebo with new MDIs and spacers at 30, 60, and 90 min such that group 1 (n=34) received albuterol every 30 min, group 2 (n=33) every 60 min, and group 3 (n=33) at 120 min only. FEV1 and vital signs were measured at T=0 and at 15, 30, 60, 90, and 120 min following initial treatment. Potassium levels were measured at T=0 and 120 min. Adverse events, the use of additional inhaled β-agonists or systemic corticosteroids, and hospitalization rates were recorded.

Measurements and results: At T=0, the groups did not differ in age, FEV1 or prescribed asthma medications. All groups showed significant improvement in FEV1 (p<0.05; T=120 vs 0 min). The conditions of groups 1 and 2 improved significantly more than those of group 3, but did not differ compared to each other. The mean±SEM change in FEV1 (T=120 vs 0 min) was 0.993±0.108, 0.858±0.135, and 0.321±0.056 L, respectively, for the three groups. Separate analysis for patients with FEV1% <40% or >40% predicted showed similar results. However, patients who initially were low responders to albuterol treatment (<15 percentage point increase at 15 min) improved significantly with 30-min treatments compared to the other two treatment regimens. Patients who initially responded with >15 percentage point increase in FEV1 at 15 min following initial albuterol inhalation benefited equally from 30- or 60-min treatments compared to 120 min. Potassium levels did not change significantly during the study. Adverse events and hospitalization rates were equivalent. After the conclusion of the study, group 3 patients required a greater number of β-agonist treatments prior to eventual discharge from the ED.

Conclusions: For acute asthma, albuterol MDI with a holding chamber can be given optimally at 60-min intervals with minimal adverse effects for the majority of patients. However, patients who initially demonstrate a low or poor bronchodilator response to albuterol should be given subsequent treatments at 30-min intervals. This will optimize care and conserve resources for patients who will benefit the most.


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