Comparison of Outcome in Salbutamol Delivery through Metered Dose Inhaler versus Nebulizer in Children with Severe Acute Exacerbation of Asthma

Abstract

Asthma is one of the most common chronic respiratory diseases among children worldwide, and severe acute exacerbations remain a leading cause of morbidity and healthcare utilization. Salbutamol, a short-acting β2-agonist, is the mainstay of therapy, commonly delivered either by nebulizer or metered-dose inhaler (MDI) with a spacer. The optimal delivery method for children, particularly in resource-limited settings like Pakistan, remains debated. Objective: To compare the efficacy of salbutamol delivered via nebulizer versus MDI with a spacer in children presenting with severe acute asthma exacerbations. Methods: This randomized controlled trial was conducted at the Department of Pediatric Medicine, Ibn-e-Siena Hospital, Multan, over a six-month period from May 2024 to October 2024. A total of 104 children aged 5–15 years with severe acute exacerbation of asthma (Pulmonary Score ≥7) were randomized into two groups: nebulizer (n=52) and MDI with spacer (n=52). Baseline demographic and clinical characteristics were recorded. All participants received adjunctive intravenous methylprednisolone and magnesium sulfate. The primary outcome was a reduction in respiratory rate at 20 minutes. Secondary outcomes included the change in pulmonary score at 4 hours and the requirement for hospitalization. Data were analyzed using SPSS version 23, with p < 0.05 considered significant. Results: The mean age of participants was 9.8 ± 2.7 years; 60.6% were male. At 20 minutes, the MDI group demonstrated a significantly greater reduction in respiratory rate compared to the nebulizer group (8.6 ± 2.4 vs. 6.9 ± 2.7 breaths/min, p = 0.002). At 4 hours, the MDI group had a lower mean pulmonary score (3.1 ± 1.2 vs. 3.8 ± 1.4, p = 0.01). Hospitalization was required in 7.7% of children in the MDI group, compared to 17.3% in the nebulizer group, although this difference was not statistically significant (p = 0.14). Stratified analyses confirmed consistent superiority of MDI across most subgroups. Conclusion: MDI with a spacer proved more effective than a nebulizer in improving short-term respiratory outcomes in children with severe acute asthma exacerbations. Given its comparable efficacy, ease of use, and reduced need for specialized equipment, MDI with a spacer represents a practical and effective alternative to nebulization in resource-constrained pediatric emergency settings.