Objective: Continuous nebulization is becoming more popular in the management of acute bronchospasm in the emergency department (ED). Controversy still exists as to the optimal dose of albuterol for such exacerbations. The present study hypothesis was that there is no difference between continuous nebulization of albuterol at 7.5 mg/hr (usual dose) and 15 mg/hr (high dose) in peak flow improvement up to three hours.
Methods: This was a randomized, controlled, double-blind trial, set in an urban county teaching ED. One hundred twenty-seven patients with acute bronchospasm and an initial peak flow (PF) less than 75% predicted were enrolled. Patients were randomized to usual-dose (UD) or high-dose (HD) groups along with a standard treatment protocol. Primary end-points were analyzed using repeated-measures analysis of variance (ANOVA), and 95% confidence intervals (95% CIs) are given for such variables.
Results: Sixty-seven patients were randomized to the HD albuterol group, and 63 completed the study. Sixty patients were randomized to the UD group, and 55 completed the study. Repeated-measures ANOVA found no difference in systolic blood pressure, diastolic blood pressure, pulse, respiratory rate, Borg dyspnea scale score, and peak flow over time between the groups. The mean (+/-SD) peak flow improvement at one hour was UD 51 (+/-49) L/min vs. HD 45 (+/-50) L/min, mean difference 6.8 L/min (95% CI = -11 to 24.9 L/min). Adjusting for baseline, the percentage increase in peak flow at one hour was UD 44% (+/-60%) vs. HD 30% (+/-40%), mean difference 14% (95% CI = -4.4% to 32.4%). Time to disposition showed a mean of 188 (+/-129) minutes for UD and 230 (+/-183) minutes for HD, mean difference 42 minutes (95% CI = -170 to 101 min). One patient in the HD group was intubated. Admission rate was UD 70.9% vs. HD 65%, mean difference 5.9% (95% CI = -10.9% to 22.7%).
Conclusions: In treating acute, moderately-severe bronchospastic ED patients with peak flow less than 75% of predicted with albuterol by continuous nebulization, 15 mg/hr appears to offer no advantage over 7.5 mg/hr in peak flow improvement or length of stay in the ED.