MDI with spacer/mask versus Nebulizer

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    Those of you who work peds ER or peds respiratory floor. What is your opinion/practice standard for the youngest age to use the facemask with an MDI for albuterol delivery? Just curious because I've always used nebulizers on little ones and MDI's with spacers on age 6 and up.

    My niece at age 2.5 was just given an MDI with spacer and mask. I think she is too young. Wondering if I'm wrong.

    Thanks!
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  3. 11 Comments so far...

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    I'm not an ER or pedi pulmo nurse but a PD/HH nurse that works with medically complex/fragile children. My one patient and his brother are not yet 2. Current evidence shows MDI & one-way valved spacer and mask is just as effective for patients of that age as per the pulmonologist at one of the top ranked pediatric hospitals in the US. In fact MDI plus spacer results in greater patient/parent compliance with the treatment regimen, plus less stress for patient/parent because the treatment takes less time than a nebulized treatment. Also studies now show that more drug is delivered and less drug is wasted into the air, provided a good seal is maintained between face and mask.

    Here are some quick articles I found: http://www.ers4kids.com/nebs.pdf
    http://www.cebp.nl/media/m702.pdf
    http://journal.publications.chestnet...icleid=1078826
    Last edit by JustBeachyNurse on Aug 7, '12 : Reason: clarification
    wooh likes this.
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    Just restating what previous poster said-- I heard the same study as I was being trained for my pulmonary peds unit position. The only ones who get neb treatments are the trach kids or the asthma kids who are on continuous treatmets. Once the asthma improves and they are switched to Q1-2 hour treatments and beyond, they are using MDIs with spacers. They more they cry the bigger breaths they take. ;-)
  6. 1
    Just Beachy Nurse, thank you for the resources. I work in a community hospital Pediatric Unit, and our Pediatric Hospitaliats have been ordering MDI's for toddlers for awhile. The nebulized treatments are considerably less effective, as they spray more on the linens and the air around the patient's head than into the patient's airway. We've been trying to get the practice used throughout the organization, but have met resistance from RT. I will pull these up and hopefully help our cause! Thanks again!!
    JustBeachyNurse likes this.
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    In the hospital, we give all our albuterol treatments via a nebulizer, regardless of the patient's age. The rationale being that single dose nebulized albuterol is more cost effective than MDIs.

    When the patient goes home they are prescribed either nebulized albuterol or an MDI with spacer depending on their age/development level. We really don't have cut and dry guidelines for who gets what. Most of our asthma exacerbations are known asthmatics, so we just refill whatever they were prescribed by their pulmonologist. I would say that it's pretty rare to see a child under 4 prescribed an MDI/spacer. But, provided that the parents are properly educated on how to use the MDI and spacer with the face mask, I don't see an obvious reason why a younger child would not be able to use one effectively. The biggest obstacle, I think, would be the very young child who is not old enough to understand the face mask and fights when the parent tries to establish a seal.
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    As an asthmatic (I also used to work peds) I will tell you from my experience. Even with a spacer, if I am wheezing and not able to take in a good breath--a MDI does not work as well as a neb. If I am breathing well and able to take good breaths then sometimes it is sufficient. If I am wheezing fairly frequently my neb works best. So I would recommend to take the ability of the child to breathe in deeply into consideration. Neb does last longer and doing it as a blow-by can make a big difference in the child receiving an adequate amount of med. I also have a child who had childhood asthma and had best results with neb as a blow-by. Using a spacer certainly is an improvement of having nothing. Just make sure the child is able to get good breaths in.
    Lisa Jane RN and tejon like this.
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    Once they're off needing continuous treatments, we do MDI as soon as they're old enough for our small MDI spacer mask to fit.
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    I was informed at a recent in-service that a spacer is okay as long as the child can understand "breathe in", and can seal their lips around the spacer. After a spray of the albuterol they have a good 3-4 seconds to breathe in before the spray settles, which is plenty long enough to say "breathe in".
    As an asthmatic, I find the spray gets in better with a spacer than just the plain MDI. During an acute attack, a neb is better for when I can't get air in as I can't get enough of a breath to actually get it all in with the spacer, I can't BREATHE IN enough and then get that air out. I was also informed at the in-service that only about 10% of people (inc. adults) use a MDI correctly, and spacers rectify the problem. I am sure the 10% would be even lower if they took out the adult's in that study!
    I used a spacer from when I was a toddler as well, as it worked fine.
  11. 1
    The key is a mask with the spacer for a toddler so the issue about sealing lips around the mouthpiece is not a problem.
    wooh likes this.
  12. 0
    My daughter used the spacer at 9 months old +. We also had a nebulizer, but that was when the inhaler didn't work well enough (acute illness). They usually cry at that age when using which is helpful as they take in deep breaths. I'm a new pediatric nurse now, but have an asthmatic child.


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