MDI with spacer/mask versus Nebulizer

JustBeachyNurse, LPN · Aug 7, 2012

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.org/article.aspx?articleid=1078826

anon456, BSN, RN · Aug 8, 2012

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. ;-)

chenselmom · Aug 8, 2012

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!!

Double-Helix, BSN, RN · Aug 8, 2012

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.

DSkelton711 · Aug 9, 2012

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.

wooh, BSN, RN · Aug 9, 2012

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.

canned_bread · Aug 13, 2012

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.

JustBeachyNurse, LPN · Aug 13, 2012

The key is a mask with the spacer for a toddler so the issue about sealing lips around the mouthpiece is not a problem.

shannen396 · Aug 14, 2012

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.

luvdancink · Aug 15, 2012

There is a lot of research out there now not in support of nebulizers. We have switched to inhalers with spacers for all ages, masks for the little ones including infants. At the other facility I work at with pediatric vented patients we have switched from nebulizers there as well to inhalers being puffed through trachs and have seen no different in outcomes. I like it as I dont have to chase a screaming toddler around a hospital room anymore We just hold them down with the mask on until they take a breath. They will eventually and once they learn what's going to happen, its not very traumatic. For those that say nebulizers are the only thing that works for them, the results just don't show that in evidenced based practice, but sometimes I wonder if maybe its the humidity more than the medication that aids these patients??? :shrug:

JustBeachyNurse, LPN · Aug 15, 2012

The specialist that ordered the MDI with spacer & mask said that they even use MDI/spacer/mask in the NICU as soon as the kiddos are big enough for their smallest mask. Quicker treatment, less stress. The nebulizers are used for those with heavy secretions, need the extra humidification, not taking deep breaths due to congestion/restriction (i.e. status asthmaticus, CF exacerbation) which makes some sense.

I will say that my patient's mother is thrilled that the doctor switched her boys to MDI/spacer as it is time saving, plus easily portable, no extra equipment to lug around.