Asthma: acute exacerbation: nebulised albuterol was more effective than intravenous albuterol.

Clinical bottom line (level 1b)

  1. Nebulised albuterol was more effective than intravenous albuterol in relieving symptoms in patients with acute severe asthma and hypercapnia (NNT = 3 at 60 minutes) .
Salmeron et al: American Journal of Respiratory Critical Care Medicine 1994; 149: 1466-1470
Expires November 2002

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: five respiratory or medical intensive care units, university hospitals, France

47 patients (aged range 16 to 75 years; mean 40, 56% male) acute severe asthma (PEFR < 150 l/min) and hypercapnia (PaCO2 > 40 mmHg)

Excluded if
  • chronic obstructive lung disease
  • chronic left heart failure
  • used bronchodilator therapy other than beta2-agonists delivered by multidose inhaler in previous 60 minutes


    • Control Group: (n = 22, 22 analysed): 5 mg albuterol nebulised twice in one hour and saline iv
    Experimental Group: (n = 25, 20 analysed): 500 mcg albuterol iv over one hour and nebulised saline

    100% followed for 60 minutes
    Outcome notes:
    • unsuccessful response : successful response: decrease in clinical rating by three points or more; decrease in PaCO2 by at least 3 mmHg; increase in PEFR > 50 l/min

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    unsuccessful response 60 minutes 3
    (13.6%)    		 13
    (52.0%)    		 -281%
    (-1065% to -25%)    		 -38.4%
    (-62.6% to -14.1%)    		 -3
    (-7 to -2)

    Comments

    1. Intravenous beta-agonists are usually given in addition to nebulised beta-agonists, rather than as an alternative.
    2. The study was very small and follow-up was short. Intravenous beta-agonists may have a delayed response. Unclear whether dosing was the same in the two groups.
    3. Cheong et al found that iv albuterol was better than nebulised, but used higher doses in the intravenous solution. No study has assessed whether the combination is better than either alone.
    4. Less frequent side effect of the nebulized route may become the reason of choice .

    Citation

    1. Salmeron S, Brochard L, Mal H, et al: nebulized versus intravenous albuterol in hypercapnic acute asthma: a multicenter, double-blind, randomized study. American Journal of Respiratory Critical Care Medicine 1994; 149: 1466-1470
    Search Terms: acute asthma in Cochrane
    Contributor: Chris Ball and Clare Wotton, November 2000
    Reviewer: Mitsuhiro Kamei

    Clinical Question.
    Patient acute severe asthma
    Intervention or Exposure nebulised albuterol
    Comparison intravenous albuterol
    Outcome symptom relief