University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• A 4 month infant presents to your pediatric office with a history and physical consistent with a viral URI and reactive airways disease.  Through observation during the office visit, it is evident that the patient will require beta-adrenergic therapy every 4 to 6 hours to ensure appropriate clinical improvement.  This patient could very well be treated as an outpatient.  How effective is albuterol delivered via an MDI-S in this infant?

Clinical Bottom Lines

1. There are no studies comparing NMT use and MDI-S use in the outpatient treatment of wheezing infants.
2. This study reports that regarding wheezing in the ambulatory infant, MDI-S administration of albuterol shows statistically significant improvement following treatment.¹
3. No statistical significance was noted with placebo therapy in either group.

Summary of Key Evidence

1. Subjects:  Forty-two patients aged 1 to 18 months presenting to the emergency department with wheezing.  Patients excluded if history of cardiac/respiratory/musculoskeletal disease, bronchodilation past 24 hrs, or history of 0₂ supplementation.
2. Design and Setting:  Double-blind, prospective, placebo-controlled, clinical crossover trail.  Group 1 (n=19) received albuterol treatments x2 followed by placebo treatment (oleic acid) q 20 minutes x2.  Group 2 (n=23) received placebo treatment q 20 minutes x2 followed by albuterol treatments q 20 minutes x2.
3. Strict scoring system used for assessments at start, before each treatment, and at the end of the study (study lasting 80 minutes).  Scoring for wheezing and retractions.
4. Group 1 scores (albuterol-placebo group) showed significant improvement from baseline regarding wheezing after 2nd albuterol treatment (p<.01).  No statistical significant improvement with placebo treatments.
5. Group 2 scores (placebo-albuterol group) showed significant improvement from baseline regarding wheezing, but only after 4th "treatment" (p<.01) No statistical significant improvement with placebo treatments.
6. Group 1 scores, while improved with time, showed no statistical significant improvement regarding retractions following either albuterol or placebo.
7. Group 2 scores showed a statistical improvement following the 4th "treatment" (p<.05).  No statistical improvement with placebo treatments.

Additional Comments

• Ideally, a study would compare NMT's and MDI-S administration of beta-agonists in outpatient infants.  It would also follow these patients to assess the safety and efficacy of MDI-S treatment following their ER discharge.  This would allow us to make more informed decisions regarding the use MDI-S for outpatient therapy.  We know that MDI-S are less expensive, less cumbersome, and less time-consuming.  Therefore, this would be the more appropriate choice for treatment (everything else being equal).

Citation

1. Hickey RW. Gochman RF. Chande V. Davis HW. Albuterol delivered via metered-dose inhaler with spacer for outpatient treatment of young children with wheezing.  Archives of Pediatrics & Adolescent Medicine. 148(2):189-94, 1994.

CAT Author: Harriet Hadley, MD

CAT Appraisers: John Frohna, MD

Date appraised: March 10, 1999