Patient Services/Wheezing/Oxygen vs. Air for Nebulization/BESt 084
Best Evidence Statement (BESt)
Date published/posted 1/18/2011
Clinical Question
P (population/problem)
I (Intervention)
C (Comparison)
O (Outcome)
Among pediatric patients with wheezing
does the use of nebulizer with oxygen
vs. the use of air nebulizer for delivery of medication
increase the improvement of respiratory symptoms as measured by respiratory score?
Target Population: Pediatric patients with wheezing 0 to 18 years of age.
Recommendation
There was insufficient evidence and lack of consensus to make a recommendation on the use of air or
oxygen to deliver nebulized medication for pediatric patients who are wheezing or have asthma.
Cincinnati Children’s Hospital policy Respiratory care Policy II 204 Oxygen Therapy. Last reviewed 12/19/08.
Discussion/summary of evidence
The literature search did not uncover a clear answer as to whether oxygen or air should be used to deliver
nebulized medication to pediatric asthma patients. The evidence found studied only adults and the use of
oxygen with asthma, emphysema, and/or COPD (Ballester 1989 [4b], Chien 2000 [4a] Gunawardena 1984 [4b],
Rodrigo 2003 [2a], Ting 2004 [5a]). One study of the use of oxygen with nebulized medication among children
was inconclusive (Gleeson 1988 [2b]). One study assessed the performance of different commercial nebulizers
(Reisner 2001 [4a]). But none of the articles directly addressed oxygen as being a more effective delivery
device over air nebulization. The strength of the body of evidence is low.
Health Benefits, Side Effects and Risks There were no health benefits or risks concluded.
References/Citations
Ballester, E., Reyes, A., Roca, J., Guitart, R., Wagner, P. D., & Rodriguez-Roisin, R. (1989). Ventilation
perfusion mismatching in acute severe asthma: Effects of salbutamol and 100% oxygen. Thorax, 44(4),
258-267. [4b].
Brand, P., Roorda, R. (2003). Drug Delivery in Pediatric Patients with Asthma. Spacer Devices vs. Nebulizers
for B2 Agonists. American Journal Drug Delivery, 1 (1), 61-70. [1a].
Castro-Rodriguez, J., Rodrigo, G. (2004). B-Agonists Through Metered-Dose Inhaler with Valved Holding
Chamber Versus Nebulization for Acute Exacerbation of Wheezing or Asthma in Children Under 5 Years
of Age: A Systematic Review with Meta-Analysis. The Journal of Pediatrics, 145, 172-177. [1a].
Chien, J.W., Ciufo, R., Novak, R., Skowronski, M., Nelson, J., Coreno, A., et al. (2000). Uncontrolled oxygen
administration and respiratory failure in acute asthma. Chest, 117(3), 728-733. [4a].
Courtney, U., McCarter, D., Pollart, S. (2005). Childhood Asthma: Treatment Update. American Family
Physician, (71), 1959-1968. [5a].
Copyright © 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Patient Services/Wheezing/Oxygen vs. Air for Nebulization/ BESt 084
Delgado, A., Chou, K., Johnson-Silver, E., Crain, E., (2003). Nebulizers vs. Metered Dose In halers With
Spacers for Bronchodilator Therapy to Treat Wheezing in Children Aged 2 to 24 months in a Pediatric
Emergency Department. Archives of Pediatrics and Adolescent Medicine, 157, 76-80. [2a].
Dolovich, M. B., Ahrens, R. C., Hess, D. R., Anderson, P., Dhand, R., Rau, J. L., Smalldone, G. C., Guyatt, G.
(2005). Device Selection Outcomes of aerosol therapy: evidence based guidelines: Amercian College of
Chest Physicians/ American College of Asthma, Allergy, and Immunology. Chest Jan;127 (1), 335-71.
[5a].
Gleeson, J.G., Green, S., & Price, J. F. (1988). Air or oxygen as driving gas for nebulised salbutamol. Archives
of Disease in Childhood, 63(8), 900-904. [2b].
Gunawardena, K.A., Patel, B., Campbell, I. A., MacDonald, J. B., & Smith, A. P. (1984). Oxygen as a driving
gas for nebulisers: Safe or dangerous? British Medical Journal (Clinical Research Ed.), 288(6413), 272274. [4b].
Hendeles, L., Hatton, R., Coons, T., Carlson, L. (2005). Automatic replacement of albuterol nebulizer therapy
by metered-dose inhaler and valved holding chamber. American Journal of Health System Pharm, 62,
1053-1061. [4a].
Leversha, A., Campanella, S., Aickin, R., Asher, M. (2002). Costs and effectiveness of spacer versus nebulizer
in young children with moderate and severe acute asthma. The Journal of Pediatrics, 136(4) 497-502. [2a].
Mohammed, K., Shepard, J., Goodman, B., Lincourt, W., Trivedi, R., Ellsworth, A., Davis, A. (2010). Repeat
dosing of Albuterol via Metered-Dose Inhaler in Infants With Acute Obstructive Airway Disease. Pediatric
Emergency Care, 26(3), 197-202.
Neto, H., Silva, D., Marani, D., Kuroda, F., Olandosky, M., Noronha, L. (2005) Different inhaler devices in
acute asthma attacks: a randomized, double-blind, placebo controlled study. Journal of Pediatria, 81(4)
298-304. [2a].
Ploin, D., Chapuis, F., Stamm, D., Robert, J., David, L., Chatelain, P., Dutau, G., Floret, D. (2000). High Dose
Albuterol by Metered-Dose Inhaler Plus a Spacer Device Versus Nebulization in Preschool Children With
Recurrent Wheezing: A Double Blind, Randomized Equivalence Trial. Pediatrics, 106 (2), 311-317. [2a].
Raimondi, L., Schottlender, J., Lombardi, D., Molfina, N. (1997). Treatment of Acute Severe Asthma with
Inhaled Albuterol Delivered via Jet Nebulizer, Metered Dose Inhaler with Spacer, or Dry Powder. Chest,
112 (1), 24-28. [2b].
Reisner, C., Katial, R., Bartelson, B., Buchmeir, A., Rossenwasser, L., & Nelson, J. (2000).
Characterization of aerosol output from various nebulizer/compressor combinations. Annals of Allergy,
Asthma, & immunology, 86(May 2001), 566. [4a].
Rodrigo, G.J., Rodriquez Verde, M., Peregalli, V., & Rodrigo, C. (2003). Effects of short-term 28% and 100%
oxygen on PaCO2 and peak expiratory flow rate in acute asthma: A randomized trial. Chest, 124(4), 13121317. [2a].
Schuh, S., Johnson, D., Stephens, D., Callahan, S., Winders, P., Canny, G. (1999). Comparison of albuterol
delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma.
Journal of Pediatrics, 135(1), 22-27. [2b].
Copyright © 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Patient Services/Wheezing/Oxygen vs. Air for Nebulization/ BESt 084
Ting, J. Y. (2004). Hypercapnia and oxygen therapy in older asthmatic patients. European Journal of
Emergency Medicine, 11(6), 355-357. [5a].
Volovitz, B., Nussinovitch, M., (2002). Management of Children with Severe Asthma Exacerbation in the
Emergency Department. Pediatric Drugs, 4(3), 141-148. [1a].
Note: Full tables of evidence grading system available in separate document:
Table of Evidence Levels of Individual Studies by Domain, Study Design, & Quality (abbreviated table below)
Grading a Body of Evidence to Answer a Clinical Question
Judging the Strength of a Recommendation (abbreviated table below)
Table of Evidence Levels (see note above)
Quality level
Definition
Systematic review, meta-analysis, or meta1a† or 1b†
synthesis of multiple studies
2a or 2b
Best study design for domain
3a or 3b
Fair study design for domain
4a or 4b
Weak study design for domain
Other: General review, expert opinion, case
5
report, consensus report, or guideline
†a = good quality study; b = lesser quality study
Table of Recommendation Strength (see note above)
Strength
Definition
“Strongly recommended”
There is consensus that benefits clearly outweigh risks and burdens
(or visa-versa for negative recommendations).
“Recommended”
There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made
There is lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process
that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
1. Grade of the Body of Evidence (see note above)
2. Safety / Harm
3. Health benefit to patient (direct benefit)
4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
5. Cost-effectiveness to healthcare system (balance of cost / savings of resources, staff time, and supplies based on published studies or
onsite analysis)
6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention,
comparison, outcome])
7. Impact on morbidity/mortality or quality of life
Supporting information
Introductory/background information
The use of nebulization in the outpatient setting is not standardized in terms of oxygen or air being the most
appropriate method of delivery.
Group/team members:
Team Leader: Tricia Luckhaupt, RNII, CPN
Support personnel: Lisa English Long, MSN, RN, CNS, Evidence based Mentor and Barbara K.
Giambra, MS, RN, CPNP, Evidence based Practice Mentor, Center for Professional
Excellence/Research and Evidence based Practice
Copyright © 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Patient Services/Wheezing/Oxygen vs. Air for Nebulization/ BESt 084
Search strategy
Databases searched: OVID MEDLINE, EBSCO CINAHL, PUBMED, SCOPUS, and GOOGLE
SCHOLAR
Search Terms: Oxygen/air nebulizer, respiratory treatments, nebulizer/air, oxygen/albuterol, nebulizer
therapy, asthma/therapy, asthma, oxygen
Filters: English language
Date range: All dates up to and including 4/2010
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• copies may be provided to patients and the clinicians who manage their care.
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Additionally, for more information about CCHMC Best Evidence Statements and the development process, contact the Center for
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Note
This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice
guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best
Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this
document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the
specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual
circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.
Reviewed against quality criteria by 2 independent reviewers
Copyright © 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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