This study compared CN of P-agonists with the standard method of BN in the initial emergency department management of asthma. Both methods were demonstrated to be effective with no significant differences in their bronchodilator activity or toxicity. Bolus nebulization was associated with a more rapid initial response, whereas FEV, improved progressively with CN. The change in FEV, was greater with CN than BN and had not yet reached a plateau after 2 hours with the former. However, the initial FEV, was lower in the CN group and this may have contributed to the aparently greater response in these patients. At the end of 2 hours, FEV, was virtually identical in both arms and we believe that the treat¬ments were equally efficacious.
The concept of continuous nebulization of p-agonists has been explored in the pediatric literature, but to our knowledge, no such study has been at¬tempted in adults. Robertson et al have shown that very frequent administration of albuterol produced a more rapid improvement in pulmonary function than conventional nebulization, but there was no overall difference between treatment groups. Two other studies have assessed continuous nebulization of terbuta- line in children who failed to respond to standard therapy consisting of intravenous aminophylline, steroids, and inhaled boluses of bronchodilator. Both demonstrated significant clinical and blood gas improvement in subjects treated with continuous nebulization for 1 to 37 hours (mean duration, 8.3 and 15.4 hours). However, neither study was controlled and pulmonary function was not measured.
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There are several theoretical reasons why CN may produce superior bronchodilation than intermittent therapy. It has been shown that three sequential inhalations of metaproterenol by metered dose inhaler every 10 minutes were superior to a single equivalent total dose. The authors postulated that the initial bronchodilation allowed for better penetration and therefore improved efficacy of subsequent doses of medication. This rationale may apply to CN as well. The method of CN may have other theoretical advantages over bolus therapy. The patients are more likely to become acclimatized to CN and therefore would maintain a more constant breathing pattern during nebulization. This would most likely result in a longer inspiratory time with subsequent reduction in inspiratory flow and more peripheral deposition of the inhaled bronchodilator aerosol.
Another potential advantage of С N is that treatment can continue for prolonged periods without relying on the timely arrival of respiratory therapist at appropriate intervals. The need for fewer paramedical personnel may also result in substantial cost savings in busy emergency departments.