Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Asthma exacerbations commonly require nebulized albuterol in the emergency department (ED). High-efficiency devices (vibrating mesh, breath-enhanced/actuated) may shorten treatment time compared with traditional jet nebulizers. We compared four commonly used nebulizer devices on treatment time and ED outcomes.

Methods: We conducted a prospective observational study of a convenience sample of patients at a high-volume, urban Level I trauma center ED (February 2019–March 2023; paused during COVID-19). Patients ≥ 3 years of age receiving clinician-ordered nebulized albuterol were eligible. Exclusions included patients with a history of chronic obstructive pulmonary disease or congestive heart failure, inability to follow commands or hold the device, and need for positive-pressure ventilation. Respiratory care practitioners used one of four devices already in use in this department: Westmed miniHEART Hi-Flo jet (Mini), Aerogen Ultra (vibrating mesh), Monaghan AeroEclipse II (breath-actuated), or Salter Labs NebuTech (breath-enhanced). The Mini group received a single 15-mg dose; others received 5-mg increments up to 15 mg with reassessment. Our primary outcome measure was the shortest time to complete delivery of the planned albuterol dose to the patient. Secondary outcomes included hospital admission and changes in asthma security scores and peak expiratory flow. We used analysis of variance post-hoc tests and adjusted linear/logistic regression. Both males and females were included; sex-stratified analyses were not prespecified.

Results: We enrolled 296 patients (Mini, n = 90; Aerogen, n = 67; AeroEclipse, n = 65; NebuTech, n = 74), 78 (26.3%) of whom were pediatric patients 3-18 years of age (Mini, n = 22; Aerogen, n = 20; AeroEclipse, n = 14, and NebuTech, n = 22). Time to complete albuterol differed by device, with mean treatment times in minutes (95% CI): Mini, 60.6 [55.9–65.3]; Aerogen, 12.3 [10.9–13.7]; AeroEclipse, 8.7 [7.7–9.7]; and NebuTech, 7.9 [7.0–8.8]. Adjusted models showed 82%, 88%, and 88% relative reductions vs Mini (all P < .01). Admission rates did not differ in total percentage (Mini, 11.1 [10]; Aerogen, 14.9 [10]; AeroEclipse, 16.9 [11]; and NebuTech, 6.8 [5] (all P > .05). Adults had lower odds of admission than pediatrics (odds ratio 0.38; 95% CI, 0.18–0.79; P = .01), with a total of 36 (12.1%) patients requiring admission, two pediatric. Asthma severity and improvements in peak expiratory flow were similar across devices, with mean post-treatment values (asthma severity score and peak expiratory flow): Mini, 5.5 and 301.1; Aerogen, 5.6 and 292.7; AeroEclipse, 5.9 and 248.5; and NebuTech, 5.7 and 301.1 (all P > .01).

Conclusion: In a real-world ED cohort, vibrating-mesh and breath-enhanced/actuated nebulizers delivered albuterol > 80% faster than a traditional jet device, potentially saving at least 45 minutes per treatment per patient, without differences in admission rates or clinical response. Adopting faster devices may improve workflow and throughput without compromising patient outcomes.