Summarize any evidence/literature or dose equivalency when converting albuterol nebulization to albuterol MDI.

What is the dosing conversion between albuterol nebulizing solution to MDI?

Comment by InpharmD Researcher

A Cochrane review and other supporting literature reported frequent observations of conversions from albuterol nebulizers to MDI+spacers at ratios of 4:1 (2.5 mg nebulizers compared to 4 puffs of 90 mcg). However, the dose ratio can vary and ranges from 1:4 to 1:6 and even up to 1:12.5 or 1:13 have been observed. The number of puffs needed may also vary based upon clinical response.

Background

A 2013 Cochrane review of studies comparing metered-dose inhalers (MDI) plus spacer versus nebulizers in adult and pediatric patients found overall that nebulizers were administered at 4 times the median dose compared to spacers (Interquartile range (IQR) 1:2 to 1:8). Of the 9 studies that observed salbutamol (Albuterol), the spacer:nebulizer dosage ratio mostly ranged from 1:4 to 1:6 or 4 to 6 puffs of 90 or 100 mcg per 2.5 mg nebulized. One study compared 3 puffs of 90 mcg with 0.15mg/kg nebulizer. Two studies observed higher spacer:nebulizer ratios at 1:12.5 and 1:13. [1]

Other review and protocol development articles have recommended the dose conversion from 2.5 mg nebulizer to 4 puffs based on evidence from asthma and chronic obstructive pulmonary disease (COPD) exacerbations but noted the puffs needed could range from 2 to 10 based on clinical response. [2], [3]

Literature Review

A search of the published medical literature revealed 3 studies investigating the researchable question:

What is the dosing conversion between albuterol nebulizing solution to MDI?

Please see Tables 1-3 for your response.

The conversion to metered-dose inhaler with valved holding chamber to administer inhaled albuterol: a pediatric hospital experience

Design

Comparative study

N= 300

Objective

To convert small-volume nebulizers (SVNs) to metered-dose inhalers with valve holding chambers (MDI-VHCs) for nonintubated pediatric patients receiving intermittent treatments.

Study Groups

SVN group (n=135)

MDI group (n=165)

Methods

The protocol was revised within their computerized physician order entry system to make MDI-VHC the default option for pediatric patients requiring inhaled albuterol bronchodilator. Physicians who still ordered albuterol SVN were encouraged to utilize the MDI-VHC.

Dose conversion used for SVN versus MDI-VHC:

SVN Dose	Equivalent MDI-VHC
2.5 mg	4 puffs
5 mg	8 puffs

Dose conversion was determined based on expert opinion from pulmonologist, respiratory therapist, and pharmacists at the institution.

Duration

January 2004 to May 2006

Outcome Measure

Albuterol administration costs, proportions of patients who received albuterol via SVN and MDI-VHC

Baseline Characteristics

N/A

Results

Table 1. Method of administration for those who received albuterol

Method of administration	Jan-May 2004	Jan- May 2005	Jan-May 2006
MDI (%)	25	63	77
SVN (%)	75	37	23

Table 2. Duration of stay among patients with asthma

	2004	2005	2006
Duration of stay, standard deviation [SD] in days	1.4 ± 0.8	1.4 ± 1.0	1.5 ± 1.0
Count	471	426	315
Minimum stay, days	1	1	1
Maximum stay, days	5	9	8

Adverse Events

Not disclosed

Authors Conclusion

There have been no changes in asthma duration of stay since the implementation of this program. Our albuterol administration costs have also decreased. We acknowledge the multidisciplinary nature of this program and the contributions of the respiratory care, nursing, and medical staffs to its success.

InpharmD Researcher Critique

The study was only observed in pediatric patients and the results may not be applicable for adults with asthma or COPD who may require MDI inhaler. The dose conversion was based upon expert opinion and not substantiated by evidence.

References:

Salyer JW, DiBlasi RM, Crotwell DN, Cowan CA, Carter ER. The conversion to metered-dose inhaler with valved holding chamber to administer inhaled albuterol: a pediatric hospital experience. Respir care. 2008; 53(3): 338-345

Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources

Design

Quality improvement project

N= 575

Objective

To investigate the impact of conversion to metered-dose inhaler (MDI) spacers to administer bronchodilator (BDs) and inhaled corticosteroids (ICSs) to hospitalized children on the utilization of hospital resources

Study Groups

Nebulizers (n=288)

MDI-spacers (n=287)

Methods

Inclusion criteria: Hospitalized children age < 14 years, presence of caregiver, requiring BD and/or ICS.

Exclusion criteria: Uncooperative patient, sick patient requiring shift to intensive care unit, unavailable caregiver.

Data from all hospitalized children receiving BDs and/or ICSs by nebulizer were gathered in the first two weeks. There was a two week washout period for the training of healthcare providers and where operational changes were implemented to enhance the conversion to MDI-spacer. In the last two weeks, data were collected from the children after conversion to MDI-spacer. Preparation time, delivery time, medication name, dosage, mode of delivery, and oxygen flow rate during nebulization therapy were collected at every treatment. For quality assurance measurement, patient/caregiver satisfaction survey was performed. Target was to collect from more than 100 treatment sessions in each part (nebulizer and MDI-spacer) for a at least 200 observational events.

Duration

April to May 2013 (six weeks)

Outcome Measure

Primary: Mean time (in minutes) of medication preparation and delivery

Secondary: Need for respiratory therapy assistance, estimated cost of treatment sessions, and patient/caregiver satisfaction

Baseline Characteristics

Table 1: Patient demographics

	Nebulizer group	MDI-spacer group
Male	170 (59%)	153 (53%)
Female	118 (41%)	134 (47%)
Age (months)
Range	46 - 58	35 - 44
Mean	52	40
Total	288	287

Table 2: MDI equivalent dosage of BDs

Medication	Solution (nebulizer) dosage	MDI equivalent dosage
Albuterol	2.5 mg	3 - 5 puffs*
Albuterol	5.0 mg	5 - 10 puffs*

*The range provided for MDI doses need to be adjusted based on (response: side-effect) assessment.

Results

Table 1: Summary of preparation and delivery times

	Nebulizer group	MDI spacer group	Time difference
Preparation time	2.05 min (95th% CI: 1.45-2.15)	0.3 min (95th% CI: 0.03e0.5)	2 min (p < 0.01)
Delivery time	9.39 min (95th% CI: 9.06e10.12	4.38 min (95th% CI: 4.2e4.56)	5 min (p < 0.01)

Adverse Events

N/A

Authors Conclusion

Conversion to MDI-spacer for the administration of bronchodilators and inhaled corticosteroids led to a reduction in preparation and delivery time. It also enabled early administration by patient/caregiver as well as potential medication cost reduction.

InpharmD Researcher Critique

The conversion used in this study was provided in a range, which does not provide a set standardized conversion protocol. However, it should be considered that the range used is similar to other supporting literature.

References:

Alhaidera SA, Alcherib HA, Al-eidc K. Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources. Int J Pediatr Adolesc Med. 2014;1(1):26-30.

Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber

Design

Quality improvement project

Objective

To discuss the scientific evidence supporting the use of metered-dose inhaler through a valved holding chamber (MDI+VHC) in place of small-volume nebulizer (SVN) to deliver bronchodilators and the steps we took to accomplish such a conversion program at our institution.

Methods

Based on the supporting evidence the institution enacted a pilot program that allowed respiratory therapists in all ICU settings to change the albuterol SVN to MDI+VHC unless patients required continuous nebulization, > 4 doses/hour, or were specifically instructed by physicians to not switch therapy. The dose conversion utilized the most commonly-seen practice based on the author's research.

After the successful pilot over several months, the protocol was then converted to cover all patients on nebulized bronchodilators within the hospital.

Dose conversion from nebulizer to MDI+VHC

Drug	Corresponding dose for MDI+VHC with mouthpiece*	Corresponding dose for MDI+VHC with mask**
Alubterol 2.5 mg	4 puffs	4 puffs
Alubterol 5 mg	8 puffs	8 puffs

* Mouthpiece was allowed for patients who could perform a slow, deep inhalation and hold their breath for 5 to 10 seconds on command

** Masks were for patients < 4 years age who cannot perform slow, deep inhalation or hold breath for 5 to 10 seconds on command.

Duration

Pilot program initiation: November - December 2003.

Outcome Measures

Use of SVN and MDI+VHC

Results

Endpoint

SVN

MDI+VHC

Use at start of conversion

Use 6-months after conversion

Percent change

27,591

19,159

-30%

5,908

9,023

+53%

Adverse Events

N/A

Study Author Conclusions

Delivery of albuterol by MDI+VHC is at least as effective as delivery by SVN and is faster, more convenient, and less expensive. A policy to switch patients from SVN to MDI+VHC for bronchodilator administration at one hospital met with limited success.

InpharmD Researcher Critique

The fluctuations in the puffs needed for patients converted to MDI+VHC was not discussed. This makes it difficult to determine whether patients who were successfully converted had to allow for more or less than the ratio that was recommended.

References:

Hendeles L, Hatoon RC, Coons TJ et al. Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber. Am J Health Syst Pharm. 2005;62(10):1053–1061.