Oral versus inhaled salbutamol for acute paediatric asthma
Date First Published:
August 19, 2011
Last Updated:
October 17, 2011
Report by:
Dr David Herd, Staff Specialist (Mater Children's Emergency Department)
Search checked by:
Emma Grove, Mater Children's Emergency Department
Three-Part Question:
In [children with suspected asthma] does [oral salbutamol] compared to [inhaled salbutamol] provide [any advantages]?
Clinical Scenario:
A one year old girl presents to the Emergency Department with acute wheeze and suspected asthma. Her GP had given her salbutamol syrup which did not appear to help. You use salbutamol via a spacer and want to know if oral bronchodilators are effective at relieving asthma symptoms.
Search Strategy:
PubMed. Similar searches were conducted for: Embase, Google Scholar, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Australian New Zealand Clinical Trials Registry, and ClinicalTrials.gov
Search Details:
[oral OR liquid OR syrup OR elixir] AND [inhaled or aerosol] AND [salbutamol OR albuterol OR ventolin OR terbutaline OR bricanyl OR beta 2 agonist] AND asthma AND [child* OR pediatric OR paediatric] LiIMIT to Humans and Clinical Trial or Randomised Controlled Trial and All Child: 0-18 years
Outcome:
14 papers were identified; six were relevant comparisons of oral and inhaled salbutamol use in the treatment of asthma in children less than 18 years of age.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Efficacy and Side Effects of Salbutamol in Acute Asthma in Children: Comparison of Oral Route and Two Different Nebulizer Systems Scalabrin DMF, Naspitz CK 1993 Brazil | 21 asthmatic children (aged 7-14 years) treated for acute asthma with: oral salbutamol, open continuous nebulisation of salbutamol, or closed-port intermittent nebulisation of salbutamol. | RCT | Mean percent change in FEV1 from baseline values | Closed-port intermittent nebulisation of salbutamol caused a significantly greater increase in FEV1 compared with oral administration of salbutamol (P < 0.05) | Small study population. |
| Mean duration of bronchodilator effect | Closed-port intermittent nebulisation resulted in a statistically longer duration of bronchodilation than oral salbutamol (P < 0.05) | ||||
| Time of peak bronchodilator effect (measured by percentage change in FEV1 from baseline) | 60 minutes for nebulised salbutamol, and 120 minutes for oral salbutamol | ||||
| Salbutamol: tablets, inhalational powder, or nebuliser? Grimwood K, Johnson-Barrett JJ, Taylor B 1981 New Zealand | 17 asthmatic children (aged 4-12 years) treated with: nebulised salbutamol, salbutamol inhalational powder, or oral salbutamol (tablet) | RCT | Percentage improvement in PEFR | Nebulised salbutamol produced a greater percentage improvement in PEFR compared with oral salbutamol (P < 0.05) | Small study population. Salbutamol inhalational powder was delivered without spacers; this would have reduced the efficiency of administration and increased the swallowed fraction of inhaled doses. |
| Comparison of metered dose inhaler and oral administration of albuterol in the outpatient treatment of infants and children Bartfield JM, Boenau IB, Lozon J, Raccio-Robak N 1995 USA | 34 patients with reactive airway disease (aged 4 months to 5 years) treated with oral (syrup) or aerosol salbutamol (with spacer/mask) | RCT | Hyperactivity | Reported for 5 of 11 patients treated with oral salbutamol, and for 1 of 13 patients treated with inhaled salbutamol (P = 0.06) | Small study population. Steroid use not controlled between treatment groups (4/11 patients treated with oral salbutamol were administered steroids; 0/13 patients treated with aerosol salbutamol received steroids, P < 0.01). Complete data was only available for 22 patients (telephone follow-up data was available for 2 patients, no follow-up data was available for 10 patients) |
| Salbutamol in the treatment of asthmatic children Berg IM, Berg T, Ringqvist I 1982 Sweden | 10 asthmatic children (aged 9-15 years) treated with oral salbutamol, aerosol salbutamol, a combination of oral and aerosol salbutamol, or placebo (oral and inhaled) | RCT | Changes in FEV1, FVC and VC | Comparable for inhaled and oral administration | Small study population. Spacers were not used, which would have decreased the efficiency of aerosolised administration and increased the swallowed fraction of inhaled doses. |
| Combination of salbutamol inhalation powder and tablets in asthma Grimwood K, Fergusson DM, Dawson KP 1983 New Zealand | 18 children with severe asthma (aged 5-12 years). Patients were treated with inhaled salbutamol powder, oral salbutamol (tablet), or a combination of oral and inhaled salbutamol | RCT | Peak percentage improvement in PEFR | Reached 30 minutes after administration of inhaled salbutamol and 2 hours after administration of oral salbutamol | Small study population. Spacers were not used, which would have decreased the efficiency of inhaled administration and increased the fraction of inhalation powder swallowed. |
| Tremor | Reported in one patient treated with oral salbutamol | ||||
| Hyperactivity and tachycardia | Reported in one patient treated with oral salbutamol | ||||
| Pulse rate | Significant increase observed in patient treated with oral salbutamol compared with those administered inhaled salbutamol (P < 0.01) | ||||
| Oral and Inhaled Salbutamol in the Prevention of Exercise-Induced Bronchospasm Francis PWJ, Krastins IRB, Levison H 1980 Canada | 16 asthmatic children (aged 7.5-16.9 years) subject to exercise tests. Patients were treated with: oral (tablet) salbutamol, aerosol salbutamol, or placebo (oral or inhaled) | RCT | Peak bronchodilator effect (measured by percent of predicted FEV1 value) | Observed after 40 minutes for inhaled salbutamol and after 120 minutes for oral salbutamol | Small study population. Study conducted in exercise-induced asthma (conclusions cannot inherently be applied to acute or chronic asthma). |
| Tremor | Observed in 10/16 patients administered oral salbutamol, and in 2/9 patients administered salbutamol aerosol |
Author Commentary:
None of the found studies demonstrated benefit. We also searched for Terbutaline studies and none were found. One study was identified of oral and inhaled salbutamol use in the prevention of exercise-induced asthma in children. A review of the pharmacokinetics of salbutamol syrup suggests that oral administration is very unlikely to be effective. (1).
1. Boulton DW, Fawcett JP. Pharmacokinetics and pharmacodynamics of single oral doses of albuterol and its enantiomers in humans. Clin Pharmacol Ther. 1997 Aug.;62(2):138–144.
1. Boulton DW, Fawcett JP. Pharmacokinetics and pharmacodynamics of single oral doses of albuterol and its enantiomers in humans. Clin Pharmacol Ther. 1997 Aug.;62(2):138–144.
Bottom Line:
Oral salbutamol is ineffective in the treatment of paediatric asthma and is associated with an increased incidence of adverse events compared with inhaled formulations. Paediatric masks and spacers can facilitate administration of inhaled salbutamol to all patients; therefore, there is no role for oral salbutamol. Oral salbutamol should be excluded from use in the treatment of childhood asthma.
References:
- Scalabrin DMF, Naspitz CK. Efficacy and Side Effects of Salbutamol in Acute Asthma in Children: Comparison of Oral Route and Two Different Nebulizer Systems
- Grimwood K, Johnson-Barrett JJ, Taylor B. Salbutamol: tablets, inhalational powder, or nebuliser?
- Bartfield JM, Boenau IB, Lozon J, Raccio-Robak N. Comparison of metered dose inhaler and oral administration of albuterol in the outpatient treatment of infants and children
- Berg IM, Berg T, Ringqvist I. Salbutamol in the treatment of asthmatic children
- Grimwood K, Fergusson DM, Dawson KP. Combination of salbutamol inhalation powder and tablets in asthma
- Francis PWJ, Krastins IRB, Levison H. Oral and Inhaled Salbutamol in the Prevention of Exercise-Induced Bronchospasm