RESEARCH

A COMPARATIVE STUDY OF TWO NEBULIZERS IN

THE EMERGENCY DEPARTMENT:
BREATH-ACTUATED NEBULIZER AND
HANDHELD NEBULIZER
Authors: Dominic Parone, BSN, RN, CEN, CFRN, Mary Stauss, MSN, RN, APN, CEN,
Carole-Rae Reed, PhD, RN, APN BC, Beth Sherman, BSN, RN, CEN, Linda Smith, RN, Rebecca Johnson, BSN, RN,
CEN, Barry Milcarek, PhD, and Krystal Hunter, MBA, Camden, NJ

Introduction: The breath-actuated nebulizer (BAN) and the patient’s dyspnea or wheezing resolved. IRB approval was
handheld nebulizer (HHN) are 2 nebulizers used in the ED of obtained prior to study commencement.
Cooper University Hospital. The purpose of this study was to
Results: There was no significant difference found between
compare the nebulizers to identify which device resulted in a
the HHN and BAN in respect to number of treatments,
resolution of symptoms with fewer treatments. The primary
respiratory rate, peak flow measurements, and Modified Borg
hypothesis was that adult ED patients with a chief complaint
scores in the 54 subjects. There was a difference of 7 points in
of wheezing and dyspnea who were given nebulized
pulse rate between the pre- and post-second BAN treatment
treatments via the BAN would require less nebulizer
(n = 51, P = 0.01). Subjects in the BAN group who completed all
treatments than those patients given nebulized treatments via
3 treatments (n = 18) had a total treatment time that was on
HHN. In addition, the secondary purposes of the study was to
average of 10 minutes longer than those in the HHN group.
determine if the BAN would have significantly higher peak
expiratory flow measurements, lower Modified Borg Score, Conclusions: This study demonstrated no clinical difference
overall decreased respiratory rate, and lower heart rates between the BAN and HHN in terms of respiratory rate, peak
compared to subjects receiving nebulized treatments via HHN. flow, perception of dyspnea, and number of treatments. It is
possible that the longer treatment times account for the elevated
Methods: A single-site, prospective, randomized, comparative
pulse rate. The data suggests that the higher cost and the
design study was conducted in the ED between March 2010
longer treatment time do not justify the use of the BAN in this
and February 2011. Fifty-four subjects presenting with dyspnea
setting. We recommend that these devices be tested with a
and wheezing and an Emergency Severity Index of 3 or 4 were
larger sample size to further test the differences between
enrolled and randomly assigned to 1 of 2 groups (BAN or HHN).
these 2 devices.
Subjects were administered 1 to 3 nebulizer treatments (#1
ipratropium bromide and albuterol sulfate, #2 ipratropium
bromide and albuterol sulfate, #3 albuterol sulfate), which was Key words: Advanced nursing guidelines; Breath actuated
consistent with the ED Advanced Nursing Guideline for nebulizer; Handheld nebulizer; Emergency department; Emergency
Wheezing. Nebulizer treatments were discontinued if a nursing; Modified Borg Scale; Peak flow

Dominic Parone is Flight Nurse Coordinator, Department of Air Medical Services, Barry Milcarek is Chief Biostatistician, Cooper University Hospital, One Cooper
Cooper University Hospital, One Cooper Plaza, Camden, NJ. Plaza, Camden, NJ.
Mary Stauss is Clinical Educator, Emergency Department & Clinical Decision Krystal Hunter is Biostatistician, Cooper University Hospital, One Cooper Plaza,
Unit, Cooper University Hospital, One Cooper Plaza, Camden, NJ. Camden, NJ.
Carole-Rae Reed is Nursing Research Coordinator, Patient Care Services, For correspondence, write: Dominic Parone, BSN, RN, CEN, CFRN, 2159 Penn-
Cooper University Hospital, One Cooper Plaza, Camden, NJ. brook Ct, Cinnaminson, NJ 08077; E-mail: parone-dominic@cooperhealth.edu.
Beth Sherman is Direct Care Nurse, Emergency Department, Cooper University J Emerg Nurs 2014;40:131-7.
Hospital, One Cooper Plaza, Camden, NJ. Available online 29 January 2013.
Linda Smith is Direct Care Nurse, Emergency Department, Cooper University 0099-1767/$36.00
Hospital, One Cooper Plaza, Camden, NJ. Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc.
Rebecca Johnson is Direct Care Nurse, Emergency Department, Cooper All rights reserved.
University Hospital, One Cooper Plaza, Camden, NJ. http://dx.doi.org/10.1016/j.jen.2012.10.006

March 2014 VOLUME 40 • ISSUE 2 WWW.JENONLINE.ORG 131

RESEARCH/Parone et al
sthma is a frequent presenting complaint in the
A emergency department. Each day, approximately
5000 ED visits, 1000 hospital admissions, and 11
patient deaths related to asthma occur across the United
States. 1 Although a patient with asthma receives individua-
lized treatment depending on the severity of the occurrence,
the initial standard of care for most patients is an inhaled
β2-adrenergic drug delivered via a handheld nebulizer. In
most cases, a respiratory therapist or an emergency nurse
administers the medication. In the emergency department at
our hospital, nurses administer these treatments using either a
breath-actuated nebulizer (BAN) or a handheld nebulizer
(HHN). Both of these devices are used for treating patients
with wheezing and associated dyspnea in our department; it is
not known which device is more effective.
Nebulizer treatments typically are initiated shortly after
triage using our Advanced Nursing Guideline for wheezing,
which allows for up to 3 nebulizer treatments (No. 1,
ipratropium bromide, 0.5 mg, and albuterol sulfate, 3 mg;
No. 2, ipratropium bromide, 0.5 mg, and albuterol sulfate,
3 mg; and No. 3, albuterol sulfate, 2.5 mg) to be
administered before a provider evaluates the patient.
The personal preference of the emergency nurse
determines whether the BAN or HHN device is used. The
practice of selecting which nebulizer to use is completely
nurse driven. The nurses who preferred to use the BAN
believed that patients receive more of the drug because of the
device's on-demand feature. Another group of nurses
preferred the HHN because they saw no difference between
the HHN and BAN. Lastly, some nurses had no preference
and selected either the BAN or the HHN depending on the
availability of the device at the time of the treatment.
Christensen et al 2 compared the BAN and the HHN in
40 adult patients with a history of pulmonary disease (50%
asthma, 10% COPD, and 40% other pulmonary disorders)
in a pulmonary function laboratory. The subjects received
one nebulized treatment from both devices on 2 separate
visits in a 24-hour period. The HHN group received 2.5 mg
of albuterol sulfate (0.5 mL) in 2.5 mL of normal saline
solution for a total volume of 3 mL. The BAN group
received 2.5 mg of albuterol sulfate (0.5 mL) in 0.5 mL of
normal saline solution for a total volume of 1 mL. Both
treatments were run to sputter. Christensen et al. reported
that subjects who received treatments via the BAN had a
significant improvement in their pulmonary function
studies. 2 They also reported a substantially shorter treatment
time with the BAN but failed to correlate the reduced
treatment time to the difference in nebulized volume.
Klopf et al 3 performed a clinical evaluation on the BAN
involving 48 ED patients with acute exacerbation of
asthma. Patients received 1 to 3 nebulized breathing treat-
132 JOURNAL OF EMERGENCY NURSING
ments based on an asthma severity staging. Klopf et al 3
concluded that patients who received nebulizer treatments
through the BAN required fewer treatments and had
decreased length of treatments and minimal adverse effects.
These investigators suggested that because the BAN pro-
duces a high proportion of droplets that are less than 4.8
micrometers in diameter, these droplets can penetrate
deeper into lung tissue and produce more bronchodilation. 3
Two studies involving pediatric patients were reviewed.
Lin et al 4 compared the BAN and a constant flow jet
nebulizer in 72 asthmatic patients ranging in age from 5 to
15 years. A β-adrenergic agonist bronchodilator, terbutaline,
was administered and demonstrated an increase in the
patients’ heart rate and pulse oximetry in the BAN group
compared with a constant flow jet nebulizer. Sabato et al 5
compared 149 ED patients who had asthma, ages 0 months
to 18 years. The patients who received bronchodilator
therapy via the BAN had a significant decrease in hospital
admission rates (P = .03), respiratory rates (P = .002), and
clinical asthma scores (P b .003) compared with the HHN
group and the 1-hour continuous nebulizer group. 5
Wang et al 6 compared the HHN and the BAN in
combined settings of an emergency department and an
allergy clinic. This pilot study involved 40 subjects with a
diagnosis of asthma or other reactive airway disease. A total
of 19 patients were excluded because of incomplete infor-
mation. The difference in peak expiratory flow (PEF) mea-
surements was compared using a total of 47 treatments from
before and after nebulizer therapy. The BAN group (n = 30)
had a 23.3% improvement in their PEF scores, whereas the
HHN group (n = 17) had a 16.7% improvement. It is not
clear if the two groups were equivalent or if the subjects
were randomly assigned. Furthermore, a large portion of
the sample was excluded. 6
In summary, these studies suggest the BAN may lead
to decreased hospital admission rates, shorter treatment
length, decreased respiratory rates, and lower clinical
asthma scores. However, none of the studies found speci-
fically compared the BAN and HHN exclusively in an adult
emergency department.
The primary purpose of this study was to compare the
HHN to the BAN in an adult emergency department to
identify which device resulted in the resolution of
symptoms with fewer treatments. The primary hypothesis
was that adult ED patients with a chief complaint of
wheezing with dyspnea who were given nebulized treat-
ments via the BAN would require fewer nebulizer
treatments than patients given nebulized treatments via
HHN. Additional hypotheses of this study were that adult
ED patients with a chief complaint of wheezing with
dyspnea given nebulized treatments via the BAN would
VOLUME 40 • ISSUE 2 March 2014

have lower Modified Borg Scale (MBS) scores, higher PEF
measurements, decreased respiratory rates, and decreased
heart rates when compared with the HHN.
Methods
STUDY DESIGN
A single-site randomized, comparative study was conducted
to compare the HHN and the BAN.
SAMPLE AND SETTING
The study was conducted in an urban emergency department
of a level I trauma center with 65,000 annual visits. The
inclusion criteria were age 20 years or older with an
Emergency Severity Index 7 (ESI) triage level of 3 or 4 and
a chief complaint of wheezing and dyspnea. Additional
inclusion criteria were hemodynamic stability and the ability
to hold a nebulizer to the mouth and properly perform a
PEF. Patients were excluded if they were unable to speak or
understand English, had recent mouth or facial trauma that
would interfere with making a good lip seal onto the
nebulizer, lung or oral pharyngeal cancer, a tracheotomy, oral
temperature greater than 38.1°C (100.5°F), chemical
exposure, aspiration, anaphylaxis, or vocal cord dysfunction.
The sample size determination of 54 participants
was calculated before beginning the study and was based
on the hypothesis that the BAN group would improve
with fewer treatments than patients who used the HHN,
for example, 1 to 2 treatments compared with a
maximum number of 3 treatments, using an α level of
0.05 for a single degree of freedom Pearson χ 2 test of
proportional differences between groups. A sample size
of 54 with an allocation ratio of 1 provides 80% power on
the test, corresponding to a medium effect size of 0.38.
Based on nurse investigator availability, eligible subjects
were enrolled between the hours of 8 AM and midnight from
March 1, 2010, to February 28, 2011. After written consent
was obtained, a sealed envelope technique was used to
randomly assign subjects to either the BAN or HHN group.
As per the study protocol, if at any time during the
treatment the subject's symptoms worsened, requiring the
nurse to increase the triage level to an ESI level of 2 or 1,
the subject was no longer included in the study.
Prior to data collection, approval for the study was
obtained from the institutional review board. All study
investigators completed the institutional review board
education requirements. The emergency nurse investiga-
tors explained the study to eligible patients and obtained
written consent. In addition, all investigators were for-
mally trained with regard to the MBS, 8 PEF, HHN,
BAN, and the study protocol. Patients participated in the
March 2014 VOLUME 40 • ISSUE 2
Parone et al/RESEARCH
study voluntarily. Confidentiality of all study participants
data was maintained.
NEBULIZERS
AeroEclipse II Breath-Actuated Nebulizer
The AeroEclipse II BAN 9 (Monaghan Medical Corp.,
Plattsburgh, NY) is a single-use nebulizer that the patient
holds to the mouth. The device is then connected to an
oxygen source with a setting of 7 to 8 L per minute. Once
connected, it nebulizes only when the patient inhales. A green
feedback button on top of the BAN gives the patient a visual
indication of when the BAN is nebulizing. During
nebulization, approximately 70% of the particles produced
by the BAN are b 2.5 μm. 10 On expiration, the patient's
exhaled ventilation is released through a vent located on the
nebulizer, which also prevents the inhalation of expired gasses.
AirLife Brand Misty Max 10 Conventional
Handheld Nebulizer
The AirLife Brand Misty Max 10 conventional HHN 11
(CareFusion, Yorba Linda, CA) is a single-use HHN that
the patient holds to the mouth. The device is connected to
oxygen at 5 to 10 L per minute. The device then
continuously nebulizes until the contents are depleted,
regardless of whether the patient is inhaling or exhaling.
During nebulization, approximately 30% of the particles
produced by the HHN are b 2.5 μm. 9
The mechanism of action varies depending on the
nebulizer selected. The HHN continuously nebulizes the
medication regardless of patient's inhalation or exhalation,
which makes it difficult to determine if the patient received
the full dose of the medication. Conversely, the BAN
nebulizes the medication only on demand during inhala-
tion. 8 Although the 2 devices differ in delivery method,
both require the patient to actively inhale to be effective.
MEASURES
Modified Borg Scale Score
The MBS is a validated and reliable tool developed by Dr
Gunner Borg 12 to measure perceived exertion. Kendrick
et al. 8 modified the MBS by adding the word “breathless-
ness” to the numeric scale. They reported a moderate and
significant inverse correlation in 102 ED patients with
bronchospasm (42 with asthma and 60 with chronic
obstructive pulmonary disease) of MBS score and peak flow
before and after treatment, with the MBS score decreasing
as peak flow increased (asthma group, r = − 0.31, P b .05;
chronic obstructive pulmonary disease group, r = − 0.42,
P b .001). Treatments used were either metered dose
inhaler or nebulizer. In our study we used Kendrick's
version. The scale is a 0 to 10 scale, with “0” representing
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RESEARCH/Parone et al
TABLE 1
Study procedure
1. Obtain written informed consent.
2. Select the random assignment (BAN or HHN group)
envelope.
3. The following demographic data are to be collected:
medical record number, age, gender, race, allergies, and
respiratory history, including asthma and COPD.
4. Obtain baseline PEF, lung sounds, blood pressure,
respiratory rate, heart rate, and MBS score.
5. Verbally instruct the subject on the correct way to use
the assigned nebulizer.
6. Administer the appropriate treatment until the
nebulizer sputters, indicating completion.
7. Obtain PEF, lung sounds, blood pressure, respiratory
rate, heart rate, and MBS score.
8. If the subject did not have resolution of wheezing or
dyspnea (MBS score b 1), a second and/or third
treatment are to be given. Repeat steps 5 though 8.
9. Cease data collection once the subject has resolution of
wheezing or dyspnea (MBS score b 1) or the completion
of the third treatment.
Nebulizer treatments were administered according to the
Cooper University Hospital Emergency
Department Advanced Nursing Guidelines. The guideline
consists of a maximum of 3 consecutive nebulizer
treatments:
No. 1: Ipratropium bromide, 0.5 mg, and albuterol
sulfate, 3 mg
No. 2: Ipratropium bromide, 0.5 mg, and albuterol
sulfate, 3 mg
No. 3: Albuterol sulfate, 2.5 mg
If the subject's symptoms worsen at any time during the
treatment, increase the triage level to ESI level 2 or above
and cease data collection.
BAN, Breath-actuated nebulizer; COPD, chronic obstructive pulmonary disease; ESI, Emer-
gency Severity Index; HHN, handheld nebulizer; MBS, Modified Borg Scale; PEF, peak
expiratory flow.
“no breathlessness at all,” “5” representing “severe breath-
lessness,” and “10” representing “maximum breathlessness.”
AsthmaCheck Peak Flow Meter
The AsthmaCheck peak flow meter 13 (CareFusion, Yorba
Linda, CA) is a handheld, single-patient use peak flow meter
device used to measure PEF. This devise meets the National
Asthma Education and Prevention Program recommended
technical guidelines for peak flow meters. The manufacture
reports the following standards: accuracy, ± 10% or 20 L/min,
134 JOURNAL OF EMERGENCY NURSING
and reproducibility, ≤ 5% or 10 L/min, with interdevice
variability of ≤ 10% or 20 L/min. 14
STUDY PROCEDURES
Patients were screened by the triage nurse and then referred to
one of the ED nurse investigators for potential enrollment. If
the patient met eligibility criteria, the patient was enrolled and
the study procedure was followed (Table 1).
DATA ANALYSIS
Descriptive statistics were used to describe groups and
variables and to determine whether data met assumptions
for planned statistical analyses. The primary hypothesis was
tested using an independent t test to compare mean
difference scores of the BAN and HHN groups. Secondary
hypotheses were tested using independent t tests to compare
group means at each measurement point and then using a
two-sided Mann Whitney test to compare the median
difference scores from each measurement time to the next.
Group equivalencies were determined using independent
t tests comparing mean age, mean baseline peak flow,
mean MBS score, mean respiratory rate, and mean heart
rates, and the Pearson χ 2 test was performed to determine
associations of sex and race.
Results
No subjects were withdrawn from the study because of
worsening symptoms. However, during the study period,
one subject declined to consent because of his personal
reservations regarding research. In addition, one subject
who consented was dropped from analysis because a face
mask was used inadvertently with the randomly selected
device. To provide equally sized groups, another subject
was enrolled.
A total of 54 patients were enrolled in the study, with
27 patients in each group. Sample demographic differences
are summarized in Table 2. The groups do not significantly
differ by age, sex, or race.
The primary hypothesis was that adult ED patients
who were given nebulized treatments via the BAN would
require fewer nebulizer treatments compared with the
HHN. Nine (33%) patients in the BAN group did not
require a third treatment compared with 4 (15%) patients
in the HHN group. However, this difference was not
significant (P = .11). A post hoc power calculation for the
Pearson χ 2 test indicated 97% power to detect the ob-
served effect size of 0.53 of the total sample. We also
tested 4 secondary hypotheses, predicting that the BAN
group would have significantly higher PEF measurements, a
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 Parone et al/RESEARCH

TABLE 2
Sample demographics
Overall Breath-actuated nebulizer Handheld nebulizer P value Test used
N Mean (SD) % N Mean (SD) % N Mean (SD) %
Age 54 41.56 (11.35) 27 42.26 (11.4) 27 40.85 (11.48) 0.65 Independent t test
Sex 54 27 27
Male 19 35.2 10 18.5 9 16.7
Female 35 64.8 17 31.5 18 33.3 0.78 Pearson χ 2
Race 54 27 27
Black 31 57.4 16 29.6 15 27.8
White 5 9.3 2 3.7 3 5.6
Hispanic 18 33.3 9 16.7 9 16.7 0.89 Pearson χ 2

lower MBS score, and an overall decreased respiratory rate
and lower heart rates compared with subjects receiving
nebulized treatments via HHN. Using Mann–Whitney and
independent t tests to compare the groups, no significant
differences were found between treatment groups (Table 3).
Discussion
No statistically significant differences were found between
the 2 groups in any of the 5 tested hypotheses. Prior
studies evaluated the BAN and the HHN, but none was
found that compared the HHN and the BAN exclusively
in adult ED patients.
NUMBER OF TREATMENTS
Although no statistically significant differences were found
in the mean number of treatments between the BAN and
HHN groups, some interesting trends were noted. Three
subjects (7%) had resolution of symptoms after the first
treatment (BAN group = 1 [33%]; HHN group = 2 [66%]).
Ten subjects (19%) had resolution of symptoms after second
treatment (BAN group = 7 [70%]; HHN group = 3 [30%]).
Forty-one subjects (76%) required all three treatments
(BAN group = 18 [44%]); HHN group = 23 [56%]).
No significant difference was found between the
proportion of patients in the BAN and HHN groups who
required less than the maximum 3 treatments, although a
P = .11 finding in the expected direction suggests that this
subgroup was perhaps too small to detect a significant result.
This study was designed to provide 80% power to detect a
medium effect size (0.38). A retrospective power calculation
indicated that the observed effect size (based on the total
sample) was actually larger than was assumed in designing
the study (0.52) and that the sample analyzed provided
97% power to detect significance at the level observed.
Random assignment provided adequate statistical control
for demographic differences between treatment groups
relative to baseline differences in MBS scores, peak flow,
and respiratory and heart rate, 4 measures of the clinical
condition of the ED patients studied. Nonetheless, the
difference observed between the treatment groups not
requiring a third treatment (14.8 % HHN and 33.3%
BAN) may be close enough to significance that adjustment
for additional confounders may provide a significant result.
Unfortunately, published literature offers little guidance for
defining such confounders among ED patients.
PEAK EXPIRATORY FLOW
Both BAN and HHN increased pulmonary function to
some degree during the course of treatment, but the HHN
effect was slightly more pronounced. HHN produced an
8% increase in mean PEF (250.93 to 273.81) and increased
both upper and lower 95% bounds by approximately 10%
(to 244.33 and 303.49, respectively). BAN produced only a
2% increase in mean PEF (256.26 to 261.33) with a 5%
increase in the 95% upper bound (to 306.67) but a 2%
decrease in the 95% lower bound (to 215.99).
MODIFIED BORG SCALE SCORE
It was clear that both the BAN and the HHN were effective in
treating subjective dyspnea, as evidenced by reductions in
mean MBS scores in the sample as a whole and in each group
to a level representing slight breathlessness (~2) and by
relative decreases in the 95% confidence limits. The effect of
devices on upper and lower confidence bounds is asymmetric.
The 95% lower bound for patients in the BAN group
decreased by 47% between first and third treatments (2.64 to
1.41), whereas the upper bound decreased by 25% (3.66 to
2.76). The 95% upper bound for patients in the HNN group
decreased 39% between first and third treatments (5.06 to

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RESEARCH/Parone et al

TABLE 3
Comparison of breath-actuated nebulizer and handheld nebulizer groups
Breath-actuated nebulizer Handheld nebulizer P value Test used
N Mean SD N Mean SD
First peak flow 27 256.3 88.9 27 250.9 74.5 0.81 Independent t test
Second peak flow 25 268.4 102.3 26 264.2 76.1 0.87 Independent t test
Third peak flow 18 261.3 91.2 23 273.9 68.4 0.62 Independent t test
First Borg score 27 3.1 1.3 27 4.1 2.4 0.08 Independent t test
Second Borg score 24 2.4 1.7 26 3.3 2.3 0.09 Independent t test
Third Borg score 17 2.2 1.3 23 2.4 1.7 0.74 Independent t test
First respiration 27 20.1 3.1 27 21.6 4.4 0.18 Independent t test
Second respiration 25 20.0 2.8 26 20.1 3.7 0.93 Independent t test
Third respiration 18 18.4 2.6 23 19.0 3.2 0.49 Independent t test
First heart rate 27 89.8 17.2 27 91.6 14.0 0.68 Independent t test
Second heart rate 25 98.6 14.2 26 93.2 13.7 0.17 Independent t test
Third heart rate 18 99.9 16.6 23 96.2 15.9 0.46 Independent t test

Median IQR Median IQR

Difference between first and baseline MBS score 27 − 1.0 ((− 2) - (− 1)) 27 0.0 ((− 2) - 0) 0.10 Mann–Whitney
Difference between second and first MBS score 24 − 1.0 ((− 2) - 0) 26 − 0.5 (− 1.25 - 0) 0.69 Mann–Whitney
Difference between third and second MBS score 18 − 1.0 (− 1.25 - 0) 23 − 1.0 ((− 2) - 0) 0.25 Mann–Whitney
Difference between first and baseline respiration 27 0.0 (0–4) 27 0 (0–2) 0.32 Mann–Whitney
Difference between second and first respiration 25 0.0 ((− 2) - 0) 26 −2 ((− 4) - 0) 0.06 Mann–Whitney
Difference between third and second respiration 18 1.5 ((− 2) - 0) 23 0 ((− 4) - 0) 0.35 Mann–Whitney
Difference between first and baseline heart rate 27 0.0 ((− 7) - 5) 27 − 1.0 ((− 5) - 2) 0.70 Mann–Whitney
Difference between second and first heart rate 25 7.0 (2–12.5) 26 0.5 ((− 4) - 7) 0.01 Mann–Whitney
Difference between third and second heart rate 18 3.5 ((− 2.5) - 6.25) 23 1.0 ((− 3) - 6) 0.90 Mann–Whitney

IQR, Interquartile range; MBS, Modified Borg Scale.

3.09), whereas the lower bound decreased by 18% (3.16 to
1.65). This asymmetry may suggest an advantage to using
HHN in patients with more severe perceived symptoms.
Another finding was the utility of the MBS to assess subjects’
subjective responses to treatment. Both nurses and subjects
found it quick and easy to use and understand.
RESPIRATORY RATE
Effects on respiratory rates (RRs) for both devices were
minimal. Both devices produced a mean decrease of
approximately 1% and decreases in 95% lower and upper
bound of 2% or less. As with the MBS score, the mean RR
showed a steady decline over all measurement points. For
the 41 subjects who completed all 3 treatments, the RR
declined from a baseline of 23.1 to 18.8 breaths per minute
after 3 treatments. The same steady decrease in RR was seen
in both the BAN and HHN groups. No significant differ-
ences were found between groups.
HEART RATE
Overall, no significant differences in heart rate were found
between groups from baseline to after the third treatment.
Both groups produced a mean decrease and decreased 95%
lower and upper bound of less than 1%. The mean baseline
heart rate of the total sample was 92.5 beats per minute
(bpm). Interestingly, this value decreased to a mean of 90.7
bpm after the first treatment but then showed an increase
after the second (95.8 bpm) and third (97.8 bpm) treatments.
A slight increase in posttreatment heart rate was expected
because of the β-adrenergic agonist effects of albuterol sulfate.
The same pattern of an initial slight decline from baseline
after the first treatment and then slight increases in heart rate
after treatments 2 and 3 was seen in both the BAN and HHN
groups. A significant difference in the median heart rate was
found between the first and second treatment (U = 182.5, P b
.01) from the first posttreatment to the second posttreatment
measurement between the BAN and HHN groups. The

136 JOURNAL OF EMERGENCY NURSING VOLUME 40 • ISSUE 2 March 2014


BAN group showed a change in median heart rate of 7 bpm
compared with the HHN group's change of 0.5 bpm. A
significant difference was found at this measurement point
alone when BAN and HHN groups were compared.
Limitations
We attempted to ensure interrater reliability and limit
variations in technique between the emergency nurse
investigators by training all data collectors before study
enrollment. Because none of the investigators were fluent in
any other language, non–English speaking patients were
excluded. ESI level 1 and 2 patients also were excluded from
this study. It is possible that the results of this study might
have been different if we had included this group of
patients. A type II error may exist, in that the study may
have been underpowered to detect group differences.
Implications for Emergency Nurses
Emergency nurses often question the effectiveness of
medical devices, along with their impact on throughput
times and cost. In this study, emergency nurses compared
the use of the BAN and HHN in the emergency
department. The data indicated that neither device was
superior to the other in terms of reducing symptoms of
dyspnea. The HHN is recommended in our emergency
department for use with routine dyspnea and wheezing.
Further studies are needed with larger samples in the ED
setting to determine whether the findings of this study can
be generalized to the larger emergency population.
Additionally, the BAN group had significantly longer
treatment times (46.8 minutes) when compared with the
HHN group (33.7 minutes) after 3 treatments (n = 41,
t(26) = 2.6, P b .02). The financial impact of using the BAN
was significantly higher than using the HHN. During this
study, the cost of the BAN was $4.55 per device compared
with the HHN, which cost $0.46 per device (89.9%
difference). The discontinuation of the BAN in our emer-
gency department generated an average cost savings of
$4400 annually. With the abundance of new medical
devices coming onto the market, emergency nurses should
systematically evaluate the usefulness of these devices to
verify their effectiveness, cost, and impact on throughput.
Conclusions
This randomized controlled study is the first one known
to our research team that compares the BAN and the
March 2014 VOLUME 40 • ISSUE 2
Parone et al/RESEARCH
HHN in the adult ED setting. The data showed that
neither device was superior in improving patient out-
comes. No significant difference was found in total
number of treatments, respiratory rate, heart rate, MBS
score, and PEF when the 2 devices were compared. These
findings, coupled with the higher cost and prolonged
treatment time, do not justify the routine use of the BAN
in our emergency department. Further evaluation and
research is needed to determine the benefits of using the
BAN in the ED setting.
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