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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Metered dose inhalers compared with nebulizers for aerosol bronchodilator delivery in mechanically ventilated adults

Patient or population: mechanically ventilated adults with need for aerosol bronchodilator therapy

Settings: critical care units

Intervention: metered dose inhalers

Comparison: nebulizers

Outcomes

No of Participants
(studies)

Quality of the evidence
(GRADE)

Impact

Reduction in airway resistance

Measured as a reduction in additional effective resistance (ΔRrs) and interrupter resistance (Rint)

Assessed before treatment and 30 minutes after the end of each modality of administration

28
(2 studies)

⊕⊕⊕⊝1
moderate

Both studies achieved a greater decrease in airway resistance using nebulizer

Mortality during critical care unit admission

Measured using mortality rate in intervention and comparison groups

During critical care admission

No studies found

N/A

Duration of mechanical ventilation

Measured as number of days

No studies found

N/A

Adverse changes to haemodynamic observations

Measured as a change in heart rate (beats per minute)

Assessed before treatment and 30 minutes after the end of each modality of administration

28
(2 studies)

⊕⊕⊕⊝2
moderate

Neither mode of delivery altered heart rate

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Downgraded for relatively few patients and events

2Downgraded for some selective outcome reporting in one study

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