Allergology International.

2006;55:167-171

ORIGINAL ARTICLE

Safety and Usefulness of a Novel

eMotion! Electric Mesh Nebulizer in
Children with Asthma
Yoko Saeki Adachi1, Toshiko Itazawa1, Motokazu Nakabayashi1, Tatsuya Fuchizawa1,
Yoshie Okabe1, Yasunori Ito1, Yuichi Adachi1, Gyokei Murakami2 and Toshio Miyawaki1
ABSTRACT
Background: A new electronic mesh nebulizer, eMotion! is known to have higher performance compared to
conventional nebulizers. However, there are some concerns about whether too much delivered dose might
cause side effects with higher frequency.
Methods: To evaluate the safety and usefulness of the nebulizer, we measured changes in heart rates and
lung functions of 73 asthmatic children when they inhaled 1 g!kg of procaterol with eMotion! or a conventional nebulizer, Junior BOY!.
Results: In 34 children with mild asthma exacerbation, physical findings, lung function and transcutaneous
oxygen saturation levels were improved after inhalation using both nebulizers. No adverse effects including significant increase of heart rate were found. Improvements in the rates of the parameters were comparable.
When response to beta2-agonist inhalation was checked in 39 children in stable condition, similar degrees of
improvement in lung function were observed, and heart rates did not change after inhalation with either nebulizers.
Conclusions: Safety and efficacy was comparable between eMotion! and a conventional nebulizer when it
was used to administer beta2-agonists in asthmatic children. However, from the fact that eMotion! needs only
3!4 minutes to inhale 2 mL solution, eMotion! could be more useful for most children who usually do not prefer
longer inhalation time with conventional compressor nebulizers.

KEY WORDS

asthma, beta2-agonist, children, eMotion!, mesh nebulizer

Inhalation therapy is important in the management of

asthma, because it allows aerosol medications to be
delivered directly to the airway while reducing systemic adverse effects . A variety of inhaler devices ,
such as compressor nebulizers, metered-dose inhalers (MDI), and dry powder inhalers (DPI), are available for the management of respiratory diseases including asthma. 1 In asthmatic children, it has been
shown that beta 2-agonists delivered by MDI plus
spacers have similar effects as compared to patients
administered with compressor nebulizers for the
treatment of acute exacerbations, 2 and studies have
shown that even preschool children are able to use

DPI.3 In spite of these facts, nebulizers are still widely

used in the treatment of bronchoconstriction , and
nebulizers are the only way to inhale budesonide suspensions for younger children.
Recently several new types of nebulizers have been
developed on the basis of the technology that uses a
vibrating mesh or plate with multiple apertures to
produce a liquid aerosol . 4 A novel eMotion! electronic mesh nebulizer which is recently available in
Japan is shown to have higher performance compared with conventional compressor nebulizers. The
most notable characteristic is its higher respirable
drug delivery rate, which means that patients could
inhale higher doses of medication during a shorter
period. Although higher performance of nebulizers

1Department of Pediatrics , Faculty of Medicine, University of

Toyama and 2Department of Pediatrics, Toyama Red Cross Hospital, Toyama, Japan.
Correspondence: Yuichi Adachi, M.D., Department of Pediatrics,
Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama

9300194, Japan.
Email: yadachi@med.u!toyama.ac.jp
Received 26 August 2005. Accepted for publication 1 December
2005.
!2006 Japanese Society of Allergology

INTRODUCTION

Allergology International Vol 55, No2, 2006 www.jsaweb.jp!

167

Adachi YS et al.
Tabl
e1 Demogr
aphyofpat
i
entpopul
at
i
on
R
eMot
i
on

Chi
l
dr
enaged
y
6
mi
l
dast
hmaat
t
ack
n
boy/
gi
r
l
Age(
y)
%FEV1.0
%PEFR
SpO2(
%)
HR(
bpm)
st
abl
est
at
e
n
boy/
gi
r
l
Age(
y)
St
ep1/2/3(
JPGL)
%FEV1.0
%PEFR
%V50
HR(
bpm)
Chi
l
dr
enaged
y
5
mi
l
dast
hmaat
t
ack
n
boy/
gi
r
l
Age(
y)
SpO2(
%)
HR(
bpm)

R
J
uni
orBOY

pv
al
ue

8
4/
4
8.
4 /
1.
8[
7 11]
68.
6 / 16.
9
89.
3 / 17.
5
95.
3 / 1.
3
109.
6 / 17.
7

9
5/
4
7.
4 /
1.
1[
6 10]
65.
3 / 8.
9
83.
2 / 24.
8
96.
1 / 1.
8
105.
9 / 19.
1

ns
ns
ns
ns
ns
ns

21
8/
13
8.
6 /
/
1.
7[
612]
8/7/6
94.
3 / 9.
0
120.
6 / 20.
1
71.
9 / 17.
6
89.
6 / 11.
5

18
9/
9
8.
6 /
1.
9[
6 13]
6/3/9
98.
1 / 14.
3
120.
8 / 27.
7
73.
2 / 25.
5
89.
0 / 13.
4

ns
ns
ns
ns
ns
ns
ns

8
6/
2
3.
3 /
1.
8[
0.
55]
96.
6 / 1.
1
128.
0 / 17.
7

9
5/
4
2.
9 / 1.
3[
1 5]
95.
4 / 2.
5
131.
4 / 17.
6

ns
ns
ns
ns

Dat
aar
eex
pr
es
s
edasmean SD[
r
ange]
,ns
;nots
i
gni
f
i
c
ant
J
PGL;J
apanes
epedi
at
r
i
cgui
del
i
nef
ort
het
r
eat
mentandmanagementofas
t
hma
SpO2;t
r
ans
c
ut
aneousox
y
gens
at
ur
at
i
on,HR;hear
tr
at
e

might be desirable in the management of asthma ,

there are some concerns about whether too much delivered dose might cause side effects with higher frequency.
In this study, we evaluated changes in heart rates
and lung function of asthmatic children by beta 2agonist inhalation using two types of nebulizers, and
showed that eMotion! had comparable safety and efficacy with the conventional compressor nebulizer.

METHODS
To compare the usefulness and safety of eMotion!
( PARI , Starnberg , Germany ) with a conventional
nebulizer , Junior BOY! ( PARI ) , changes in lung
functions, transcutaneous oxygen saturation (SpO2)
levels and heart rates of 73 asthmatic children were
measured prior to and 15 minutes after beta2-agonist
inhalation. Children were also asked and examined
for the presence of any adverse symptoms such as
nausea, headaches, palpitations, and tremors. Inhalation of 1 g!
kg of procaterol (Otsuka Pharmaceutical,
Tokyo , Japan ) in 2 ml of disodium cromoglycate

168

(Astellas Pharma, Tokyo, Japan) was performed to

rescue 34 children with mild exacerbation , and to
evaluate the responsiveness to beta 2-agonist in 39
children with stable conditions as one of the routine
clinic procedures . There were no significant differences in the characteristics of the children between
the two nebulizers (Table 1). In all the children, heart
rate and SpO2 level was measured with a Nellcor
Pulse Oxymeter N-550 (Tyco Healthcare, Massachusetts, USA), and changes in lung function were also
measured with an Auto Spiro HS-7S (Minato Medical
Science, Osaka, Japan) in school-aged children. Informed consent was obtained from the patients or
their guardians.
Results were shown as mean +! statistical deviation (SD). Statistical comparison of the mean values
in each group was performed by Wilcoxon signedranks test, and the Mann-Whitneys test was used to
compare the mean values between groups. P values <
0.05 were considered significant.

Allergology International Vol 55, No2, 2006 www.jsaweb.jp!

Safety of eMotion! for Children with Asthma

**

**

RESULTS

120

%FEV1.0 (%)

100
80
60
40
20
0
pre
B

post

pre

160

post
**

140

%PEFR (%)

120
100
80
60
40
20

DISCUSSION

0
pre
C

post

pre

100

post
*

SpO2 (%)

98
96
94
92
90
0

In school-aged children with mild exacerbations, lung

function and oxygen saturation levels were significantly improved with beta 2-agonist inhalation
(Fig. 1). There were no significant differences in improving rates of forced expiratory volume in 1 second
(FEV1.0), peak expiratory flow rates (PEFR) and SpO2
between the two nebulizers. In younger children with
mild exacerbations, physical findings such as wheezing and dyspnea were improved after beta 2-agonist
inhalation without significant changes in SpO2 levels.
In all the children, heart rates were not changed by
beta 2-agonist inhalation with either nebulizers
(Fig. 2). There were no adverse symptoms except for
one 6 year-old boy who experienced tremors after inhalation with Junior BOY!.
In our out-patient clinic, responsiveness to beta2agonist inhalation was checked in school-aged children in stable condition as one of the routine procedures. Lung functions including FEV1.0, PEFR, and
maximum expiratory flow rates at 50% of forced vital
capacity (!50) were significantly improved after beta2agonist inhalation (Table 2). Improving rates of each
parameter were similar in the two nebulizers. Beta2agonist inhalation had no effect on heart rates in stable conditions . No patients complained of any adverse symptoms after beta2-agonist inhalation.

pre

post

eMotion

pre

post

Junior BOY

Fi
g.1 Changesi
nl
ungf
unct
i
onandoxygensat
ur
at
i
onby
bet
a2agoni
sti
nhal
at
i
on i
n school
aged chi
l
dr
en wi
t
h mi
l
d
ast
hmaexacer
bat
i
on.Af
t
erbet
a2agoni
sti
nhal
at
i
onwi
t
ht
wo
di
f
f
er
entnebul
i
zer
s,FEV1.0 (
A)
,PEFR (
B)
,and SpO2 (
C)
wer
esi
gni
f
i
cant
l
yi
mpr
oved.*
;p 0.
05,*
*
;p 0.
01

Allergology International Vol 55, No2, 2006 www.jsaweb.jp!

In this study, we showed that a new electronic mesh

nebulizer , eMotion! had comparable efficacy and
safety with a conventional compressor nebulizer, Junior BOY!. Before initiating this study, eMotion! was
expected to be more efficient because of its higher
nebulizer performance, as Lipworth et al. showed using a similar type nebulizer in severe asthmatic patients.5 Our subjects were in mildly exacerbated or almost stable conditions. In these situations, the conventional nebulizer we used showed sufficient bronchodilator effect . From these results , in order to
judge the superiority of eMotion!, we recommend
that children with severe asthma attacks who do not
respond sufficiently to beta2-agonist inhalation using
a conventional nebulizer should be evaluated further.
Moreover, Junior BOY! itself has already shown better performance compared to the others developed
more than a decade ago. For example, respirable fraction of the particles produced by Junior BOY! is 60%,
which is comparible to eMotion! (the manufacturers
data). For the treatment of asthmatic children with
mild symptoms equivalent to our subjects, the performance of Junior BOY! could be sufficient.
Regarding evaluation of nebulizer performance, inhalation time is one of the important parameters .
There is a substantial difference in the inhalation
time between eMotion! and conventional compressor nebulizers: eMotion! usually takes only 3!4 min-

169

Adachi YS et al.
B

160

160

Heart Rate (bpm)

Heart Rate (bpm)

140
120
100

140
120
100
80

80
0

0
pre

post

eMotion

pre

pre

post

Junior BOY

post

pre

eMotion

post

Junior BOY

Fi
g.2 Changesi
nhear
tr
at
esi
nc
hi
l
dr
enwi
t
hmi
l
das
t
hmaex
ac
er
bat
i
on.Nos
i
gni
f
i
c
ant
changeswer
ef
oundi
nhear
tr
at
esaf
t
erbet
a2agoni
s
ti
nhal
at
i
oni
nei
t
hers
c
hool
agedc
hi
l
dr
en(
A)oryoungerchi
l
dr
en(
B)
.

Tabl
e2 Ef
f
ectofbet
a2agoni
sti
nhal
at
i
onf
orast
hmat
i
cc
hi
l
dr
eni
ns
t
abl
ec
ondi
t
i
on
R
eMot
i
on

pr
e
%FEV1.0
%PEFR
.
%V50
HR(
bpm)

R
J
uni
orBOY

post

pv
al
ue

94.
3 / 9.
0
120.
6 / 20.
1
71.
9 / 17.
6

105.
0 / 10.
9
135.
1 / 21.
2
94.
4 / 17.
0

0.
001
0.
01
0.
001

89.
6 / 11.
5

90.
4 / 11.
8

ns

pr
e

pos
t

98.
1 / 14.
3 106.
3 / 15.
0
120.
8 / 27.
7 129.
6 / 30.
0
73.
2 / 25.
5 92.
5 / 26.
7
89.
0 / 13.
4

91.
7 / 12.
0

pval
ue
0.
001
0.
05
0.
001
ns

HR;hear
tr
at
e,ns
;nots
i
gni
f
i
c
ant

utes to inhale 2 ! 3 mL of solution , whereas Junior

Boy! takes 6!8 minutes. The longer the inhalation
time, the less likely the tendency for children to take
constant deep breaths which allows maximal aerosol
delivery to the lower respiratory tract. Our subjects
had been familiarized to the inhalation procedure ,
and everyone completed inhalation without any problems in this study. However, in a regular clinical setting, it is often observed that a child develops a bad
temper during long inhalation periods. From the fact
that almost no medication is deposited into the airway
of a crying child,6 shorter treatment time could be an
advantage.
Another better performance characteristic of eMotion! is higher delivered dose compared with Junior
Boy! (46.9% vs 24.0%, from the manufacturers data).
There was a concern about whether too much dose
might cause side effects with higher frequency . Inhaled beta2-agonist is known to cause several adverse
effects like nausea, headaches, palpitations, and tremors due to its systemic effect. Chou et al. compared
the effect of the administration of beta2-agonists by
an MDI plus spacer with that of a nebulizer for the
treatment of acute asthma exacerbation in children. 7
Although both devices were similarly effective, fewer
children in the spacer group had episodes of vomiting, and children in the nebulizer group had a greater

170

mean percent increase in heart rate after beta 2agonist inhalation ( 15% vs 5% ) . Kerem et al. also
showed similar results, 8 and the Cochrane systemic
review reported that the MDI plus spacer may have
advantages compared to nebulizers for children with
acute asthma because of the lower heart rate for spacers. 2 In the present study, no adverse effects including significant increases of heart rate were found in
children using both nebulizers. The dose of beta 2agonists used in this study was lower compared to
that used in the emergency setting, where inhalation
of higher doses of beta 2-agonists are usually performed 2 to 3 times in the first one hour. Although no
controlled study has been undertaken to determine
the optimal dose of beta2-agonists for the treatment
of children with acute asthma attacks, at least the present study showed that eMotion! is safe at the ordinary dose of beta2-agonists. However, further studies
will be necessary when eMotion! is used for inhalation of budesonide nebulizing suspensions, because
the adverse effects of inhaled steroid is related to the
accumulating dose.
In conclusion , a new electronic mesh nebulizer ,
eMotion! is clinically safe and effective when it is
used for administration of beta2-agonists to children
with asthma. The shorter inhalation time may be a
contributing factor for the favorable acceptance and

Allergology International Vol 55, No2, 2006 www.jsaweb.jp!

Safety of eMotion! for Children with Asthma

compliance by patients.

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powder inhalers as evaluated by an In-Check Meter. Pediatr. Int. 2006;48:62-65.
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Allergology International Vol 55, No2, 2006 www.jsaweb.jp!

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