BACKGROUND: Recent guidelines for the management of asthma have advocated the use of a pressurized metered-dose inhaler (MDI) and spacer in the delivery of salbutamol. However, there is a dearth of research in children with severe exacerbation. OBJECTIVES: To compare the effectiveness of MDI with spacers versus nebulizers in drug delivery of salbutamol for the management of pediatric severe asthma exacerbations. METHODOLOGY: A systematic search of the Pubmed, Cochrane library, Herdin, WPRIM, ClinicalTrials and reference review databases was conducted for studies containing “severe asthma” using MDI and spacer as an intervention with nebulization as a comparator. RESULTS: Of 220 articles, 4 met the criteria. In the subgroup analysis, children who received salbutamol through MDI showed no significant difference in hospital admission, pulmonary score, heart and respiratory rate, oxygen saturation, and lung function. CONCLUSION: In severe asthma exacerbations, there is evidence to support that MDI compared with nebulizer is statistically equal in terms of hospital admission, pulmonary scores, clinical improvement, and side effects RECOMMENDATIONS Further randomized controlled trials are suggested to explore the intricacies of drug delivery in management of severe asthma. A meta-analysis may be made possible in the future with more evidence.