Am Fam Physician. 2005;72(5):945-951
The American College of Chest Physicians (ACCP) and the American College of Asthma, Allergy, and Immunology (ACAAI) have released evidence-based recommendations to guide physicians in choosing aerosol devices and drug formulations for patients with pulmonary disease. Investigators assessed the available scientific evidence addressing the question of whether device selection affects efficacy and the adverse effects of treatment. The report was published in the January 2005 issue of Chest.
The authors conducted a meta-analysis of randomized controlled trials (RCTs) that evaluated patients receiving inhaled corticosteroids, beta2 agonists, or anticholinergics delivered through a metered-dose inhaler (MDI), an MDI with a spacer or holding chamber, a nebulizer, or a dry powder inhaler.
Various options for inhaled aerosol therapy include small-volume jet nebulizers; ultrasonic nebulizers; pressurized MDIs; MDIs with holding chamber, reverse-flow spacer, or spacer; and dry powder inhalers. Each type of aerosol device has its own advantages and disadvantages (Table 1). When choosing which device is best for a patient, physicians should consider the patient’s age (Table 2) and illness, the clinical setting, and the availability of the therapies.
| Type of aerosol device | Advantages | Disadvantages |
|---|---|---|
| Dry powder inhaler |
|
|
| Holding chamber, reverse-flow spacer, or spacer |
|
|
| Pressurized MDI |
|
|
| Small-volume jet nebulizer |
|
|
| Ultrasonic nebulizer |
|
|
| Aerosol delivery method | Age of patient |
|---|---|
| Breath-actuated MDI | Older than five years |
| Dry powder inhaler | Five years or older |
| MDI | Older than five years |
| MDI with chamber | Older than four years |
| MDI with chamber and mask | Four years or younger |
| MDI with endotracheal tube | Neonate |
| Small-volume nebulizer | Two years or younger |
Recommendations
The meta-analysis of RCTs found that nebulizers and dry powder inhalers are no more effective than MDIs or MDIs with spacers in age-appropriate groups. Efficacy is based on the correct use of the chosen device, not the choice of device.
When selecting an aerosol delivery device, physicians should consider the following questions:
In what devices is the desired drug available?
What device is the patient likely to be able to use properly?
Which devices are the least costly?
Are all types of inhaled drugs for asthma or chronic obstructive pulmonary disease (COPD) compatible with the same type of device? (Using the same type of device for all inhaled drugs may facilitate patient instruction and decrease the chance for confusion.)
Which devices are the most convenient for the patient and family (outpatient setting) or medical staff (acute care setting) to use?
How durable is the device?
Does the patient or physician have a specific device preference?
After a device is chosen, the physician should implement proper patient education and follow-up on the patient’s technique.
DEVICE SELECTION IN THE HOSPITAL ACUTE CARE SETTING
Physicians should use continuous or intermittent nebulization or MDIs with spacer or holder to deliver short-acting beta2 agonists (e.g., albuterol [Ventolin], metaproterenol [Alupent], terbutaline [Brethine]) in emergency department or inpatient settings. Patients in the intensive care unit, especially those receiving mechanical vitalization, also should receive beta2 agonists through nebulizers or MDIs.
DEVICE SELECTION IN THE OUTPATIENT SETTING
Physicians should use MDIs with or without a spacer or holder or a dry powder inhaler to deliver short-acting beta2 agonists to outpatients with asthma. Inhaled corticosteroids should be dispensed to patients with asthma through an MDI with a spacer or holder or through a dry powder inhaler.
Physicians should use MDIs with or without spacers or holders, nebulizers, or dry powder inhalers to dispense beta2 agonists and anticholinergic agents to patients with COPD.