Practice Guidelines

ACCP and ACAAI Release Guidelines on Inhaled Aerosol Therapy for Patients with Pulmonary Disease

Am Fam Physician. 2005 Sep 1;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.

TABLE 1

Advantages and Disadvantages of Various Types of Aerosol Devices for Treatment of Pulmonary Disease

Type of aerosol device Advantages Disadvantages

Dry powder inhaler

Breath actuated

Less patient coordination required

Propellant not required

Small and portable

Short treatment time

Dose counters in most newer designs

Requires moderate to high inspiratory flow

Some units are single dose

Can result in high pharyngeal deposition

Not all medications available

Holding chamber, reverse-flow spacer, or spacer

Reduces need for patient coordination

Reduces pharyngeal deposition

Not all medications available

Many use CFC propellants in United States

Inhalation can be more complex for some patients

Can reduce dose available if not used properly

More expensive than MDI alone

Less portable than MDI alone

Integral actuator devices may alter aerosol properties compared with native actuator

Pressurized MDI

Portable and compact

Treatment time is short

No drug preparation required

No contamination of contents

Dose-dose reproducibility high

Some can be used with breath-actuated mouthpiece

Coordination of breathing and actuation needed

Device actuation required

High pharyngeal deposition

Upper limit to unit dose content

Remaining doses difficult to determine

Potential for abuse

Small-volume jet nebulizer

Patient coordination not required

Effective with tidal breathing

High dose possible

Dose modification possible

No CFC release

Can be used with supplemental oxygen

Can deliver combination therapies if compatible

Not portable

Pressurized gas source required

Lengthy treatment time

Device cleaning required

Contamination possible

Not all medications available in solution form

Does not aerosolize suspensions well

Device preparation required

Performance variability

Expensive when compressor added

Ultrasonic nebulizer

Patient coordination not required

High dose possible

Dose modification possible

No CFC release

Small dead volume

Quiet

Newer designs small and portable

Faster delivery than jet nebulizer

No drug loss during exhalation (breath-actuated devices)

Expensive

Need for electrical power source (wall outlet or batteries)

Contamination possible

Not all medications available in solution form

Device preparation required

Does not nebulize suspensions well

Possible drug degradation

Potential for airway irritation with some drugs


CFC = chlorofluorocarbons; MDI = metered-dose inhaler.

Adapted with permission from Dolovich MA, MacIntyre NR, Andersen PJ, Camargo CA Jr, Chew N, Cole CH, et al. Consensus statement: aerosols and delivery devices; American Association for Respiratory Care [Published correction appears in Respir Care 2000;45:1416]. Respir Care 2000;45:591.

TABLE 1   Advantages and Disadvantages of Various Types of Aerosol Devices for Treatment of Pulmonary Disease

View Table

TABLE 1

Advantages and Disadvantages of Various Types of Aerosol Devices for Treatment of Pulmonary Disease

Type of aerosol device Advantages Disadvantages

Dry powder inhaler

Breath actuated

Less patient coordination required

Propellant not required

Small and portable

Short treatment time

Dose counters in most newer designs

Requires moderate to high inspiratory flow

Some units are single dose

Can result in high pharyngeal deposition

Not all medications available

Holding chamber, reverse-flow spacer, or spacer

Reduces need for patient coordination

Reduces pharyngeal deposition

Not all medications available

Many use CFC propellants in United States

Inhalation can be more complex for some patients

Can reduce dose available if not used properly

More expensive than MDI alone

Less portable than MDI alone

Integral actuator devices may alter aerosol properties compared with native actuator

Pressurized MDI

Portable and compact

Treatment time is short

No drug preparation required

No contamination of contents

Dose-dose reproducibility high

Some can be used with breath-actuated mouthpiece

Coordination of breathing and actuation needed

Device actuation required

High pharyngeal deposition

Upper limit to unit dose content

Remaining doses difficult to determine

Potential for abuse

Small-volume jet nebulizer

Patient coordination not required

Effective with tidal breathing

High dose possible

Dose modification possible

No CFC release

Can be used with supplemental oxygen

Can deliver combination therapies if compatible

Not portable

Pressurized gas source required

Lengthy treatment time

Device cleaning required

Contamination possible

Not all medications available in solution form

Does not aerosolize suspensions well

Device preparation required

Performance variability

Expensive when compressor added

Ultrasonic nebulizer

Patient coordination not required

High dose possible

Dose modification possible

No CFC release

Small dead volume

Quiet

Newer designs small and portable

Faster delivery than jet nebulizer

No drug loss during exhalation (breath-actuated devices)

Expensive

Need for electrical power source (wall outlet or batteries)

Contamination possible

Not all medications available in solution form

Device preparation required

Does not nebulize suspensions well

Possible drug degradation

Potential for airway irritation with some drugs


CFC = chlorofluorocarbons; MDI = metered-dose inhaler.

Adapted with permission from Dolovich MA, MacIntyre NR, Andersen PJ, Camargo CA Jr, Chew N, Cole CH, et al. Consensus statement: aerosols and delivery devices; American Association for Respiratory Care [Published correction appears in Respir Care 2000;45:1416]. Respir Care 2000;45:591.

TABLE 2

General Age Requirements for Correct Use of Various Aerosol Delivery Devices

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


MDI = metered-dose inhaler.

Information from National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute, April 1997; NIH Publication No. 97-4051.

TABLE 2   General Age Requirements for Correct Use of Various Aerosol Delivery Devices

View Table

TABLE 2

General Age Requirements for Correct Use of Various Aerosol Delivery Devices

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


MDI = metered-dose inhaler.

Information from National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute, April 1997; NIH Publication No. 97-4051.

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.


Copyright © 2005 by the American Academy of Family Physicians.
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