Practice Guidelines: ACCP and ACAAI Release Guidelines on Inhaled Aerosol Therapy for Patients with Pulmonary Disease - September 1, 2005

September 1, 2005 Table of Contents

Practice Guidelines

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

AMBER HUNTZINGER

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.

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.

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.

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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