Practice Guidelines

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

AMBER HUNTZINGER

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.

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.

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 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:

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.

Practice Guideline Briefs

CARRIE A. MORANTZ

AMBER HUNTZINGER

HIV Prevalence and Testing Trends in Men Who Have Sex with Men

The Centers for Disease Control and Prevention (CDC) has released new data on trends for human immunodeficiency virus (HIV) testing among men who have sex with men. The report, "HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who Have Sex with Men-Five U.S. Cities, June 2004-April 2005," was published in the June 24, 2005, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5424a2.htm.

The CDC analyzed data from five cities participating in the National HIV Behavioral Surveillance system. Of 1,767 men who had one or more male sex partners, 450 (25 percent) tested positive for HIV. Nearly one half of infected men did not know that they were HIV positive. The prevalence of previously undetected infections was highest among nonwhite men younger than 30 years.

Most men with previously undetected infections had been tested before for HIV (84 percent), but fewer than one half had been tested within the previous year (approximately 42 percent). The most common reason given for not being tested was fear of discovering that they were HIV positive. Other reasons included worry that others would find out or that their name would be reported to the government; fear of losing their job, family, or insurance coverage; and fear of needles. Nearly 20 percent of men with previously undetected HIV infections said they had not done anything to put themselves at risk for infection.

The CDC concludes that men who have sex with men should be encouraged to be tested for HIV at least annually, and prevention programs should focus on reaching persons who are unaware of their HIV status, especially in at-risk populations.

CDC Reports on U.S. Heat-Related Mortality

The Centers for Disease Control and Prevention (CDC) has released updated statistics on the rates of hyperthermia and heat-related deaths. The report, "Heat-Related Mortality-Arizona, 1993-2002, and United States, 1979-2002," was published in the July 1, 2005, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a2.htm.

Continued exposure to ambient heat that is close to body temperature contributes to a significant number of deaths from hyperthermia, especially among older adults (i.e., 65 years or older). From 1979 to 2002, a total of 4,780 deaths were attributed to extreme heat in the United States. The incidence of such deaths was three to seven times greater in Arizona than in the United States overall from 1993 to 2002.

Older adults, children, and persons without access to air conditioning are at increased risk for heat-related illness and death. Persons with chronic mental disorders or cardiopulmonary disease, and persons taking medications that affect salt and water balance (e.g., diuretics, anticholinergics, tranquilizers that impair sweating) also are at greater risk.

Heat exhaustion is the most common form of heat-related illness. Signs of heat exhaustion include intense thirst, heavy sweating, weakness, paleness, anxiety, dizziness, fatigue, headache, nausea, and vomiting. Core body temperature may range from below normal to slightly elevated, and skin may be cool and moist. If left untreated, heat exhaustion can progress to heat stroke, a severe illness defined as a core body temperature of at least 40.6°C (105.1°F) accompanied by hot, dry skin and central nervous system abnormalities such as delirium, convulsions, and coma.

The CDC recommends that public health agencies in areas affected by extreme heat identify susceptible populations and risk behaviors, educate populations at risk, and design and implement location-specific heat response plans.

AHA Scientific Statement on Off-Pump vs. On-Pump Coronary Artery Bypass Grafting

The American Heart Association (AHA) has released a scientific statement on the effectiveness of off-pump versus on-pump coronary artery bypass grafting (CABG) for myocardial revascularization. The Council on Cardiovascular Surgery and Anesthesia collaborated with the Interdisciplinary Working Group on Quality of Care and Outcomes Research to review clinical data from retrospective studies, meta-analyses, and randomized trials that compared the two methods. The full report was published in the May 31, 2005, issue of Circulation.

Off-pump CABG does not use cardiopulmonary bypass or cardioplegia, while standard on-pump CABG involves the use of a heart-lung machine and medication to arrest the heart. On-pump CABG has been the gold standard for managing myocardial revascularization; however, it has been unclear whether outcomes with standard CABG are superior to outcomes with off-pump CABG.

Although the AHA report did not determine that one method was superior to the other, it showed trends that were associated consistently with each.

Positive trends associated with off-pump CABG

Positive trends associated with on-pump CABG

The AHA concludes that patients receiving CABG have excellent outcomes regardless of the method. However, outside factors (e.g., surgeon skill, hospital quality, systems approach) are significant in determining the outcome after coronary revascularization. Further large-scale prospective randomized trials are needed to definitively answer whether one method is more effective than the other. In the meantime, the AHA recommends choosing the method with which the surgeon is most comfortable and most skilled.

NCHS Statistics on the Use of Electronic Medical Records

Data from the National Center for Health Statistics (NCHS) on the use of electronic medical records in health care were published in the May 13, 2005, issue of Morbidity and Mortality Weekly Report. The full report is available online at http://www.cdc.gov/nchs/data/ad/ad353.pdf.

According to the NCHS, electronic medical records were used most frequently in the emergency department, followed closely by outpatient departments. Electronic medical records were used less frequently in physician offices. About 73 percent of physicians used the technology for billing patients, 17 percent for maintaining medical records, and 8 percent for ordering prescriptions. The technology was used for automated drug dispensing systems in 40 percent of emergency departments but only in 18 percent of outpatient departments. See the accompanying figure for results by setting.

Answers to This Issue's Clinical Quiz Q1. C Q2. D Q3. A Q4. C Q5. C Q6. D Q7. A, C Q8. A, C Q9. A, C Q10. A, B, C Q11. B, C, D Q12. A, B, D Q13. A, C Q14. A, B, C, D

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