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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 deviceAdvantagesDisadvantages
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

Aerosol delivery methodAge of patient
Breath-actuated MDIOlder than five years
Dry powder inhalerFive years or older
MDIOlder than five years
MDI with chamberOlder than four years
MDI with chamber and maskFour years or younger
MDI with endotracheal tubeNeonate
Small-volume nebulizerTwo years or younger


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.


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.


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.

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