Chest
Special ReportDevice Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology
Section snippets
Methodology
We undertook a systematic overview of the pertinent literature. The databases that were searched were MEDLINE, Embase, and the Cochrane Library (Table 3 available on-line only). A broad search strategy was chosen to combine terms relating to aerosol devices or drugs with those relating to the diseases of interest in various patient groups and in a number of clinical settings (Fig 1). Only randomized controlled trials (RCTs) in human subjects published in English were selected. The search
Aerosol Delivery of Short-Acting β2-Agonists in the Hospital ED
Nineteen RCTs that compared aerosol delivery devices in the ED met the criteria for inclusion in the analysis. All used a parallel design and assessed the response to one of three β2-agonist bronchodilators (ie, albuterol, metaproterenol, or terbutaline). No studies were available that compared nebulizers to MDIs alone in patients with acute asthma presenting to the ED. The majority of these studies compared delivery by nebulizer to that by an MDI with a spacer/holding chamber. All were type 1
Short-Acting β2-Agonists for Asthma in the Outpatient Setting
Twenty-eight RCTs compared devices for the delivery of β2-agonists to outpatients. Most trials used a crossover design, and all were of type 2a or 2b. In other words, study outcomes assessed the comparability of the effect in the clinical laboratory setting in patients who had been carefully trained in and screened for proper use of the device. Consequently, they did not directly assess effectiveness as “quick relief” treatment for outpatient asthma symptoms (the primary role that these agents
Discussion
The results of this systematic review of RCTs were essentially the same in each of the clinical settings evaluated above. None of the pooled metaanalyses (Tables 20 and 21, available on-line only) showed a significant difference between devices in any efficacy outcome in any patient group. Thus, the relative effectiveness of delivery methods does not provide a clear basis for selecting one device over another. This does not mean that the device choice for a specific patient does not seem to
Summary of RCT Results
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The delivery of β2-agonists in the ED setting by nebulizers or MDIs with holding chambers (eg, AeroChamber, Volumatic, or InspirEase) is equally effective for improving pulmonary function and reducing symptoms of acute asthma in both adult and pediatric patients (quality of evidence: good).
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The delivery of β2-agonists in the ED setting by DPI (eg, Rotahaler or Turbuhaler) has been inadequately studied, but trials in adults have suggested DPIs may be as effective as nebulizers or MDIs with
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Cited by (0)
Professor Dolovich has served as a speaker for Forest Laboratories, 3M Pharma, and Aventis, and as a consultant for GlaxoSmithKline and Delex Therapeutics, and has received research funding from 3M Pharma, Trudell Medical International, and Altana Pharma. Dr. Ahrens, in the past 12 months, has received research funding from or has had a consulting relationship with the following organizations with a potential financial interest in the subject of the manuscript: AstraZeneca; Aventis; Boehringer Ingelheim; GlaxoSmithKline; Innovata Biomed Limited; Medic-Aid Limited; Monaghan Medical Corporation; and 3M Corporation. Dr. Hess has served as a consultant for Pari and has received research funding from Cardinal Health. Dr. Anderson has participated in clinical trials for GlaxoSmithKline, Boehringer Ingelheim, Astra-Zeneca, and Novartis. Dr. Dhand has served as a speaker for GlaxoSmithKline and Boehringer Ingelheim, has sponsored meetings for GlaxoSmithKline, Boehringer Ingelheim, and Sepracor, and has performed research funded by Sepracor Inc and Omron. Dr. Rau has no financial interest or involvement in any organization with a direct financial interest in the subject of this article, but he has served as a consultant for Respironics, as a speaker for Sepracor Pharmaceutical, and as a consultant and speaker for and performed research funded by Trudell Medical International and Monaghan Medical Corporation. Dr. Smaldone has served as a consultant to several device and pharmaceutical companies that are connected to aerosol therapy, primarily the nebulization of drugs. Those companies with a direct financial interest in nebulization include Monaghan/Trudell Medical International, Aerogen, Pari, and Profile Therapeutics.
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