Chest
Volume 127, Issue 1, January 2005, Pages 335-371
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Special Report
Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology

https://doi.org/10.1378/chest.127.1.335Get rights and content

Background

The proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Evidence-based guidelines for the selection of the appropriate aerosol delivery device in specific clinical settings are needed.

Aim

(1) To compare the efficacy and adverse effects of treatment using nebulizers vs pressurized metered-dose inhalers (MDIs) with or without a spacer/holding chamber vs dry powder inhalers (DPIs) as delivery systems for β-agonists, anticholinergic agents, and corticosteroids for several commonly encountered clinical settings and patient populations, and (2) to provide recommendations to clinicians to aid them in selecting a particular aerosol delivery device for their patients.

Methods

A systematic review of pertinent randomized, controlled clinical trials (RCTs) was undertaken using MEDLINE, EmBase, and the Cochrane Library databases. A broad search strategy was chosen, combining terms related to aerosol devices or drugs with the diseases of interest in various patient groups and clinical settings. Only RCTs in which the same drug was administered with different devices were included. RCTs (394 trials) assessing inhaled corticosteroid, β2-agonist, and anticholinergic agents delivered by an MDI, an MDI with a spacer/holding chamber, a nebulizer, or a DPI were identified for the years 1982 to 2001. A total of 254 outcomes were tabulated. Of the 131 studies that met the eligibility criteria, only 59 (primarily those that tested β2-agonists) proved to have useable data.

Results

None of the pooled metaanalyses showed a significant difference between devices in any efficacy outcome in any patient group for each of the clinical settings that was investigated. The adverse effects that were reported were minimal and were related to the increased drug dose that was delivered. Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation.

Conclusions

Devices used for the delivery of bronchodilators and steroids can be equally efficacious. When selecting an aerosol delivery device for patients with asthma and COPD, the following should be considered: device/drug availability; clinical setting; patient age and the ability to use the selected device correctly; device use with multiple medications; cost and reimbursement; drug administration time; convenience in both outpatient and inpatient settings; and physician and patient preference.

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

  • 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).

  • 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.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

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