Note from the National Guideline Clearinghouse™ (NGC): The following recommendations summarize the content of the guideline. Please refer to the original guideline document for more information. The quality of the evidence (good, fair, low, expert opinion), the net benefit (substantial, intermediate, small/weak, none, conflicting, negative), and the strength of recommendations (A-D, I, E/A, E/B, E/C, E/D) are listed at the end of the "Major Recommendations" field.
When selecting an aerosol delivery device, the following questions should be considered:
- In what devices is the desired drug available?
- What device is the patient likely to be able to use properly, given the patient's age and the clinical setting?
- For which device and drug combination is reimbursement available?
- Which devices are the least costly?
- Can all types of inhaled asthma/chronic obstructive pulmonary disease (COPD) drugs that are prescribed for the patient (e.g., short-acting beta-agonist, corticosteroid, anticholinergic, and long-acting beta-agonist) be delivered with the same type of device (e.g., nebulizer, manually actuated metered dose inhaler [MDI], MDI with spacer/holding chamber, or breath-actuated device [i.e., automatically activated MDI or dry powder inhaler (DPI)])? Using the same type of device for all inhaled drugs may facilitate patient teaching and decrease the chance for confusion among devices that require different inhalation techniques.
- Which devices are the most convenient for the patient, family (outpatient use), or medical staff (acute care setting) to use, given the time required for drug administration and device cleaning, and the portability of the device?
- How durable is the device?
- Does the patient or clinician have any specific device preferences?
Whichever device is chosen, it is clear that proper patient education on its use is critical and that the assessment of inhalation technique should be part of subsequent visits to the physician.
Aerosol Delivery of Short-Acting Beta2-Agonists in the Hospital Emergency Department
- Both the nebulizer and MDI with spacer/holding chamber are appropriate for the delivery of short-acting beta2-agonists in the emergency department (ED). Quality of evidence: good; net benefit: substantial; strength of recommendation: A.
- Because data for DPIs are limited, and high quality data for standard MDIs (without spacer/holding chamber) and breath-actuated MDIs are unavailable, the guideline developers are unable to recommend the use of these devices in the ED until more information is available. Quality of evidence: low; net benefit: none; strength of recommendation: I.
- Many factors would lead the clinician to appropriately select a particular type of aerosol delivery device in this setting. These factors include the patient's ability to use the device correctly, the preferences of the patient for the device, the unavailability of an appropriate drug/device combination, the compatibility between the drug and delivery device, the lack of time or skills to properly instruct the patient in the use of the device or to monitor the appropriate use, and the cost of therapy. Quality of evidence: low; net benefit: substantial; strength of recommendation: B.
Aerosol Delivery of Short-Acting Beta2-Agonists in the Inpatient Hospital Setting
- Both nebulizers and MDIs with spacer/holding chambers are appropriate for use in the inpatient setting. Quality of evidence: good; net benefit: substantial; strength of recommendation: A.
- Because the data for DPIs, standard MDIs without spacer/holding chambers, and breath-actuated MDIs have been inadequately studied in this setting, the guideline developers are unable to recommend the use of these devices in patients requiring hospitalization for asthma or COPD until more information is available. Quality of evidence: low; net benefit: none; strength of recommendation: I.
- Many factors would lead the clinician to appropriately select a particular type of aerosol delivery device in this setting. These include the patient's inability to use the device correctly, the preferences of the patient for the device, the unavailability of the drug/device combination, the compatibility between the drug and the delivery device, the lack of time or skills to properly instruct the patient in the use of the device or in monitoring the appropriate use, and the cost of therapy. Quality of evidence: low; net benefit: substantial; strength of recommendation: B.
Intermittent Versus Continuous Nebulizer Delivery of Beta2-Agonists
- Frequent intermittent nebulization and continuous nebulization are both appropriate alternatives in severely dyspneic patients in the ED or intensive care unit (ICU). Quality of evidence: good; net benefit: substantial; strength of recommendation: A.
Aerosolized Beta2-Agonists in Patients Receiving Mechanical Ventilation
- Both nebulizers and MDIs can be used to deliver beta-agonists to mechanically ventilated patients. Quality of evidence: fair; net benefit: substantial; strength of recommendation: A.
- Careful attention to details of the technique employed for administering drugs by MDI or nebulizer to mechanically ventilated patients is critical, since multiple technical factors may have clinically important effects on the efficiency of aerosol delivery. Quality of evidence: low; net benefit: substantial; strength of recommendation: B.
Short-Acting Beta2-Agonists for Asthma in the Outpatient Setting
- For treatment of asthma in the outpatient setting, both the MDI, used with or without spacer/holding chamber, and the DPI are appropriate for the delivery of short-acting beta2-agonists. Quality of evidence: good; net benefit: substantial; strength of recommendation: A.
- The appropriate selection of a particular type of aerosol delivery device in this setting includes the patient's ability to use the device correctly, the preferences of the patient for the device, the availability of the drug/device combination, the compatibility between the drug and delivery device, the lack of time or skills to properly instruct the patient in the use of the device or to monitor the appropriate use, the cost of the therapy, and the potential for reimbursement. Quality of evidence: low; net benefit: substantial; strength of recommendation: B.
Inhaled Corticosteroids for Asthma
- For the treatment of asthma in the outpatient setting, both the MDI with a spacer/holding chamber and the DPI are appropriate devices for the delivery of inhaled corticosteroids. Quality of evidence: good; net benefit: substantial; strength of recommendation: A.
- For outpatient asthma therapy, the selection of an appropriate aerosol delivery device for inhaled corticosteroids includes the patient's ability to use the device correctly, the preferences of the patient for the device, the availability of the drug/device combination, the compatibility between the drug and delivery device, the lack of time or skills to properly instruct the patient in the use of the device or monitor the appropriate use, the cost of therapy, and the potential for reimbursement. Quality of evidence: low; net benefit: substantial; strength of recommendation: B.
Beta2-Agonists and Anticholinergic Agents for COPD
- For the treatment of COPD in the outpatient setting, the MDI, with or without spacer/holding chamber, the nebulizer, and the DPI are all appropriate for the delivery of inhaled beta2-agonist and anticholinergic agents. Quality of evidence: good; net benefit: substantial; strength of recommendation: A.
- For outpatient COPD therapy, the selection of an appropriate aerosol delivery device for inhaled beta2-agonist and anticholinergic agents includes the patient's ability to use the device correctly, the preferences of the patient for the device, the availability of the drug/device combination, the compatibility between the drug and the delivery device, the lack of time or skills to properly instruct the patient in the use of the device or monitor its appropriate use, the cost of therapy, and the potential for reimbursement. Quality of evidence: low; net benefit: substantial; strength of recommendation: B.
Definitions:
Quality of the Evidence
Good = Evidence is based on good randomized controlled trials or meta-analyses.
Fair = Evidence is based on other controlled trials or randomized controlled trials with minor flaws.
Low = Evidence is based on nonrandomized, case-control, or other observational studies.
Expert Opinion = Evidence is based on the consensus of the carefully selected panel of experts in the topic field. There are no studies that meet the criteria for inclusion in the literature review.
Net Benefit
Substantial
Intermediate
Small/weak
None
Conflicting
Negative
Quality of Evidence |
Net Benefit |
Substantial |
Intermediate |
Small/Weak |
None |
Conflicting |
Negative |
Good |
A |
A |
B |
D |
I |
D |
Fair |
A |
B |
C |
D |
I |
D |
Low |
B |
C |
C |
I |
I |
D |
Expert opinion |
E/A |
E/B |
E/C |
I |
I |
E/D |
Strength of Recommendations
A = Strong recommendation
B = Moderate recommendation
C = Weak recommendation
D = Negative recommendation
I = No recommendation possible (inconclusive)
E/A = Strong recommendation based on expert opinion only
E/B = Moderate recommendation based on expert opinion only
E/C = Weak recommendation based on expert opinion only
E/D = Negative recommendation based on expert opinion only