This is the current release of the guideline.

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:

1. In what devices is the desired drug available?
2. What device is the patient likely to be able to use properly, given the patient's age and the clinical setting?
3. For which device and drug combination is reimbursement available?
4. Which devices are the least costly?
5. 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.
6. 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?
7. How durable is the device?
8. 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

1. 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.
2. 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.
3. 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

1. 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.
2. 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.
3. 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

1. 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

1. 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.
2. 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

1. 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.
2. 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

1. 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.
2. 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

1. 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.
2. 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

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

None provided

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2005 Jan

American College of Allergy, Asthma and Immunology - Medical Specialty Society
American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

ACCP/ACAAI Evidence-based Guideline Panel on Device Selection and Outcomes of Aerosol Therapy

Primary Authors: Myrna B. Dolovich, PEng, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Richard C. Ahrens, MD, Division of Pediatric Allergy and Pulmonary Diseases, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City IA; Dean R. Hess, PhD, RRT, FCCP, Harvard Medical School, Boston, MA; Paula Anderson, MD, FCCP, Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AK; Rajiv Dhand, MD, FCCP, Division of Pulmonary, Critical Care, and Environmental Medicine, University of Missouri-Columbia, Columbia, MO; Joseph L. Rau, PhD, RRT, Cardiopulmonary Care Sciences, Georgia State University, Atlanta, GA; Gerald C. Smaldone, MD, PhD, FCCP, Department of Medicine, Pulmonary/Critical Care Division, State University of New York at Stony Brook, Stony Brook, NY; and Gordon Guyatt, MD, FCCP, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

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.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on March 11, 2005. The information was verified by the guideline developer on April 4, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.