New Guidelines Conclude All Aerosol Therapy Devices Equally Effective

For the first time, the American College of Chest Physicians (ACCP) and the American College of Allergy, Asthma, & Immunology (ACAAI) have developed joint evidence-based guidelines for the selection of aerosol delivery devices. Published in the January issue of CHEST, the peer-reviewed journal of the ACCP, the guidelines were developed by an international panel of pulmonary experts and provide recommendations on overall device selection and device selection for several commonly encountered clinical settings.

Based on a systematic review of pertinent randomized, controlled trials (RCT), panel members compared metered-dose inhalers (MDIs) with or without spacers/holding chambers, dry powder inhalers, and nebulizers, delivering both bronchodilators (beta2-agonists) and inhaled corticosteroids in order to determine the best recommendations for device selection. To achieve a fair comparison, RCTs were selected only if the same drug was used in the different delivery systems tested. Due to the limited number of published RCTs of inhaled corticosteroids, the majority of the studies reviewed and selected were RCTs of bronchodilators. Overall, guidelines state that aerosolized medication delivery systems, when used with comparable drug doses, provide equivalent efficacy and, therefore, recommend that health-care providers not base device selection exclusively on device efficacy but rather on several criteria, including device availability; cost; convenience; and the patient's age, competence in using the device, and preference.

"The current practice of device selection for the delivery of aerosolized asthma or COPD medication is largely based on the device's effectiveness in delivering the medication to the patient. Although there are advantages and disadvantages associated with each device and medication, when used properly, all aerosol devices can work equally well and can be interchanged," said guidelines chair Myrna B. Dolovich, P.Eng, Associate Clinical Professor Medicine & Radiology, McMaster University, Hamilton, Ontario, Canada. "Health-care providers should choose a device based on the individual characteristics of each patient. If asthma control is not achieved using one delivery device, it may be beneficial for patients to switch to another device after consulting with his or her provider."

Guidelines also incorporate recommendations for device selection in specific clinical settings, including the emergency department, ICU, and inpatient and outpatient situations. Specific recommendations include:

# Inpatient setting: Nebulizers and MDIs with spacer/holding chambers are appropriate for use in the inpatient setting.

# Emergency department setting: Nebulizers and MDIs with spacer/holding chambers are appropriate for delivery of beta2-agonists in the emergency department.

# Patients supported by mechanical ventilation: Careful attention to details of the technique employed for administering medications 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.

Panel members also strongly recommend that clinicians provide patients with sufficient instruction on the use of their aerosol inhaler in order to maximize asthma control.

"Many health-care providers are confused by the large number of aerosol delivery devices available and have difficulty explaining their correct use to patients," said Professor Dolovich. "Physicians, respiratory therapists, and nurses caring for patients with respiratory diseases should be familiar with issues related to performance and correct use of aerosol delivery devices in order to instruct their patients on proper usage."

"Evidence-based guidelines are based on a comprehensive review of clinical research findings, allowing medical professionals to make the most effective and patient-focused decisions on the diagnosis and treatment of diseases," said Paul A. Kvale, MD, FCCP, President of the American College of Chest Physicians. "The new evidence-based guidelines for aerosol therapy integrate individual clinical expertise with the best available evidence on respiratory medication and delivery devices. Ultimately, by following these evidence-based guidelines, clinicians will have a more current and consistent approach to selecting aerosol therapy for patients."

"Use of inhaled aerosols has revolutionized the care of obstructive respiratory disease by allowing the selective delivery of optimal concentrations of drugs to the airway without creating the undesirable side effects that might result from systemic administration," said Myron J. Zitt, MD, President of the American College of Allergy, Asthma & Immunology. "Nonetheless, the caregiver is in a quandary as to which aerosol delivery system is best for his or her patient. The new evidence-based guidelines provide additional criteria for device selection. Regardless of what delivery system is chosen, patient education is essential to assure optimal outcomes."