New guidelines make it easier to select aerosol therapy devices

February 2005

NORTHBROOK, Ill. — New asthma guidelines for selecting drug delivery devices conclude that all the systems are equally effective, so pediatricians should use other criteria for selecting a device for patients.

Instead of device efficacy, pediatricians should consider patient-related factors, according to the recommendations, because all aerosolized medication delivery systems are equally effective when used properly. Physicians should consider the patient’s ability to use the device correctly, the patient’s preferences, the availability of the drug and the delivery device, the compatibility between the drug and the device, and the amount of time staff have to teach proper technique.

Collaborative effort

For the first time, the American College of Chest Physicians (ACCP) and the American College of Allergy, Asthma & Immunology (ACAAI) have worked together to develop evidence-based guidelines to help physicians select aerosol delivery devices. Published in a recent 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 as well as device selection for several commonly encountered clinical situations.

Based on a systematic review of randomized, controlled trials, panel members compared metered-dose inhalers (MDIs) with or without spacers or holding chambers, dry powder inhalers and nebulizers, delivering both bronchodilators and inhaled corticosteroids.

To be fair, studies were selected only if the same drug was used in the different delivery systems tested. Due to the limited number of published studies of inhaled corticosteroids, most of the studies reviewed and selected were of bronchodilators.

Overall, the guidelines state that aerosolized medication delivery systems, when used with comparable drug doses, provide equivalent efficacy. Therefore, they 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, according to a press release from the ACCP.

“The current practice of device selection for the delivery of aerosolized asthma or chronic obstructive pulmonary disease 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, PEng, associate clinical professor of medicine and radiology, McMaster University, Hamilton, Ontario. “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.”

Panel members also strongly recommend that clinicians provide patients with sufficient instruction on the use of their aerosol inhaler 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 Dolovich, in the release. “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.”

Patient-focused

Paul A. Kvale, MD, president of the ACCP, said the new guidelines tried to make the decision focused on the needs of the patient. “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,” he said in the release.

“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 ACAAI, in the release. “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.”

In addition, the guidelines say that in an emergency, nebulizers and MDIs with spacers/holding chambers are appropriate for delivering ß2-agonists.

For more information:

• Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines. CHEST. 2005;127:335-371.