The Role of Nebulizers in Airways Disease Management
Abstract
The role of nebulizers in the outpatient management of airways disease remains controversial. Clear and specific guidelines for the use of nebulizers in chronic obstructive pulmonary disease (COPD) in outpatients are lacking, probably because of the dearth of evidence regarding the effectiveness of long-term nebulizer therapy in the domiciliary setting that takes into account perceptions and preferences of patients.
This subject may assume greater importance with the growing availability of newer high-efficiency nebulizers that overcome some (but not all) of the disadvantages of older jet-type and ultrasonic devices. This article reviews the advantages and disadvantages of various aerosol delivery devices, published guidelines regarding the indications for home nebulizer therapy, and the limited evidence that has accumulated thus far concerning the effectiveness of such therapies in the management of COPD.
Conventional nebulizers include jet-type (or pneumatic) and traditional ultrasonic devices.1 The disadvantages of conventional nebulizers are that these devices are bulky and expensive, require alternating current (to operate the compressor for the pneumatic device and activate the piezoelectric crystal for the ultrasonic nebulizer), are not portable, require frequent cleaning, are time-consuming for dispensing medication, and exhibit wide variability in output characteristics (depending on the nebulizer brand, fill-volume, and flow rate of the compressed gas that drives the jet-type nebulizer). Hand-held inhalers—metered-dose inhalers (MDIs) and dry powder inhalers (DPIs)—were developed partly to overcome these disadvantages, MDIs having been introduced about 50 years ago.
Advantages and Disadvantages of Hand-held Inhalers
Hand-held inhalers have a number of advantages: they are simple to use, compact, portable, and rugged, have a multi-dose capacity, offer rapid and convenient dosing, yield aerosol particles that are largely in the respirable range, offer highly reproducible dosing from puff to puff, and are more economical and efficient than traditional nebulizers. On the other hand, they have several disadvantages: MDIs are technique-dependent (requiring proper hand–lung co-ordination), have high-particle velocity, require propellants that are environmentally safe such as hydrofluoroalkane (HFA) (with which not all medications are compatible), and are associated with frequent errors in technique and with non-compliance. While DPIs are breath-activated (thus obviating the need for hand–lung co-ordination) and yield aerosols with zero particle velocity, some delivery systems require a loading procedure for each dose, and faster inspiratory flow rates might be required to de-aggregate the powder.
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