Chest
EditorialsAerosol Therapy: Nebulizer vs Metered Dose Inhaler
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Domiciliary nebulized salbutamol solution in severe chronic airway obstruction
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Cited by (28)
Survey of patients' views of domiciliary nebuliser treatment for chronic lung disease
2002, Respiratory MedicineThere is some controversy amongst respiratory physicians over the value of domiciliary nebuliser use for chronic lung conditions. Most recommendations for assessment of suitability for this form of treatment rely upon response to lung function tests and reported improvements in exercise ability. Relatively little emphasis has been placed upon the patient view of this therapy. This survey examined the subjective views of patients receiving domiciliary nebulisers regarding this treatment. A postal questionnaire was sent to 82 patients using home nebuliser treatment provided by the respiratory clinic at Whipps Cross University Hospital, London. It consisted of 29 structured questions covering topics of well-being and symptom control, self-confidence, dependency, time and technical issues, as well as side effects and compliance. Most patients surveyed had chronic obstructive lung disease. For almost all sections of the questionnaire patients reported overwhelmingly that the benefits of using a nebuliser outweighed potential disadvantages. The main perceived advantages were the ability for patients themselves to control symptoms and to be less dependent on General Practitioners, hospitals and carers. Compliance was generally excellent, and the reported side effects were minor and relatively infrequent. The results strongly support the view that nebulisers are helpful in managing chronic lung disease in the community, with benefit to patient well-being and potential health cost savings.
Bronchodilating effect of oxitropium bromide in heart disease patients with exacerbations of COPD: Double-blind, randomized, controlled study
2002, Respiratory MedicineAnti-cholinergic agents are considered the bronchodilator therapy of first-choice in the treatment of patients with stable chronic obstructive pulmonary disease (COPD) associated with heart disease since they may be as effective or more effective than inhaled β2-agonists and, moreover, they do not interact with cardiac β -adrenoceptors. The aim of our study was to evaluate the bronchodilator activity of oxitropium bromide in outpatients suffering from exacerbations of COPD associated with heart diseases (ischaemic heart disease and/or arrhythmias). We recruited 50 consecutive outpatients (33 males and 17 females, mean age 68·6 years, 15 current smokers and 35 ex-smokers). Each patient performed body plethismography in basal condition and 30 min after inhalation of 200 μg metered dose inhaler (MDI) oxitropium bromide administered by a device (Fluspacer®). FEV1, FVC, MMEF25-75, sRaw and tRaw were evaluated. Thirty minutes after 200 μg oxitropium bromide administration, we observed a significant improvement in FEV1 11·6%±1 (mean ±) (P<0·01); FVC, MMEF25-75 sRaw variation was respectively: 9·2%±0·6, 31·4±2·9,−19·9±1·1. Placebo did not significantly change pulmonary function. Our data suggest that oxitropium bromide bronchodilator activity is effective in exacerbations of COPD.
Formoterol Turbuhaler® for as-needed therapy in patients with mild acute exacerbations of COPD
2001, Respiratory MedicineWorsening of underlying bronchospasm may be associated with acute exacerbations of chronic obstructive pulmonary disease (COPD). As airway obstruction becomes more severe, the therapeutic option is to add a short-acting inhaledβ2 -agonist as needed to cause rapid relief of bronchospasm. Unfortunately, however, the most effective dosage may increase above that recommended during acute exacerbations. Formoterol (Oxis®) Turbuhaler®has a rapid onset of action (within minutes) and demonstrates a maintained effect on airway function. In this study, we examined the effects of formoterol used as needed in 20 patients with acute exacerbations of COPD. A dose–response curve to inhaled formoterol (9 μ g per inhalation) or placebo was constructed using three separate inhalations, i.e. a total cumulative dose of 27 μ g. Dose increments were given at 20-min intervals, with measurements being made 15 min after each dose. Formoterol, but not placebo, induced a large and significant (P<0·001) dose-dependent increase in forced expiratory volume in 1 sec (FEV1) [mean differences from baseline = 0·1311 after 9 μ g formoterol (95% Cl: 0·096–0·167)] 0·181 1 after 18μ g formoterol (95% Cl: 0·140–0·222 1) and 0·208 1 after 27 μ g formoterol (95% Cl: 0·153–0·2631). However, 27 μ g formoterol did not induce further benefit [0·0271 (95% Cl: −0·008–0·062 1);P= 0·121] when compared with 18 μ g formoterol. Results of this study suggest the use of higher than customary dose of formoterol for as-needed therapy to provide rapid relief of bronchospasm in patients suffering from acute exacerbations of partially reversible COPD.
Comparative Trial of Continuous Nebulization Versus Metered-Dose Inhaler in the Treatment of Acute Bronchospasm
1995, Annals of Emergency MedicineStudy objective: To compare continuous nebulization with the use of a metered-dose inhaler (MDI) with spacer device for delivery of albuterol in acute bronchospastic episodes in the emergency department. Design: Prospective, randomized, double-blinded, placebo-controlled clinical trial. Setting: Urban ED with a 28,000 annual census. Participants: Patients older than 18 years of age presenting to the ED with an acute bronchospastic episode. Intervention: After conducting evaluation and collecting baseline data, we treated each patient with a continuous-flow nebulizer set to deliver 15 mg/hour of albuterol or a placebo by face mask. Subsequently, each patient received four puffs (albuterol or placebo) from an MDI with a spacer device. The four MDI puffs were followed by 5 minutes on nebulization, and this sequence was continued until predetermined therapeutic end points were reached or side effects developed. The optimal MDI dose was then determined and repeated each hour for the 3-hour time period of the study. Results: Repeated-measures ANOVA testing revealed statistically and clinically significant improvements over time within each treatment group in peak flow (F=3.864, P =.0057), Borg score (F=14.77, P =.0001), pulse (F=9.642, P =.0001), and respiratory rate (F=3.081, P =.0093). However, no significant differences could be detected between treatment groups over time except for systolic blood pressure (F=8.231, P =.0141), and this change was not considered clinically significant. Conclusion: On the basis of the findings of this study, we conclude that continuous nebulization is equally effective as MDI with spacer device for delivery of albuterol to treat acute bronchospastic episodes in the ED. Each method of delivery offers advantages. Each ED should decide which modality to use on the basis of its own resources. [Levitt MA, Gambrioli EF, Fink JB: Comparative trial of continuous nebulization versus metered-dose inhaler in the treatment of acute bronchospasm. Ann Emerg Med September 1995;26:273-277.]
An experimental in vitro model was used to determine the effects of intraluminal catheter diameter and length on the delivered dose and particle-size characteristics of salbutamol (albuterol) aerosol delivered by metered dose inhaler (MDI) (Ventolin, 100 µg per puff). The dose of aerosolized drug that exited a 16-cm-long tracheal tube with an inner diameter (ID) of 6 mm was compared with that from 4 catheters of differing diameters and lengths that were inserted individually into the tracheal tube. The salbutamol MDI canister was actuated ten times into each delivery system, and the effluent aerosol was trapped onto a filter. The filtrate was dissolved in methanol, and the salbutamol concentration was determined using high-performance liquid chromatography. For the 3 22-cm-long catheters, the delivered dose (mean ± SD) of salbutamol per actuation for the 22-standard wire gauge (SWG) catheter was 97.5 ± 3.9 µg, which was similar to that for the 19-SWG catheter (102.3 ± 2.5 µg) but was significantly less than that for the 14-SWG catheter (108.2 ± 4.2 µg) (p<0.05). These delivered doses exceeded those of the 6.0-mm-ID tracheal tube alone (2.33 ± 0.76 µg) and the 13-cm-long 19-SWG catheter (2.17 ± 0.29 µg) (p<0.001). In a second experiment using a cascade impactor, the distribution of aerosol particle diameters that exited the 6-mm-ID tracheal tube was compared with that exiting a 13-cm-long 19-SWG catheter that extended halfway down the tracheal tube and with that exiting a 22-cm-long 19-SWG catheter inserted into the distal end of the 6-mm-ID tracheal tube. The mass median aerodynamic diameter (mean ± SD) of the salbutamol aerosols delivered through both the 6.0-mm-ID tracheal tube (1.1 ± 0.1 pm) and that of the 13-cm-long 19-SWG catheter (1.2 ± 0.2 pm) were significantly less than that delivered through the 22-cm-long 19-SWG catheter (2.0 ± 0.1 pm) (p<0.05). The authors conclude that delivery of respirable aerosol can occur through narrow catheters that function as extended nozzles for MDIs. Optimal dosing will be obtained when the catheter extends the full length of the tracheal tube.
To compare the effectiveness of administration of albuterol by nebulizer or by a metered-dose inhaler having a holding chamber attachment (hereafter “inhaler”) for treatment of acute asthma in an emergency department (ED).
A randomized, double-blind, placebo-controlled intervention study conducted at two sites.
The EDs of a large municipal hospital and a university teaching hospital.
Thirty-five patients 10 to 45 years of age seeking treatment at an ED for acute asthma.
Patients were randomly assigned to receive either albuterol by nebulizer plus placebo by inhaler (n = 20) or albuterol by inhaler plus placebo by nebulizer (n = 15). The dose was repeated every 30 min until the FEV1 was at least 80 percent of predicted, the patient became asymptomatic, or 6 doses had been given.
All references in this article to spirometric measurements of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and peak expiratory flow rate (PEFR) represent percentages of the predicted normal value. No significant (p>0.58) differences occurred in baseline mean FEV1, FVC, or PEFR for the two groups. For both groups, significant improvement occurred in mean FEV1 at 30 min (p<0.02) and at 60 min (p<0.02), and in maximum mean FEV1 (p<0.001). However, no significant (p>0.6) differences occurred between groups in mean FEV1, FVC, or PEFR at 30 and 60 min, or in maximum improvement attained. The sample size was sufficiently large to detect a 12 percent difference in improvement with a power of 90 percent. Thirty-three of 35 patients were treated successfully with the study protocol, became asymptomatic, and were discharged home. One patient from each group required further treatment.
There was no detectable difference in effectiveness of albuterol administered by nebulizer or the inhaler system for treatment of acute asthma. There was no detectable difference in effectiveness of albuterol administered by nebulizer or the inhaler system for the treatment of acute asthma when the dose was titrated to clinical response. When compared with nebulizer, the metered-dose inhaler with holding chamber delivers a full dose of albuterol more quickly and at no higher cost.