Nebulizer use has been linked to worse asthma outcomes, but the precise reason(s) for this relationship is not known. We assessed the frequency of nebulized beta2-agonist use in high-risk inner-city adults with asthma and compared asthma self-management practices according to nebulizer use in this population. This was a cross-sectional study conducted over 6 weeks from July to August 2000. A convenience sample (N=50) was recruited from an inner-city emergency department (ED). Adults (age > or = 18 years) were eligible if they had a physician diagnosis of acute asthma exacerbation. Data regarding asthma symptoms, acute care utilization, use of nebulized beta2-agonist for symptom relief, and indicators of asthma self-management (physician for asthma care, use of controller medications, current cigarette smoking, and substance use) were collected by an interviewer-administered survey. Nebulized beta2-agonist use was reported by 54.0% of patients during the 30 days before their ED visit. Nebulizer users reported more severe asthma symptoms (96.3% vs. 73.9% with moderate or severe persistent asthma, p=0.02) than nonusers. Nebulizer users were more likely to have a physician for asthma care (85.2% vs. 56.5%, p=0.02), have more frequent care from their physicians in the past 12 months (e.g., >3 visits: 59.3% vs. 30.4%, p=0.02), and notify their physician during their asthma exacerbation (39.1% vs. 7.7%, p=0.04). Compared with nonusers, nebulizer users reported better care across other indicators of care, though differences between groups were not significant. After accounting for symptom severity, results were largely unchanged. If these findings are confirmed in other studies with larger numbers of patients, we conclude that the relationship between nebulizer use and higher asthma morbidity largely represents preferential use of nebulizers by patients with more symptomatic disease.