Most doctors and patients misbelieve that a nebulizer is more effective than an inhaler for asthma

University of FloridaJun 2 2005

Battling a child’s asthma attack could be as simple as sliding a plastic tube onto the end of an inhaler, but many health-care providers don’t offer this option to parents, say University of Florida researchers, who are calling for change.

Using a metered-dose albuterol inhaler with a holding chamber attached to it and increasing the number of puffs to treat breathing difficulties works as well as the nebulizer breathing treatment doctors typically prescribe, studies conducted at UF more than 10 years ago show. It also causes fewer side effects in children, studies conducted elsewhere have shown.

Yet doctors and respiratory therapists across the country have been slow to adopt the newer method, even at the hospital where many UF faculty practice, according to a report published this month in the American Journal of Health-System Pharmacy.

A policy implemented last year at Shands at UF medical center, however, increased use of the inhaler and holding chamber method by 53 percent in the intensive care unit and has given researchers hope that more doctors and respiratory therapists will convert to the newer technique.

“Most doctors and patients misbelieve that a nebulizer is more effective than an inhaler,” said Leslie Hendeles, a UF professor of pharmacy and pediatrics and the lead author of the report. “There’s no difference in any outcome measure except in young children.”

Young children, Hendeles said, actually fare better with an inhaler and holding chamber, also called a spacer, than they do with the nebulizer treatment and suffer fewer side effects, such as rapid heartbeat.

Children under 5 who used an inhaler with a spacer were admitted to the hospital less often and made greater improvements than those who used a nebulizer, likely because they receive more medication into their lungs in a shorter amount of time, a study released in the Journal of Pediatrics last year states.

Across the United States, 9 million children under 18 have asthma and 4 million of them had an attack last year, according to the American Academy of Allergy, Asthma and Immunology.

A nebulizer is a machine that reduces liquid albuterol, the medicine commonly used to treat breathing troubles, to a fine mist that patients breathe in through tubes. The treatment typically requires 15 to 20 minutes to administer, compared with one to two minutes with the inhaler and holding chamber method.

An albuterol inhaler contains the same medication at a lower dose, Hendeles said. Typically, using an inhaler is a juggling act for an asthmatic, who must hold the inhaler, squeeze the device to release the medicine and breathe in at the same time. Medication often can be lost this way, Hendeles said. Attaching a spacer makes an inhaler more effective, trapping the medicine while the patient breathes it in.

To make the dosage similar to a nebulizer treatment, patients also inhale more puffs of the inhaler than doctors usually prescribe. The holding chambers also cost less for hospitals and patients – a spacer typically costs $20 whereas a nebulizer can cost $150 to buy – save time, do not require electricity and are more portable, making this method a better choice for most patients, Hendeles added.

Most patients with breathing troubles are typically prescribed an inhaler to use when they leave the hospital anyway, so teaching them how to do it at the hospital actually helps them transition back into normal life, said Timothy Coons, the director of Shands’ cardiopulmonary services department.

“What we want to do is get the patient back to a normal level of daily activity,” Coons said.

UF physicians supported prescribing an inhaler with a holding chamber instead of nebulizer treatment when the research was presented to them, but Hendeles said nebulizer therapy continued to dominate at the hospital.

To encourage a change, UF researchers gained approval to allow respiratory therapists in the surgical intensive care unit to substitute one treatment for the other, depending on a patient’s situation.

At first, therapists had to clear every substitution with a doctor. But eventually, therapists were permitted to automatically switch a nebulizer order for an inhaler and holding chamber.

Nebulizer use in the surgical intensive care unit dropped 30 percent in six months, the report states.

The hospital’s respiratory care department recently expanded the policy to include all therapists, requiring them to take two hours of training and reminding them about the technique each day, said Leah Carlson, the interim clinical coordinator for Shands respiratory care who co-authored the report and wrote the policy.

“We’re starting to see a real change,” she said. “In the end it’s going to be better for patients.”

Dr. Myrna Dolovich, an associate clinical professor of medicine at McMaster University in Ontario, Canada, said some health-care providers have been slow to accept the inhaler and holding chamber method because they worried about increasing the inhaler dosage. But nebulizer doses of albuterol are larger than an inhaler dose, even when the inhaler dose is doubled, she said.

“You put a lot more drug in the nebulizer, (but) it gives you less drug in the lung,” she said. “(Patients) can get a more effective dose from a (metered-dose inhaler) and holding chamber.”