This document discusses factors to consider when optimizing aerosol medication delivery for patients. It emphasizes the importance of a holistic assessment that considers whether the medication and device are compatible with the patient's needs, lifestyle, and ability to operate the device correctly. A range of device types are outlined and compared, including nebulizers, metered dose inhalers, dry powder inhalers, and soft mist inhalers. Ongoing education of patients is stressed to ensure best outcomes. References are provided for further guidelines on prescribing respiratory medications.

1. Is the device compatible with the
required medication?
Can the medication be combined or
co-administered with other needed
medications?
Is the medication available in a cheaper
or more convenient format?
Can they operate the device appropriately?
Do they understand when to use the
device/medication?
Can they afford the device?
Does the device fit their lifestyle?
Does the patient have a preference?
Optimizing Aerosol Medication Delivery For Your Patients
Kelly N. Becker-Hess, MSN, FNP-BC
Borgess Medical Center
kellybfnp@gmail.com
Michael W. Hess, RRT
Department of Veterans Affairs
mhessrrt@gmail.com
KNOW YOUR PATIENT KNOW YOUR SITUATION KNOW YOUR MEDICATIONS
Administration of medications via the inhalation route is a critical component of pulmonary disease treatment, yet studies indicate up to 60% of
patients do not use their delivery devices correctly. How can clinicians balance the competing requirements of ease of use, accurate dose delivery,
and cost in order to prescribe the most effective device for their patients? Current evidence suggests the use of holistic assessment considering
many factors, as well as ongoing education, in order to achieve the best outcomes and improve quality of life for these patients.
EDUCATE, EDUCATE, EDUCATE
Will the patient be using the device as an
inpatient or outpatient?
Will the patient have assistance available,
if necessary?
Does the patient require multiple
respiratory medications?
PNEUMATIC NEBULIZER ULTRASONIC NEBULIZER VIBRATING MESH NEBULIZER
METERED DOSE INHALER DRY POWDER INHALER SOFT MIST INHALER
 Can administer multiple medications simultaneously
 Can use mask or mouthpiece for patient ease
 Simple and cheap
 Many driving sources (wall flowmeter, compressor, etc.)
 Breath-assisted versions are gold standard in research
 Variable mass median aerodynamic diameter (MMAD)
affects delivered dose
 Sensitive to/dependent on positioning
 Residual drug volume (varies by manufacturer)
 May not be cleaned appropriately in outpatient setting
 More expensive than basic pneumatic models
 Requires electrical power source
 Possible reliability issues
 Cannot use with suspension-based medications
 Consistent particle size
 Improved respirable dose delivery
 Very low residual drug volume
 No added inspiratory flow for ventilated patients
 Can be battery-powered for portability
 Extremely quiet
 Supreme portability
 Do not require power source or gas drive
 Mature technology with ongoing improvements
 Built-in or add-on dose counters
 Compatible with assistive devices (spacers/holding chambers)
 Inhalation technique is CRITICAL to administration
 Requires significant amount of hand-eye-breath coordination
for effective use
 Risk of patient sensitivity to propellants/other additives
 Supreme Portability
 Does Not Require Power Source or Gas Drive
 Mature Technology With Ongoing Improvements
 Built-in Dose Counter
 More passive inhalation technique
 Requires sufficient inspiratory flow to actuate
 Sensitive to humidity
 Potential for medication spillage
 Patient-loaded models require dexterity/finger strength
 Patient-loaded models also not self-contained (require
separate medication storage)
 Very high initial equipment costs
 Requires electrical power source
 Relatively complex design
 New technology with limited clinician familiarity
 Potential for significant cost savings in inpatient setting
 Uniform aerosol particle size
 Excellent respirable dose delivery
 No added inspiratory flow for ventilated patents
 Extremely quiet
 Supreme portability
 Does not require power source or propellant
 Integral one-way valve prevents contamination
 Built-in dose counter
 Slow-moving, easy-to-inhale aerosol plume
 Complex design
 Limited effectiveness data available
 Requires significant finger strength / dexterity
 Brand new technology, higher cost
 Limited drug selection
Is education and competency assessment
being done at every encounter?
Are there any new barriers to using the
current device (eg. worsening dementia or
arthritis)?
Does the patient need any supplemental
media (eg. brochure, instructional video)?
References:
Lareau S, Hodder R. Teaching inhaler use in chronic obstructive pulmonary disease patients. J American Acad Nurs Practitioners. 2012;24: 113-120
Press V, Arora V, Shah L. Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: A randomized trial. J Gen Intern Med 2012;27(10): 1317-1325
Dolovich M, Hess D, Dhand R. Device selection and outcomes of aerosol therapy: Evidence-based guidelines. Chest. 2005;127(1): 335-371
Geller D. Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler. Resp Care. 2005;(50)10: 1313-1322
Streepy K, Dawson A, Grigonis A. Conversion from metered dose inhalers to a vibrating mesh nebulizer in long term acute care hospitals: Cost effectiveness and respiratory staff perception. Poster presentation, retrieved from http://www.aerogen.com
DISCLOSURES:
The authors of this poster
report no conflicts of
interest for this work
Tashkin D, Klein G, Colman S. Comparing COPD treatment: Nebulizer, metered dose inhaler, and concomitant therapy. Am J Med. 2007;120: 435-441
Arunthari V, Bruinsma R, Lee A. A prospective, comparative trial of standard and breath-actuated nebulizer: Efficiacy, safety, and satisfaction. Resp Care. 2012;57(8): 1242-1247
Dalby R, Eicher J, Zierenberg B. Development of Respimat soft mist inhaler and its clinical utility in respiratory disorders. Medical Devices: Evidence and Research. 2011;4: 145-155
Rau J, Ari A, Restepo R. Performance comparison of nebulizer designs: Constant-output, breath-enhanced, and dosimetric. Resp Care. 2004;49(2): 174-179
Ram F, Carvalho C, White J. Clinical effectiveness of the Respimat inhaler device in managing chronic obstructive pulmonary disease: Evidence when compared with other handheld inhaler devices. Int J of COPD. 2011;6: 129-139

2. Do You Want To Know More?
Guidelines:
 See the entire American College of Chest Physicians/American College of Asthma, Allergy and
Immunology report: “Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines” at
http://www.guideline.gov/content.aspx?id=6382
 Current best-practice guidelines and other reference materials for the treatment of Chronic Obstructive
Pulmonary Disease (COPD), including diagnosis, management and prevention, are available from the
Global Initiative for Chronic Obstructive Lung Diseases (GOLD) at http://www.goldcopd.org
 National Asthma Education and Prevention Program Expert Panel Report 3 on the diagnosis and
management of asthma, including the Stepwise Approach for Managing Asthma, is freely available for
download at http://www.nhlbi.nih.gov/guidelines/asthma/asthmasumm.pdf
 Compare Medicare drug coverage plans, view coverage limitations and plan preferences, including views
customized to the patient’s ZIP code and medication list, at
http://www.medicare.gov/find-a-plan/questions/home.aspx
Educational Materials:
 Instructional videos for various inhaler types, as well as handouts, flyers, and iOS apps are available for
patients and healthcare providers in several languages are at http://www.use-inhalers.com. The site also
features a targeted “Kid’s Section” for young asthma patients.
 Reference guides, testing screeners, and educational videos for COPD patients, caregivers, and healthcare
professionals are available at http://www.copdfoundation.com.
 Materials for creating lung disease-friendly environments, supporting patient advocacy, and improving
disease management, as well as access to patient support groups for asthma, COPD, and other pulmonary
issues from the American Lung Association are at http://www.lung.org/lung-disease.
 Treatment guidelines, current research information, and clinical trial access for cystic fibrosis patients
created by the Cystic Fibrosis Foundation can be found at http://www.cff.org.
PLEASE NOTE: This list is not comprehensive. The authors have no affiliation with any of the organizations listed here. Inclusion
on this list should not be construed as an endorsement of any organization or the materials they provide.
Contact the Authors:
 Kelly N. Becker-Hess, MSN, FNP-BC: kellybfnp@gmail.com
 Michael W. Hess, RRT: mhessrrt@gmail.com
Please feel free to contact us any time with additional questions you may have or to share your experiences
with prescribing aerosol medication using these guidelines!