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Nebs No More After 24: Improving Use of Appropriate of Respiratory Therapies:
An Educator's Facilitator Guide
Christopher Moriates MD; Theodore Omachi MD MBA; Michelle Mourad MD
Department of Medicine, University of California, San Francisco

Overall Project Goals:
• To decrease unnecessary nebulizer usage for patients • To increase appropriate transitions from nebulizers to MDIs • To improve patient self-administration of MDIs.
Educational Goals:
• To provide information about the evidence, associated costs and resource usage between nebulizers versus metered-dose inhalers (MDIs) in the treatment of hospitalized patients with COPD • To raise awareness about nebulizer overuse at UCSF hospital Suggested Process:
We recommend setting aside 5-20minutes (depending on how much discussion you would
like to have) to engage your teams about the usage of nebulizer therapy in hospitalized
patients. This is meant to foster a discussion on appropriate respiratory therapy ordering
by allowing them to discuss their practices. We have provided a brief summary of related
articles, some data about costs and suggested questions below to help guide the
discussion.

Suggested Questions for Facilitated Discussion:
You can start by leading the team through a discussion of the use of nebulizers. Perhaps
ask your residents/medical students:
• Who gets neb treatments when they come into the hospital? Why do we use
neb treatments over MDI?
Nebs may be helpful in patients that are too altered or in too much distress to coordinate MDI usage. Intubated patients should NOT necessarily be administered nebs because MDIs are more effectively administered directly into the ventilatory circuit. • What benefit do nebs give over MDIs?
Systematic reviews have shown no significant difference between devices in any
efficacy outcome in any patient group for each of the clinical setting investigatFurthermore, studies have specifically shown that bronchodilator delivery by an MDI is
equivalent to wet neb in acute treatment of adults with airflow obstruction. This has even
been studied in patients acutely presenting to the ED: MDIs with spacers performed just
as well as nebs among patients with COPD and asthma in an ED
This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative.

To improve drug delivery, as in the above studies, MDIs are often used with spacers –
Spacers are available for all MDIs here at UCSF. We will also have the option of using a
spacer with facemask to improve seal, if providers or RT deem this to be necessary.
Standard Spacer (aerochamber) Spacer with Face Mask
• How much do nebs cost compared to MDIs?
Neb administration is costly, mostly due to labor costs from the direct involvement of RTs.
In 2012, UCSF spent more than $3.5 Million in direct costs providing neb treatments!
At UCSF we use more nebulizer therapies than other similar hospitals – this is likely just
due to a local culture that has traditionally widely used nebs.
• What are the potential benefits of starting MDIs early during hospitalization?
1. Decreased cost and resource utilization for UCSF Medical Center – and ultimately
for patients / the healthcare system as a whole
2. Opportunity to teach patients how to properly use their MDIs – the RTs are trained to
teach patients and to evaluate their ability to properly use MDIs. They have agreed to do
this for our patients at time of transition from Nebs to MDIs
3. Provide patients with confidence in the inhalers (Have you ever heard a patient say:
"Nebs are the only thing that makes me better because every time I come to the hospital I
get nebs." We can help disavow them of this false belief.)
• Do you think that patients in the hospital know how to properly use their
inhalers?
In one study (Press et al86% of patients misused their inhalers (some patients did
not even take the cap off their inhaler prior to using!), but all of them (100%) were able to
achieve mastery after training!
• What steps will be taken to optimize MDI delivery after a transition from
RTs will help determine whether your patient may safely use an MDI and help teach them. This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative. RTs will be present during the initial MDI administration after a transition from nebs and, if necessary, for all MDI administration during the initial 24 hours after transition. Nurses will then be present during MDI administration to confirm successful delivery. Some patients can be given a facemask to attach to their inhaler to improve usage. RTs will recommend this and provide it for patients if they feel that it is necessary. Patients can get more than 2 puffs of their inhaler at a time. RT can help assess the number of puffs to be administered prior to transition from nebs to MDIs. What specifically can you and your teams do to help?

1. Do not write for nebs or prn nebs for patients being admitted without a
pulmonary primary issue (For instance, a patient being admitted for cellulitis
but has underlying COPD. These patients previously at UCSF may have been
started on nebs at time of admit, but we should just keep them on their
outpatient inhaler regimen!)
2. Transition your COPD/asthma patients from nebs to MDIs as soon as you
feel is safe. We recommend that this be done within 24hours after
hospitalization in the vast majority of patients. "Nebs No More After 24."
When you order MDIs, the RT will help assess whether your patient can use
their MDI appropriately, and can make recommendations regarding dosage and
whether the patient needs a facemask, etc.
a. RT can help determine the appropriate dosage for your particular patient if needed (such as, Albuterol 4puffs Q4hr). b. Remember to transition both Albuterol AND Atrovent/Ipratroprium nebs - you can consider Combivent as an appropriate inhaler. Thank you for being part of this initiative, role modeling the discussions with your teams, and for the care you provide! The UCSF Division of Hospital Medicine High Value Care Committee References Cited, with Abstracts:
1.
Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. Jan 2005;127(1):335-371. Turner MO, Patel A, Ginsburg S, FitzGerald JM. Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Archives of internal medicine. Aug 11-25 1997;157(15):1736-1744. Mandelberg A, Chen E, Noviski N, Priel IE. Nebulized wet aerosol treatment in emergency department--is it essential? Comparison with large spacer device for metered-dose inhaler. Chest. Dec 1997;112(6):1501-1505. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. Journal of general internal medicine. Jun 2011;26(6):635-642. This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative. 1. Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand R, Rau JL, Smaldone GC, Guyatt G.
Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American
College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest.
2005 Jan;127(1):335-71.
BACKGROUND: The proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Evidence-based guidelines for the selection of the appropriate aerosol delivery device in specific clinical settings are needed. AIM: (1) To compare the efficacy and adverse effects of treatment using nebulizers vs pressurized metered-dose inhalers (MDIs) with or without a spacer/holding chamber vs dry powder inhalers (DPIs) as delivery systems for beta-agonists, anticholinergic agents, and corticosteroids for several commonly encountered clinical settings and patient populations, and (2) to provide recommendations to clinicians to aid them in selecting a particular aerosol delivery device for their patients. METHODS: A systematic review of pertinent randomized, controlled clinical trials (RCTs) was undertaken using MEDLINE, EmBase, and the Cochrane Library databases. A broad search strategy was chosen, combining terms related to aerosol devices or drugs with the diseases of interest in various patient groups and clinical settings. Only RCTs in which the same drug was administered with different devices were included. RCTs (394 trials) assessing inhaled corticosteroid, beta2-agonist, and anticholinergic agents delivered by an MDI, an MDI with a spacer/holding chamber, a nebulizer, or a DPI were identified for the years 1982 to 2001. A total of 254 outcomes were tabulated. Of the 131 studies that met the eligibility criteria, only 59 (primarily those that tested beta2-agonists) proved to have useable data. RESULTS: None of the pooled meta analyses showed a significant difference between
devices in any efficacy outcome in any patient group for each of the clinical settings that
was investigated. The adverse effects that were reported were minimal and were related to the
increased drug dose that was delivered. Each of the delivery devices provided similar outcomes in
patients using the correct technique for inhalation.
CONCLUSIONS: Devices used for the delivery of bronchodilators and steroids can be
equally efficacious. When selecting an aerosol delivery device for patients with asthma and
COPD, the following should be considered: device/drug availability; clinical setting; patient age and
the ability to use the selected device correctly; device use with multiple medications; cost and
reimbursement; drug administration time; convenience in both outpatient and inpatient settings;
and physician and patient preference.
This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative. 2. Turner MO, Patel A, Ginsburg S, FitzGerald JM. Bronchodilator delivery in acute airflow
obstruction. A meta-analysis. Arch Intern Med. 1997 Aug 11-25;157(15):1736-44.
OBJECTIVE: To compare the effect of bronchodilator delivery by use of a metered-dose inhaler (MDI) or wet nebulizer on objective measurements of acute airflow obstruction in adult patients. METHODS: Published and unpublished research was identified by MEDLINE searches for articles published from 1966 to 1994, review of scientific citations, review of article bibliographies, communication with experts in the area of asthma therapy and aerosol delivery, primary investigators, and a manufacturer of spacer devices. Eighteen studies were selected from 159 potentially relevant articles by independent review in triplicate. Selection criteria included randomized trials that compared bronchodilator delivery by use of an MDI and wet nebulizer in adults with acute exacerbations of asthma or chronic obstructive pulmonary disease who were treated in an emergency department or a hospital. Data for patient characteristics, study setting, bronchodilator doses, outcomes, and methodological quality were independently extracted. RESULTS: Twelve studies with a total of 507 patients had sufficient data to calculate an effect size (in SD units) for improvement in airflow obstruction after bronchodilator delivery. All but 2 studies used spacer devices with the MDI. The overall treatment effect size was -0.02 (95% confidence interval [CI], -0.20 to 0.16) that favored the MDI, but the magnitude of the effect size was not clinically or statistically significant. No significant effect was observed in the subgroup analyses that compared the diagnosis: asthma, -0.17 (CI, -0.41 to 0.07) compared with chronic obstructive pulmonary disease, 0.23 (CI, -0.35 to 0.81); bronchodilator dose; or methodological quality. The results of a sensitivity analysis that included 5 of 6 excluded studies supported the findings from the primary analysis: 0.05 (CI, -0.11 to 0.20). CONCLUSIONS: Bronchodilator delivery by means of an MDI or wet nebulizer is equivalent
in the acute treatment of adults with airflow obstruction. Spacer devices were used for
bronchodilator delivery with an MDI in most studies and are recommended for the treatment of
acute airflow obstruction. The choice of the delivery method will depend on the need for expedient
treatment, availability of staff, consideration of costs, and findings from studies designed to
evaluate treatment effects from larger than standard doses of bronchodilators delivered by use of
an MDI.
This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative. 3. Mandelberg A, Chen E, Noviski N, Priel IE. Nebulized wet aerosol treatment in emergency
department--is it essential? Comparison with large spacer device for metered-dose
inhaler. Chest. 1997 Dec;112(6):1501-5.
OBJECTIVE: To determine the efficacy of a metered-dose inhaler (MDI) with a large spacer device as compared to nebulized wet aerosols in the treatment of an unselected population with severe airflow limitation. DESIGN: Randomized, double blind, placebo-controlled trial. SETTING: University Hospital Department of Emergency Medicine (DEM). PATIENTS: Fifty patients, referred to the DEM between October 1, 1994 and March 31, 1995 with a severe, acute obstructive pulmonary event. Thirteen patients were diagnosed as having COPD; 37 patients were diagnosed as having asthma. INTERVENTION AND RESULTS: Patients received either placebo MDI through a 750-mL cone- shaped spacer (Glaxo) [2 puffs] and nebulized salbutamol aerosol 0.5 mL in 1.5 mL saline solution (group 1, n=25) or salbutamol MDI and 0.5 mL saline solution in 1.5 mL saline solution administered in the same manner as above (group 2, n=25). The above treatment was repeated three times every 15 min, unless side effects appeared. Upon enrollment into the study, the FEV1 in group 1 was 0.780.7 L (meanSD), 32% of predicted, and in group 2, 0.740.51 L, 29% of predicted (p=0.83). The FEV1 values after the first, second, and third interventions were as follows: in group 1, 1.180.99 L, 1.400.8, and 1.470.79, respectively, and in group 2, 1.170.99 L, 1.461.01, and1.540.79 (p=0.83, 0.36, and 0.48, respectively). We observed no difference in spirometric measurements between the two groups at any time. CONCLUSION: Even in the setting of the unselected group of patient referrals to the DEM
for episodes of severe airflow limitation, the clinical and the objective bronchodilator responses
to the administration of salbutamol are independent of the method of delivery: MDI with a large
spacer vs aerosol nebulization.
This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative. 4. Press VG, Arora VM, Shah LM, Lewis SL, Ivy K, Charbeneau J, Badlani S, Nareckas E, Mazurek A, Krishnan JA. Misuse of respiratory inhalers in hospitalized patients with
asthma or COPD. J Gen Intern Med. 2011 Jun;26(6):635-42.
BACKGROUND: Patients are asked to assume greater responsibility for care, including use of medications, during transitions from hospital to home. Unfortunately, medications dispensed via respiratory inhalers to patients with asthma or chronic obstructive pulmonary disease (COPD) can be difficult to use. OBJECTIVES: To examine rates of inhaler misuse and to determine if patients with asthma or COPD differed in their ability to learn how to use inhalers correctly. DESIGN: A cross-sectional and pre/post intervention study at two urban academic hospitals. PARTICIPANTS: Hospitalized patients with asthma or COPD. INTERVENTION: A subset of participants received instruction about the correct use of respiratory inhalers. MAIN MEASURES: Use of metered dose inhaler (MDI) and Diskus devices was assessed using checklists. Misuse and mastery of each device were defined as <75% and 100% of steps correct, respectively. Insufficient vision was defined as worse than 20/50 in both eyes. Less-than adequate health literacy was defined as a score of <23/36 on The Short Test of Functional Health Literacy in Adults (S-TOFHLA). KEY RESULTS: One-hundred participants were enrolled (COPD n = 40; asthma n = 60). Overall,
misuse was common (86% MDI, 71% Diskus), and rates of inhaler misuse for participants with
COPD versus asthma were similar. Participants with COPD versus asthma were twice as likely to
have insufficient vision (43% vs. 20%, p = 0.02) and three-times as likely to have less-than-
adequate health literacy (61% vs. 19%, p = 0.001). Participants with insufficient vision were more
likely to misuse Diskus devices (95% vs. 61%, p = 0.004). All participants (100%) were able to
achieve mastery for both MDI and Diskus devices.
CONCLUSIONS: Inhaler misuse is common, but correctable in hospitalized patients with
COPD or asthma. Hospitals should implement a program to assess and teach appropriate inhaler
technique that can overcome barriers to patient self-management, including insufficient vision,
during transitions from hospital to home.
This project is supported by the UCSF Center for Healthcare Value - Care Delivery Initiative.

Source: http://healthvalue.ucsf.edu/sites/healthvalue.ucsf.edu/files/wysiwyg/Facilitator%20Guide%20-%20Nebs%20No%20More%20After%2024%20Footer.pdf