Choose better device to treat asthma and put on a happy face

Unfortunately (and unintentionally), the method being used in the photo is the least efficient and most expensive way to deliver anti-inflammatory agents or bronchodilators. This photo sends out the wrong message at a time when fiscal constraints on the health care system require that the use of any therapy be evidence-based (if possible), clinically efficient and cost-effective.

There is considerable evidence that small-volume nebulizers, whether they are jet nebulizers (as in the photo) or ultrasonic nebulizers, should be replaced by metered-dose inhalers with valved holding chambers. Randomized controlled trials of treatment of acute asthma have shown that such devices are much more efficient than nebulizers,[1,2] and studies from various centres have estimated that use of these devices results in cost savings of from 25% to 60% for equivalent benefit.[3-6] Furthermore, treatment equivalent to that received in 5 minutes with the use of a metered-dose inhaler would require 10 to 15 minutes with a small-volume nebulizer.

Had he used a metered-dose inhaler with a valved holding chamber to treat his asthma, the young fellow on the front cover would have been able to go out to play with his friends much sooner and would therefore have had a much happier look on his face.

Michael T. Newhouse, MD, MSc,
FRCPC, FACP, FCCP
Clinical professor of medicine
McMaster University
Director
Barnett Medical Aerosol Research
Laboratory
St. Joseph's Hospital
Hamilton, Ont.

References

1. Colacone A, Afilalo M, Wolkove N, Kreisman H. A comparison of Albuterol administered by metered dose inhaler (and holding chamber) or wet nebulizer in acute asthma. Chest 1993; 104: 835-41.
2. Idris AH, McDermott MF, Raucci JC, Morrabel A, McGorray S, Hendeles L. Emergency department treatment of severe asthma. Metered-dose inhaler plus holding chamber is equivalent in effectiveness to nebulizer. Chest 1993; 103: 665-72.
3. Summer W, Elston R, Tharpe L, Nelson S, Haponik EF. Aerosol bronchodilator delivery methods. Relative impact on pulmonary function and cost of respiratory care. Arch Intern Med 1989; 149: 618-23.
4. Bowton DL, Goldsmith WM, Haponik EF. Substitution of metered-dose inhalers for hand-held nebulizers. Success and cost savings in a large acute-care hospital. Chest 1992; 101: 305-8.
5. Jasper AC, Mohsenifar Z, Kahan S, Goldberg HS, Koerner SK. Cost-benefit comparison of aerosol bronchodilator delivery methods in hospitalized patients. Chest 1987; 91: 614-8.
6. Berenberg MJ, Baigelman W, Cupples LA, Pearce L. Comparison of metered-dose inhaler attached to an aerochamber with updraft nebulizer for the administration of metaproterenol in hospitalized patients. J Asthma 1985; 22: 87-92.

[The associate editor-in-chief responds:]

Dr. Newhouse correctly identifies the cover photo of the Mar. 15 issue as a child using an expensive form of asthma therapy. However, this was not unintentional. The purpose of the cover photo is not to tell physicians how to practise, but to identify issues and pique interest. In this case, one of the main findings of Krahn and associates' study was that the cost of drugs was the single largest direct cost of treating asthma, accounting for $124 million a year. Indeed, one of the questions that naturally arises from this finding is Should we review our prescribing practices for asthma? Newhouse provides one useful response to this question.

Patricia Huston, MD, MPH
Associate editor-in-chief