Nebulized Respiratory Medications: Friend or Foe?

Abstract

Older persons with chronic obstructive pulmonary disease (COPD) receive inhaled short-acting and long-acting beta-agonists, anticholinergic agents, and corticosteroids to optimize management of their respiratory condition. According to the most recently published COPD guidelines from Global Initiative for Chronic Obstructive Lung Disease (GOLD), the American College of Physicians (ACCP), and American Thoracic Society/European Respiratory Society, shortacting inhaled beta-agonists are recommended for acute symptom exacerbations, and longacting agents are recommended for maintenance. Table 1 depicts the stepwise approach to managing COPD according to the GOLD guidelines. Short-acting bronchodilators (e.g., albuterol by inhalation) are appropriate for all stages of COPD on an as-needed basis. In patients with moderate or more severe disease, longacting bronchodilators (e.g., long-acting inhaled beta-agonists, long-acting anticholinergic agents or combined anticholinergic/long-acting betaagonist products) are the recommended agents for maintenance in patients with persistent symptoms occurring multiple times weekly (Table 2). 3 Inhaled corticosteroids are a consideration when wheezing is present and when symptoms become severe. Beta-adrenergic agonists, anticholinergic agents, and corticosteroids can be delivered by metered dose inhaler (MDI), dry powder inhaler (DPI), or compressor nebulizer. Drug efficacy is a function of the amount of medication delivered to the airways, which can vary with inhalation technique, device, and drug potency. In older patients, coordination of the handheld inhalers, whether MDI or DPI, can be challenging. It has been reported that approximately 60% of older patients have adequate technique for delivery of medication from MDI, comparable to technique adequacy in younger patients.