Letters To The Editor

In reference to “nebulized bronchodilators instead of metered‐dose inhalers for obstructive pulmonary symptoms”

© 2016 Society of Hospital Medicine

I read with great interest Moriates and Feldman's article advocating inhalers in obstructive disease.[1] Although I agree with the main thoughts of their argument, there are issues for consideration.

Patient education on proper inhaler use is needed, and Press et al.[2] offer hope of improvement. However, as acknowledged by Press et al., with any skill, it is unclear whether mastery is retained long term. Molimard et al.[3] found inhaler misuse occurring in the outpatient setting, suggesting this may be an ongoing problem, or that some patients may be unable to master this complex skill.

Inhaler therapy is recommended due to the benefits mentioned by the authors. However, discharge planning should focus more on appropriate device selection. Mahler et al.[4] identified patients with chronic obstructive pulmonary disease with a suboptimal peak inspiratory flow rate in whom use of an inhaler might be ineffective. A subsequent study in this population demonstrated significant improvements in forced expiratory volume in 1 second, total lung capacity, and inspiratory capacity with nebulizer therapy compared to a dry powder inhaler.[5] Other high‐risk populations may include patients with neuromuscular disease or impaired manual dexterity (eg, Parkinson's, poststroke) inhibiting proper inhaler use.

Therefore, although metered‐dose inhaler therapy is preferred over nebulized therapy, I would caution too sweeping a recommendation missing certain populations with a reason for alternative delivery.

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