The authors reply “nebulized bronchodilators instead of metered‐dose inhalers for obstructive pulmonary symptoms”

We certainly agree with Dr. LaBrin that there are a minority of inpatients and outpatients who might benefit from nebulizer therapy. In our review article,[1] we attempted not to make a sweeping generalization, even if we did not explicitly mention some chronic obstructive pulmonary disease patients with suboptimal peak inspiratory flow rate (PIFR) or those with neuromuscular disease as populations where nebulizer therapy may be preferred. Our recommendation included this statement: Inpatient use of nebulizers may be more appropriate than metered‐dose inhalers (MDIs) for patients with dementia or altered mental status, as well as those in extreme distress resulting in an inability to coordinate inhaler usage. Very low health literacy may be an additional barrier to appropriate MDI teaching and usage.[1] Our list was not all‐inclusive, and patients with suboptimal PIFR or with neuromuscular disease are good additions to this recommendation.

As for proper MDI technique, it is unclear whether MDI teaching will result in long‐term mastery of the skill.[2] The only way to master a skill is to practice it. Thus, by prescribing MDIs and training patients on their proper usage during every admission, we will provide medically appropriate patients with many opportunities to practice the skill and reinforce effective techniques.