Current guidelines recommend
inhalation therapy as the preferred route of
drug administration for treating
chronic obstructive pulmonary disease (
COPD). Previous systematic reviews in
COPD patients found similar clinical outcomes for drugs delivered by handheld
inhalers - pressurized
metered-dose inhalers (pMDIs),
dry powder inhalers (DPIs) - and
nebulizers, provided the devices were used correctly. However, in routine clinical practice critical errors in using handheld
inhalers are highly prevalent and frequently result in inadequate symptom relief. In comparison with pMDIs and DPIs, effective
drug delivery with conventional pneumatic
nebulizers requires less intensive patient training. Moreover, by design, newer
nebulizers are more portable and more efficient than traditional jet
nebulizers. The current body of evidence regarding
nebulizer use for maintenance
therapy in patients with moderate-to-severe
COPD, including use during exacerbations, suggests that the efficacy of long-term
nebulizer therapy is similar, and in some respects superior, to that with pMDI/DPIs. Therefore, despite several known drawbacks associated with nebulized
therapy, we recommend that maintenance
therapy with
nebulizers should be employed in elderly patients, those with severe disease and frequent exacerbations, and those with physical and/or cognitive limitations. Likewise, financial concerns and individual preferences that lead to better compliance may favor nebulized
therapy over other
inhalers. For some patients, using both
nebulizers and pMDI/DPI may provide the best combination of efficacy and convenience. The impact of maintenance
nebulizer treatment on other relevant clinical outcomes in patients with
COPD, especially the progressive decline in lung function and frequency of exacerbations, needs further investigation.