Metered-Dose Inhalers vs. Nebulizers

| 15 Comments

A nubulizer is a device that takes a liquid solution and turns it into a fine mist that can be inhaled.  I frequently  hear patients refer to it as a “breathing machine” that gives a “breathing treatment”.  Albuterol is the most common nebulized medication and is used to treat wheezing and chest tightness in asthmatics and emphysema patients.  The primary advantage to nebulizers is that they are very easy to use.  Place the medication in the machine, flip the switch, and breathe normally from the mouthpiece or mask til the medication is finished- around 10 minutes.

The alternative to nebulizers is the simple metered-dose inhaler, or MDI.  MDIs are harder to coordinate than a nebulizer, but when they are used with a spacer device,

Aerochamber

Aerochamber

as pictured on the right, coordination is much easier and the delivered dose is more consistent.  Learning to use a spacer device takes under a minute.

There is a common misconception that nebulizer therapy is a stronger treatment than an MDI.  This is simply not true.  Multiple studies have shown that patients receiving albuterol from an MDI/spacer combination do just as well as, if not better than, patients receiving nebulized albuterol.

MDIs offer several advantages.  First, they are much quicker to use.  Two puffs from an MDI/spacer takes 30 seconds or so if done properly vs. 10 minutes or so for a nebulizer treatment.  Second, MDIs cause fewer side effects.  Nebulized albuterol causes much more heart rate increase and tremor than albuterol from an MDI/spacer.  Third, MDIs are much cheaper to use.  Not including the cost of the nebulizer and related supplies, nebulized albuterol costs $2-$2.50 per dose versus $.40-$.50 per dose for MDI delivered albuterol.

So, MDIs are cheaper, quicker, have fewer side effects and have equal effectiveness.  Sounds like we have a winner.

Dr. O

15 Comments

  1. 1) It is much more difficult to get the proper dosage with an inhaler, because a person suffering from COPD cannot inhale with great force. Thus, the majority of the medication ends up in their mouth (where it does no good), rather than in their lungs. The nebulizer provides a far superior delivery method.

    2) Generic albuterol inhalers were once available for as little as $5 (per 120 metered doses), but thanks to advocates of “global warming” mythology, the cheapest inhaler is now over $45, and insurance companies classify them as “tier-3 drugs”. The nebulizer solutions are still classified as “tier-1”.

    With a typical insurance plan, one inhaler costs $50; the equivalent amount of nebulizer solution costs less than $5, and allows greater precision in dosing.

    For seniors and disabled persons, Medicare-B pays for nebulizers and nebulizer solution. They do NOT pay for inhalers.

    • First, my post pertains primarily to asthmatics.

      Very few people cannot inhale forcefully enough for an inhaler to work, especially when used with a spacer. COPD/emphysema does not cause difficulty with inspiration, but rather with exhalation, so it should not affect the amount of medication delivered with an inhaler. Studies examining the change in lung function show that 2 puffs from an inhaler cause the same amount of bronchodilation as a nebulizer treatment. The amount of medication is actually much less precise with a nebulzer. Thus, the nebulizer is not a superior delivery method.

      I agree that the increased cost of HFA albuterol is a problem and I would argue that there should be a generic equivalent. Nevertheless, at current market prices, one HFA albuterol inhaler with 200 puffs costs as little as $40 retail. If one dose is 2 puffs, that’s $.40 per dose. A 20ml bottle of albuterol sulfate solution costs $16 retail and provides 40 doses. Amazingly, that’s also $.40 per dose if you don’t count the costs of the nebulizer, tubing, and mothpiece and the waste from improper measuring. So, the nebulizer will be more expensive at retail. When nebulizer treatments cost less, it’s because the cost is subsidized by our taxes and insurance premiums. We all pay indirectly.

  2. I am asthmatic and I have used MDI before but its not working for me. Maybe I don’t know how to properly use it so I stick with the neutralizer. Its more easier to use.

  3. I rather use a nebulizer because it is more effective. In the other hand, inhalers are more portable and can be brought in different places.

  4. I have severe asthma and am on 500/50 advair and 10mg of singulair. I’ve tried xolair but it was ineffective for me.

    I carry an MDI everywhere I go… but it’s not quite the same as the nebulizer. With the MDI the dose is delivered at one time (or half the dose). There are issues with inhalation, though there is little concern spare serious issues, that an individual would be unable to effectively use an MDI. That being said, it is my thought and belief that because of the impact of the delayed delivery through the use of SVN instead of MDI, there is a more drastic impact.

    If within the first minute our airways open a little, that means in minute two the medication can reach more deeply into our lungs to have a greater impact… and even greater still in minute three, four…. The MDI definitely has its place. It is portable, user-friendly and moderately affordable.

    I grew up using SVN, have achieved relatively decent function with SVN while MDI resulted in necessity of 500/50 of advair (which is really quite insane), and believe that the more gradual delivery allows for a greater impact.

    I was in the ER tonight because my MDI did nothing… but 10 minutes with an SVN and I was breathing like I was perfectly fine. There are, of course, side effects… I was jittery, twitchy, and my heart was pounding… but I could breathe, so I didn’t really care. I got an SVN and an RX for Albuterol Sulfate. I still have the MDI, and will still use it when I’m out if needed… I never leave home without it – it is, quite literally, my lifeline.

    The SVN though, has consistently allowed me greater control. Maybe it’s the placebo effect. Maybe there’s really something there. Either way, it works for me and, as my grandma used to say “bend over or open up because this is going in you one way or the other…” the other one said, though “if it ain’t broke, don’t fix it.”

  5. I’ve been a Respiratory Therapist for 18 years. Studies comparing nebulizers to MDI’s are not based on a patient coming in in with severe respiratory distress. These patients have tachypnea and shallow breaths. I would never use an MDI on a patient with severe breathing problem.

    • I agree. If a patient is in extremis, nebs are a better choice due to coordination issues. MDIs are a much better choice for routine at home use.

      Of all my 100+ posts, this one gets the most feedback.

  6. I think the nebulizer is better, whether or not one is in extremis. It forces the user to sit quietly for several minutes and breathe slowly and steadily, rather than taking relatively quick inhalations through a spacer tube and moving on. The nebulizer also moistens the lungs, which helps to loosen thick mucus. It may be used with unmedicated water just to keep the lungs moist. No charge for that.

  7. I wanted to add some input on this subject. I am both a medical professional that uses nebulizer treatments and MDI’s in her job, as well as an asthma sufferer herself. you have calculated that and MDI treatment is around $.40 which I believe to be true, but my albuterol nebulizer treatments only cost $4.00 for a box of 25 which means it’s $.16 a dose. Nebulizer cup set-ups aren’t very costly and only need replaced once a month, and once the nebulizer machine is purchased it’s one that will last a while. so if you have a patient that has frequent exacerbations or severe asthma, a nebulizer would be a cheaper option for them. However MDI’s are handy as far as being portable, etc.
    As for their effectiveness, I find (aside from the increased symptoms with Neb Albuterol) that the nebulizer is much more effective. I notice this with not only my patients, but also myself. In fact I was having increased asthma problems last week, and although my MDI worked as a rescue inhaler, the neb was MUCH more effective at calming down my asthma. I can only speak from personal experience for the second part. I believe (although some might argue this) that the nebulizer solution delivers increased moisture in the airways which also helps to loosen the sticky mucous associated with asthma. Some pulmonologists even prescribe NS to be delivered via nebulizer to help loosen secretions in patients. So you are not only getting the medication, but an aid to help with the extra mucous that often accompanies Asthma.

    • There may be something to the nebulized saline. Nevertheless, studies show that nebulized albuterol and MDI albuterol from a spacer produce the same change in FEV1. I think many patients benefit from the simple act of breathing deeply and calmly during the nebulizer treatment.

  8. I asked the question : are nebulizers more for asthmatics or emphysema.
    I have both, am male and 70 years old and only stopped smoking (thank God), albeit
    too late, last January.
    Now, since July I have used my nebulizer daily (except for maybe 1 or 2 days),
    and my asthma seems more severe, even when I get upset emotionally, etc.,
    here comes the panic and an asthma attack.
    I always have the MDI or I would be dead as I never know when I’m going to
    get SOB. I have copd, of course, which includes emphysema as well as chronic
    bronchitis.
    One man earlier in this discussion was talking about his SVN. What is that?
    Maybe my increased need for the nebulizer lately has been due to the atmospheric conditions here in Atlanta, with all the folage from the rainy days
    we had earlier for weeks. Any ideas on that?
    For long term maintenance (if you will), I use Flovent 110 mcg BID and it
    certainly helps with the inflammation. I tried Advair, Singulair, Formoderal
    and other labas and they drove me nuts, like my mind was going to explode.
    I just can’t tolerate those labas. Sprivia gave me constant constipation, larger
    BPH and constant blood shot eyes. Is there anything newer out there with
    less side effects that will help keep my airways open longer as the labas do?
    All info most graciously accepted.
    Lewis

    • So- lots of questions here.

      First, congrats on quitting smoking. That’s the best thing you could have done for your health.

      My comparison of MDIs vs nebulizers was meant for asthmatics, not for emphysema. Both are obstructive lung diseases, difficulty getting the air out, but the mechanical problems in each are very different.

      SVN= Small Volume Nebulizer.

      I’m not in the ATL, but air quality can certainly affect respiratory symptoms.

      Singulair is not a LABA. It helps reduce airway inflammation and bronchospasm caused by chemicals called leukotrienes.

      A couple of new meds out are out there. Roflumilast aka Daliresp is a pill that is a maintenance med for COPD. Indacterol aka Arcapta is a once-daily LABA.

      Good Luck

  9. This is an old but good thread.
    I’ll add my own two cents as an Internal Medicine Physician who has asthma:

    A neb treatment has 2500 mcg of Albuterol, while two puffs of an MDI is 200 mcg of the same medicine. The increase in heart rate often noted with the neb reflects the higher dose. So how do we explain the often reported similar subjective and lung response in patients regardless of delivery method ? I’m not sure, but I wonder if the neb dose could be lowered without sacrificing response for those instances where the MDI is effective. Or approach nebs like we do with an MDI: start with 500 – 1000 mcg, and if desired take a second treatment.

    I personally use an MDI out of convenience and because it matches well my asthma ‘lifestyle,’ which is often prophylactic before exercise. On the other hand, if I was dealing with an exacerbation at home e.g. related to an upper respiratory infection I would prefer a nebulizer approach. Hands down.

    Lastly, an update on prices: Walmart sells a “90 day supply” of 75 neb doses for $10, or 13 cents per standard 2.5 mg treatment. I personally buy 3 – 10 brand name or well known generic MDIs at a time through an international pharmacy that ships from UK, NZ or Israel for an end cost after shipping of $12 – $15 per 200 dose MDI.

    PSA: MDIs are only as good as the technique of the patient. It really behooves each person to either invest the time and effort to learn great technique, or to use a spacer. And particularly for asthmatics, inhaled steroids are the bedrock of treatment, not escape inhalers. If an asthmatic is spending too much money on beta agonist inhalers the probable answer is not to find a cheaper supply of Albuterol (or similar agents,) but to control the asthma better with an appropriate inhaled steroid regime.

    All the best, everybody.

  10. Sorry, one additional comment ..
    This article
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1974824/

    is a fantastic summary of the different technologies available and likely efficacy in different patient groups. A close reading will help people maximize their purchases.

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