Monday, July 21, 2014

Nebulizers: old habits die hard

- Jennifer Middleton, MD, MPH

Last week's JFP discussed an updated Cochrane review reasserting that nebulizers cost more, cause more side effects, and offer equivalent treatment compared with a metered dose inhaler (MDI) and a spacer (aerochamber). The Cochrane reviewers conducted a systematic review of 39 trials that included both children and adults as well as office and emergency department (ED) settings. They found no difference in hospital admission rates for adults or children who received albuterol via a MDI and spacer versus a nebulizer. Hospital length of stay was no different for adults who received albuterol via an MDI/spacer versus a nebulizer. Children's ED visit time was, on average, 33 minutes less for those who received albuterol with an MDI/spacer instead of a nebulizer. Children using an MDI/spacer had less tremor, and both children and adults using an MDI/spacer had less tachycardia.

(If you'd like to read more about asthma, check out this AFP By Topic on asthma. You can also brush up on spacer techniques here.)

This is not new information; several randomized controlled studies and the original 2003 Cochrane review demonstrated similar findings. If your office and/or hospital setting is anything like mine, though, nebulizers are everywhere, despite a decade's worth of research showing that MDIs offer equivalent therapy with fewer side effects and less cost. Why the continued love affair with nebulizers when they're not only therapeutically equivalent to MDIs with spacers but also cause more side effects, cost more per dose, and result in longer ED visits?

Well, a study from last year found that 80% of COPD patients and their families felt that using a nebulizer was better than using an MDIA small study of pediatricians found that most would benefit from "better training" regarding spacer use. These small studies may not be generalizable to an American family medicine office, but it's still possible that patients like using nebulizers and that physicians are more comfortable ordering nebulizers. And, I have to confess that it's much more efficient in my office for my nurse to give an albuterol nebulizer treatment than it is to track down a clean spacer and educate a patient on how to use it.

UItimately, the nebulizer epidemic is part of a larger problem in medicine: physicians are slow to change their practice to accommodate new evidence-based findings. Debate exists as to how long it takes for evidence-based research to percolate into widespread physician behavior changes, but estimates around 10-20 years are not hard to believe. Physician leaders have hypothesized the reasons behind this lag, including this NEJM editorial likening local physicians' practices as "where the [information] highway reaches its end and divides into a number of smaller avenues and lanes, and it is also where...concepts may get lost." One team of researchers theorize that just reading about new evidence is insufficient for physicians to place that information in the proper context when applicable patient situations arise; they advocate for more case-based learning in continuing medical education (CME).

Perhaps the first step for each of us is to just acknowledge that the lag exists; perhaps the next step is to think about how each of our "avenues and lanes" might systematically ensure that evidence-based changes become routine care faster. Perhaps we also must advocate for innovation in how CME is delivered.

How do you translate evidence-based changes into your daily practice?