Is there a role for nebulized bronchodilators in severe but stable COPD

A small minority of COPD patients may derive additional benefit from the very high dose of bronchodilator therapy that can be delivered from a nebulizer [13,14]. Most patients can derive equal benefit from treatment using hand-held inhalers or spacer devices. Nebulized treatment should only be prescribed after a formal trial comparing the response to nebulized treatment with the response to high-dose treatment using hand-held inhalers as recommended in British Thoracic Society and European Respiratory Society Guidelines for nebulizer use [13,14].

Hand-held inhalers and nebulizers each achieve about 10% lung deposition of the prescribed dose (depending on which individual device is used). However, a nebulizer will usually deliver a higher dose (e.g. 2.5 mg of nebulized salbutamol is the same dose as would be delivered by 25 puffs from a salbutamol inhaler). Most patients will derive no additional benefit from the higher dose of nebulized treatment (but side-effects may be increased).

However, for patients who do require high-dose treatment, a nebulizer may be more convenient than multiple puffs from an MDI spacer. The European Nebulizer Guidelines suggest that patients who require 10 or more puffs from hand-held inhalers to achieve symptomatic relief may find a nebulizer more convenient [14].

For some patients, especially with coexisting bronchiectasis, a nebulized b-agonist may assist mucus clearance [15]. Benefit of this sort can only be identified by a trial of nebulized treatment in the patient's home, ideally using loaned equipment. Some patients use nebulized saline between doses of bron-chodilator treatment to assist mucus expectoration and relieve breathless-ness [16].

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