Aerosol delivery device selection for spontaneously breathing patients: 2012.

Using an electronic literature search for published articles indexed in PubMed between January 1990 and August 2011, the update of this clinical practice guideline is the result of reviewing 84 clinical trials, 54 reviews, 25 in vitro studies, and 7 evidence-based guidelines. The recommendations below are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: 1: It is recommended that selection of the appropriate aerosol generator and interface be made based on the patient's age, physical and cognitive ability, cost, and the availability of the prescribed drug for use with a specific device. 2: Nebulizers and pressurized metered-dose inhalers (pMDIs) with valved holding chambers are suggested for use with children ≤ 4 years of age and adults who cannot coordinate the use of pMDI or dry-powder inhaler (DPI). 3: It is suggested that administration of aerosols with DPIs be restricted to patients ≥ 4 years of age who can demonstrate sufficient flow for the specific inhaler. 4: For patients who cannot correctly use a mouthpiece, aerosol masks are suggested as the interface of choice. 5: It is suggested that blow-by not be used for aerosol administration. 6: It is suggested that aerosol therapy be administered with a relaxed and nondistressed breathing pattern. 7: Unit dose medications are suggested to reduce the risk of infection. 8: It is suggested that nebulizer/drug combinations should be used as approved by the FDA. 9: It is recommended that healthcare providers know the correct use of aerosol generators; they should teach and periodically re-teach patients about how to use aerosol devices correctly. 10: It is suggested that intermittent positive-pressure breathing should not be used for aerosol therapy. 11: It is recommended that either nebulizer or pMDI can be used for aerosol delivery during noninvasive ventilation.