CHEST: Cutting Drug Dose by Enhancing Nebulizers in COPD Seen Safe and Thrifty

SALT LAKE CITY, Nov. 1 -- Upgrading nebulizers to deliver less medicine less often saved staff time and overall costs for treating patients hospitalized with chronic obstructive pulmonary disease, researchers here reported.

The changes to a newer drug and a reduction in its dose did not compromise patients' health or safety, according to a poster presentation at CHEST 2006, the meeting of the American College of Chest Physicians.

First, the clinicians at Crouse Hospital in Syracuse, N.Y., replaced albuterol with Xopenex (levalbuterol) because patients were having breakthrough bouts of shortness of breath even when albuterol was delivered six times a day.

Next, the clinicians and therapists dropped the individual dose of Xopenex from 3 mL, to 1.5 mL, and finally to 1 mL. They found that by using Xopenex at 1 mL every eight hours at the same frequency and switching to a more efficient nebulizer, they could reduce the amount of time it took to deliver each dose, the overall cost of medication and supplies, as well as hourly therapist costs.

The nebulizer change involved a switch from the standard small-volume nebulizer to the speedier AeroEclipse Breath Actuated Nebulizer (BAN), which permitted more efficient drug delivery.

"When you work at a non-profit community hospital, you are always looking for ways of delivering good medicine for less cost," said Robert Pikarsky, BSRT, administrative director for respiratory services at Crouse Hospital. "We found that by using the faster AeroEclipse nebulizer we can deliver Xopenex more efficiently," he said.

Instead of delivering the standard 3 mL dose of Xopenex, respiratory therapists, under a hospital-arranged study protocol, poured the drug into 1 mL doses that were then delivered to patients in 1 mL treatments. As with the 3 mL dose, the 1 mL doses were given every eight hours.

However, it takes just 2.67 minutes to deliver the 1 mL dose compared with 8.33 minutes to deliver the 3 mL dose. The 5.66-minute saving per treatment translate into many hours when therapists and clinicians have to deliver more than 30,000 doses a year, Pikarsky said.

Doctors moved away from albuterol in favor of Xopenex, he said, because patients were having breakthrough bouts of shortness of breath even when albuterol was being delivered six times a day. With albuterol, breakthroughs occurred 13.7 times for every 100 treatment days.

With Xopenex given in any protocol, breakthroughs were cut by more than half. Delivered via the standard mask, given in the standard dose with the AeroEclipse device, or even given in the lower dose with the AeroEclipse device, breakthrough bouts occurred only 4.91 to 7.18 times in 100 treatment days, differences that were not statistically significant.

"The difference from my standpoint," said Stephen Alkins, M.D., a pulmonary specialist in Syracuse whose patients are at Crouse Hospital, "was that I wasn't getting those emergency calls at home that my patients needed additional treatment. This new nebulizer even with the lower dose appears to do the job," he added.

Pikarsky said that in the two-month trial of the system, the hospital respiratory therapists and nurses were able to save 99 hours of time, a labor savings of about ,000.

On an annual basis, switching from the 3 mL treatment to the 1 mL treatment would save ,693 in labor costs, although that advantage would be offset by an increase of ,851 to use the more efficient nebulizer, leaving a yearly net savings of ,842. The pharmacy costs did not change.

"Basically that would save up to one job position, but practically that means that one person would be free to perform other duties at the hospital where staffing is always tight," Pikarsky said.

He also noted that the study was performed using hospital staff and funds and was not paid for by the pharmaceutical industry or the manufacturer of the device.

"This was a two-month trial," cautioned Donald Tashkin, M.D, of the University of California, Los Angeles, who commented as he reviewed the poster presentation. "We need to see if in practice the efficiency demonstrated in the trial can be carried forward. We also have to be sure that the reduction in medicine does not affect outcomes."