Advantages and disadvantages of various aerosol devices

Type	Advantages	Disadvantages
Jet nebulizer^*	Patient coordination not required High doses possible Allows tidal breathing technique Can be used at any age Can be used with artificial airways Inexpensive	Slower delivery Contamination possible Requires cleaning and disinfection after each use Device preparation required before treatment Not all medications available Less efficient than other devices (dead volume loss) Compressors are generally bulky and noisy High variability between brands
Mesh nebulizer (eg, Aeroneb, eFlow, Omron MicroAir, I-neb)	Patient coordination not required High doses possible Quiet Faster delivery than jet nebulizer Portable, battery operated	Expensive Contamination possible Device preparation required before treatment Cleaning required after dose Not all medications available
Ultrasonic nebulizer (eg, OPTI-NEB, Beetle Neb, Lumiscope, MiniBreeze)	Patient coordination not required High doses possible Small dead volume Quiet Faster delivery than jet nebulizer	Expensive Contamination possible Prone to malfunction Device preparation required before treatment Cannot use with medications in suspension (eg, budesonide)
Pressurized metered dose inhaler (pMDI)	Convenient May be less expensive than nebulizer Portable Rapid delivery No drug preparation required Difficult to contaminate Multidose convenience	Drugs formulated as solutions require shaking of the canister before actuation Requires actuation-inhalation coordination High pharyngeal deposition Difficult to deliver high doses Limited number of drugs available Cleaning and priming instructions are specific for each product
pMDI with valved holding chamber (spacer)	Eliminates need for actuation-inhalation coordination Allows use of tidal breathing technique Less pharyngeal deposition than pMDI alone Incorporates visual-auditory feedback	More expensive than pMDI alone Less portable than pMDI alone Requires good seal of facemask if used Feedback is not very accurate
Dry powder inhaler (DPI)	Convenient Propellant not required Portable Breath actuated Rapid delivery Dose counter included No need for valved holding chamber/spacer	Requires strong and consistent inspiratory effort Some units are single dose and need loading of the capsule before each use Can result in high oropharyngeal deposition Not all medications available Vulnerable to humidity Not suitable for younger children Cannot be used effectively in mechanically ventilated patients Using alongside other devices requiring slow inhalation can result in errors in administration of the medications
Soft mist inhaler (SMI)	Higher lung deposition than pMDIs or jet nebulizers Less pharyngeal deposition than pMDIs Longer duration of spray Low risk of contamination Is propellant free Dose counter included Can be used in mechanically ventilated patients	Requires actuation by patient Needs coordination between actuation and inhalation^¶ Requires loading of cartridge into inhaler before first use Not all medications available Device has to be discarded 90 days after firing the first dose

* Many brands are commercially available in both disposable and nondisposable designs for use in the hospital and at home.

¶ The relatively slower moving (3- to 10-fold) and longer duration spray (10- to 20-fold) from an SMI compared with a pMDI makes it easier for a patient to coordinate breathing and actuation.

References:

Berlinski A. Small-volume nebulizers. In: Pediatric Pulmonology, Asthma, and Sleep Medicine: A Quick Reference Guide, Stokes DC, Dozor AJ, Brooks LJ, et al (Eds), American Academy of Pediatrics 2018.
Berlinski A. Metered dose inhalers. In: Pediatric Pulmonology, Asthma, and Sleep Medicine: A Quick Reference Guide, Stokes DC, Dozor AJ, Brooks LJ, et al (Eds), American Academy of Pediatrics 2018.
Berlinski A. Dry powder inhalers. In: Pediatric Pulmonology, Asthma, and Sleep Medicine: A Quick Reference Guide, Stokes DC, Dozor AJ, Brooks LJ, et al (Eds), American Academy of Pediatrics 2018.

Adapted from: Dolovich MA, MacIntyre NR, Anderson PJ, et al. Consensus statement: Aerosols and delivery devices. Respir Care 2000; 45:589.

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Advantages and disadvantages of various aerosol devices