Nebulizer use by black and latinx adults with moderate to severe asthma

Published: October 18, 2021

Although inhalers are usually recommended for quick relief of asthma symptoms and are less likely than nebulizers to have aerosol spread if used correctly, many patients report using nebulizers. In the PeRson EmPowered Asthma Relief (PREPARE) study, a pragmatic, randomized clinical trial of 1201 Black and Latinx adults with asthma, 70% of participants owned a nebulizer. In The Journal of Allergy and Clinical Immunology: In Practice, Apter and Carroll et al report findings from a qualitative sub-study of the PREPARE study. The sub-study aimed to understand Black and Latinx adults’ experiences, preferences, and decision-making with the use of nebulizers.

The investigators interviewed 40 of the 1201 participants of the PREPARE study. PREPARE participants were 18 to 75 years of age, self-identified as African American/Black or Hispanic/Latinx, had a history of asthma for at least 1 year, were prescribed inhaled steroids, and had uncontrolled asthma defined as either a score of 19 or less on the Asthma Control Test or an asthma exacerbation in the past year. Participants were randomized either to an additional puff of inhaled steroid with each as-needed puff of short-acting beta-agonist (SABA) plus usual care, or to usual care alone. If a patient in the intervention group used nebulized SABA, 5 puffs of inhaled steroid were recommended with nebulization. Participants were invited into the sub-study if they indicated use of a nebulizer at least once in the past month on both their baseline survey and at least 1 additional monthly survey. Letters of invitation for the sub-study were mailed to 252 PREPARE participants. The first 40 of 105 who initially responded to the letters were enrolled: 20 Black, 10 Latinx English-speaking, and 10 Latinx Spanish-speaking adults. Interviews in English or Spanish as preferred by the participant asked about asthma medication use, nebulizer characteristics, nebulizer history, use of rescue inhalers, and insurance/copay.

Among the 40 participants, the average age was 50 years, and 88% were female. Participants reported using a nebulizer on average 3.5 times/wk. Regular use was common, and frequency ranged from less than daily to up to 6 times daily. Almost all reported longstanding use of a nebulizer, none for less than 2 years. Nebulizers were prescribed by allergists, emergency department (ED) or hospital physicians, pediatricians, pharmacists, primary care physicians, and pulmonologists, in many instances related to an attempt to avoid an ED visit or hospitalization. Most reported better relief of symptoms with a nebulizer and many used a nebulizer after insufficient mitigation of symptoms with an inhaler, and to prevent an ED visit.  

Although there was variation in the extent to which cost was an issue, many participants reported that the nebulizer was less costly for them compared to inhalers. Because nebulizers can be billed as durable medical equipment, their cost is covered by Medicare, Medicaid, and commercial insurance. Also, nebulizer medications, like albuterol, are inexpensive. Participants described households in which more than one inhabitant had asthma and in which nebulizers were shared.

This sub-study has some limitations. As with qualitative research generally, the sample size is small and the generalizability to other populations is not clear. Strengths include a broad geographic representation and robust patient advisor involvement throughout the project. Based on findings from this study, the authors recommend that clinicians explore patients’ use of and experience with nebulizers in understanding patients’ asthma control and as part of a person-centered, shared decision-making approach for asthma management.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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