Valerie Press, MD, MPH, on the Transition to a Combination Nebulizer and Metered Dose Inhalers

Utilizing a combination of metered dose inhalers (MDIs) and nebulizers instead of nebulizers alone may result in cost savings, according to a recent study presented at CHEST 2020.1

The researchers used 2 cost models to examine the number of patients, medication costs, and labor costs for nebulized medications, as well as education for MDIs.

The results demonstrated that the savings costs that accompany switching to a combination of the 2 rather than nebulized medications alone is largely from a reduction in the labor costs associated with nebulizer use. The findings also indicate that switching to this combination presents health care providers with the opportunity to reinforce proper inhaler technique.

Lead author Valerie Press, MD, MPH, who is an assistant professor of medicine in the Department of Medicine at the University of Chicago, answered our questions about the study findings and their implications.


Pulmonology Consultant: Your study analyzed how transitioning to MDIs following 24 hours of nebulized medications resulted in cost savings. What was the motivation for this study?

Valerie Press: Our team has spent over a decade studying inhaler misuse. The vast majority of patients hospitalized with chronic obstructive pulmonary disease (COPD) or asthma cannot effectively use their inhaled medication devices (ie, respiratory inhalers). This means they are at risk of not getting the desired effect from their rescue or controller medications.

Additionally, most patients will be discharged home with prescriptions for respiratory inhalers. Clinical guidelines recommend assessing and teaching inhaler technique at all health care encounters. This would include hospitalization. However, since the majority of hospitalized patients are prescribed nebulized therapies, there is less opportunity to provide this assessment and education during the hospitalization.

The program “Nebs No More After 24,” which was conducted at the University of California San Francisco by Dr Moriates and team,2 showed that a dedicated program can help transition patients from nebs (nebulized medications) to MDIs to allow for these teaching opportunities, and this can be cost effective.

PULM CON: What do these results mean for clinical practice?

VP: These results could be used to evaluate whether other hospitals would want to explore similar programs of appropriate transition from nebs to MDIs during the hospitalization coupled with patient education.

PULM CON: Your study notes that switching to MDIs also presents an opportunity for the reinforcement of proper inhaler technique. What tips do you usually give to your patients who may not be using their inhaler correctly?

VP: We use a “Teach-To-Goal” education strategy that involves observing the patients’ technique followed by directed, tailored education and demonstration to correct missteps. This is followed by the patient using “teach-back” or “show-back” to see if and how his or her technique has improved. Multiple rounds can be completed until the patient demonstrates sufficient technique.

PULM CON: What are some existing knowledge gaps in transitioning to MDIs after nebulized medications that still need to be addressed?

VP: There are misunderstandings by both patients and clinicians regarding the concept that they think nebulized treatments are stronger. However, when used correctly, respiratory inhalers are as effective as nebulizer machines at delivering the medication. The key is to ensure that patients are assessed and taught to have adequate inhaler technique skills.



  1. Kondo R, Austin J, Arora V, Press V. Cost saving simulation for the transition from nebulizer to combination of nebulizer and metered dose inhalers (MD). Paper presented at: CHEST 2020; October 18-21, 2020, Virtual.
  2. Moriartes C, Novelero M, Quinn K, Khanna R, Mourad M. “Nebs No More After 24”: a pilot program to improve the use of appropriate respiratory therapies. JAMA Int Med. 2013;173(17):1647-1648.