Reprinted from Respiratory Care (Respir Care 1993;38:1189-1195)
AARC Clinical Practice Guideline
Intermittent Positive Pressure Breathing
IPPB 1.0 PROCEDURE:
Intermittent positive pressure breathing
IPPB 2.0 DESCRIPTION/DEFINITION:
IPPB is a technique used to provide short-term or intermittent mechanical ventilation for the purpose of augmenting lung expansion, delivering aerosol medication, or assisting ventilation(1)
- 2.1 IPPB is not a therapy of first choice for aerosol delivery or lung expansion in spontaneously breathing patients when other less expensive and less invasive therapies can reliably meet clinical objectives.(2-8)
- 2.2 IPPB can include volume-, pressure-, time-limited, or flow-cycled ventilation.
- 2.3 IPPB may be applied to intubated as well as nonintubated patients.
IPPB 3.0 SETTINGS:
IPPB can be administered in settings that include hospital, clinic, extended care facility, and home.
IPPB 4.0 INDICATIONS:
- 4.1 The need to improve lung expansion
- 4.1.1 The presence of clinically important pulmonary atelectasis when other forms of therapy have been unsuccessful (incentive spirometry, chest physiotherapy, deep breathing exercises, positive airway pressure) or the patient cannot cooperate(9-l4)
- 4.1.2 Inability to clear secretions adequately because of pathology that severely limits the ability to ventilate or cough effectively and failure to respond to other modes of treatment(13)
- 4.2 The need for short-term ventilatory support for patients for are hypoventilated as an alternative to tracheal intubation and continuous ventilatory support(12-2l)
- 4.3 The need to deliver aerosol medication (We are not addressing aerosol delivery for patients on long-term mechanical ventilation)(4)
- 4.3.1 Although some authors oppose the use of IPPB in the treatment of severe bronchospasm (acute asthma, unstable or status asthmaticus, exacerbated COPD),(6,22-24) we recommend a careful, closely supervised trial of IPPB when treatment using other techniques (metered dose inhaler [MDI] or nebulizer) has been unsuccessful(1,25-33)
- 4.3.2 IPPB may be used to deliver aerosol medications to patients with fatigue as a result of ventilatory muscle weakness (eg, failure to wean from mechanical ventilation, neuromuscular disease, kyphoscoliosis) or chronic conditions in which intermittent ventilatory support is indicated (eg, ventilatory support for home care patients and the more recent use of nasal IPPV for respiratory insufficiency).(l,l5-2l)
IPPB 5.0 CONTRAINDICATIONS:
Although no absolute contraindications to the use of IPPB therapy (except the oft-cited tension pneumothorax) have been reported, the patient with any of the following should be carefully evaluated before a decision is made to initiate IPPB therapy.
- 5.1 Intracranial pressure (ICP) > 15 mm Hg
- 5.2 Hemodynamic instability
- 5.3 Recent facial, oral, or skull surgery
- 5.4 Tracheoesophageal fistula
- 5.5 Recent esophageal surgery
- 5.6 Active hemoptysis
- 5.7 Nausea
- 5.8 Air swallowing
- 5.9 Active untreated tuberculosis
- 5.10 Radiographic evidence of bleb
- 5.11 Singulation (hiccups)
IPPB 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Increased airway resistance(34)
- 6.2 Barotrauma, pneumothorax(34)
- 6.3 Nosocomial infection(34)
- 6.4 Hypocarbia(4,35)
- 6.5 Hemoptysis(4,35)
- 6.6 Hyperoxia when oxygen is the gas source(34)
- 6.7 Gastric distention(34)
- 6.8 Impaction of secretions (associated with inadequately humidified gas mixture)(34)
- 6.9 Psychological dependence(34)
- 6.10 Impedance of venous return(34)
- 6.11 Exacerbation of hypoxemia
- 6.12 Hypoventilation
- 6.13 Increased mismatch of ventilation and perfusion
- 6.14 Air trapping, auto-PEEP, overdistended alveoli
IPPB 7.0 LIMITATIONS OF PROCEDURE OR DEVICE:
- 7.1 All of the mechanical effects of IPPB are short-lived--lasting < or = an hour after treatment(35,36)
- 7.2 Based on the available literature, MDI or compressor-driven nebulizers should be considered the devices of choice for aerosol therapy to COPD and stable asthma patients.(l,3-8)
- 7.3 Only a very small percentage of the aerosol output deposits in the airway.(37) Delivery of a therapeutic dose via IPPB may require as much as a tenfold increase in medication amount over MDI(38,39)
- 7.4 Efficacy of device for ventilation and aerosol delivery is technique dependent (eg, coordination, breathing pattern, selection of appropriate inspiratory flow, peak pressure, inspiratory hold).(40,51)
- 7.5 Efficacy is dependent on the design of the device (eg, flow, volume, and pressure capability as well as aerosol output and particle size).(40,42,52-54)
- 7.6 IPPB is equipment- and labor-intensive as a method of delivery of aerosol.(40,42,55-59)
- 7.7 Limited portability and lack of convenience may affect patient compliance.
IPPB 8.0 ASSESSMENT OF NEED:
- 8.1 Presence of atelectasis
- 8.2 Reduced pulmonary function as evidenced by reductions in timed volumes, and vital capacity (eg, FEV1 < 65% predicted, FVC < 70% predicted, MVV < 50% predicted, or VC < 10 mL/kg) precluding an effective cough
- 8.3 Neuromuscular disorders or kyphoscoliosis with associated decreases in lung volumes and capacities
- 8.4 Fatigue or muscle weakness with impending respiratory failure
- 8.5 Presence of acute severe bronchospasm or exacerbated COPD that fails to respond to other therapy
- 8.5.1 Regardless of the type of delivery device used (MDI with spacer or small volume, large-volume, or ultrasonic nebulizer), it is important to recognize that the dose of the drug needs to be titrated to give the maximum benefit.(37,39)
- 8.5.2 Based on proven therapeutic efficacy, variety of medications, and cost-effectiveness, the MDI with accessory device should be the first method to consider for administration of aerosol.(42,55-59,6l,62)
- 8.6 With demonstrated effectiveness, the patient's preference for a positive pressure device should be honored.
IPPB 9.0 ASSESSMENT OF OUTCOME:
- 9.1 Tidal volume during IPPB greater than during spontaneous breathing (by at least 25%)
- 9.2 FEV1 or peak flow increase
- 9.3 Cough more effective with treatment
- 9.4 Secretion clearance enhanced as a consequence of deep breathing and coughing
- 9.5 Chest x-ray improved
- 9.6 Breath sounds improved
- 9.7 Favorable patient subjective response
IPPB 10.0 RESOURCES:
- 10.1 Equipment
- 10.1.1 IPPB device or pressure-support; volume-, pressure-, or time-limited ventilator or manual resuscitation device
- 10.1.2 Connecting tubing
- 10.1.3 Nebulizer (small-volume, large-volume, or ultrasonic) and medication or normal saline, or MDI with accessory adapter, or humidifier
- 10.1.4 Mouthpiece, flange (lip seal), nose clip, mask, or endotracheal tube adapter
- 10.1.5 Tissues and emesis basin or container for collecting or disposing of expectorated sputum
- 10.1.6 Gloves, goggles, gown, and mask as indicated
- 10.1.7 Hand-held spirometer or other volume-measuring device
- 10.1.8 Oral and/or endotracheal suction equipment
- 10.2 Personnel: A spectrum of education and skill levels is required for personnel who administer IPPB therapy. Different clinical situations warrant the degree of training necessary to provide optimal respiratory care:
- 10.2.1 Level I caregiver may be the provider of service after Level II personnel have established need for a specific device by patient assessment, and the first administration has been completed. Level I personnel must demonstrate
- 10.2.1.1 ability to prepare, measure, and mix medication;
- 10.2.1.2 proper technique for administration of medication;
- 10.2.1.3 proper use of equipment, including adjustment of machine settings to meet patient demands;
- 10.2.1.4 effective cleaning of equipment;
- 10.2.1.5 proper disposal of wastes;
- 10.2.1.6 ability to encourage effective breathing patterns and coughing techniques;
- 10.2.1.7 ability to modify technique (after communication with physician) in response to recognized complications and adverse reactions or change in severity of symptoms as determined by observation and vital-signs determination;
- 10.2.1.8 ability to implement Universal Precautions and proper infection control.
- 10.2.2 Level II Personnel must demonstrate all Level I skills and
- 10.2.2.1 ability to perform physical exam--auscultation, inspection, percussion, and vital signs;
- 10.2.2.2 ability to assess patient condition and patient response to therapy;
- 10.2.2.3 ability to perform peak expiratory flowrate, spirometry, and ventilatory mechanics measurement;
- 10.2.2.4 proper use and knowledge of limitations of IPPB equipment and aerosol device and ability to fit mask and/or identify best application device for particular patient;
- 10.2.2.5 ability to recognize and respond to therapeutic changes, adverse response, and complications of aerosol medications;
- 10.2.2.6 ability to modify dosage of medication and/or frequency of administration as prescribed in response to severity of symptoms;
- 10.2.2.7 ability to negotiate care plan and modifications with physician and healthcare team;
- 10.2.2.8 understanding of effects of increased pressure on ventilation, perfusion, and sputum mobilization;
- 10.2.2.9 ability to modify technique in response to adverse reactions;
- 10.2.2.10 ability to instruct patient/family/caregiver in goals of therapy and
- 10.2.2.10.1 proper technique for administration,
- 10.2.2.10.2 proper use of equip ment,
- 10.2.2.10.3 cleaning of equipment,
- 10.2.2.10.4 breathing patterns and cough techniques,
- 10.2.2.10.5 recognition of communications and technique modification in response to adverse reactions,
- 10.2.2.10.6 frequency modification in response to severity of symptoms;
- 10.2.2.11 understanding and compliance with Universal Precautions and infection control issues related to cleaning and maintaining equipment and handling of secretions and hazardous waste.
- 10.2.3 Level III--Self-administration of IPPB. Patients who are to self-administer IPPB should demonstrate to the supervising clinician
- 10.2.3.1 proper technique for administration;
- 10.2.3.2 proper use of equipment;
- 10.2.3.3 proper cleaning of equipment;
- 10.2.3.4 ability to measure and mix medications;
- 10.2.3.5 breathing patterns and cough techniques;
- 10.2.3.6 technique modification in response to adverse reactions, duration or frequency modification in response to severity of symptoms.
IPPB 11.0 MONITORING:
Items from the following list should be chosen as appropriate for the specific patient.
- 11.1 Performance of machine trigger sensitivity, peak pressure, flow setting, FIO2 inspiratory time, expiratory time, plateau pressure, PEEP
- 11.2 Respiratory rate and volume
- 11.3 Peak flow or FEVl/FVC
- 11.4 Pulse rate and rhythm from EKG if available
- 11.5 Patient subjective response to therapy--pain, discomfort, dyspnea
- 11.6 Sputum production--quantity, color, consistency, and odor
- 11.7 Mental function
- 11.8 Skin color
- 11.9 Breath sounds
- 11.10 Blood pressure
- 11.11 Arterial hemoglobin saturation by pulse oximetry (if hypoxemia is suspected)
- 11.12 Intracranial pressure (ICP) in patients for whom ICP is of critical importance
- 11.13 Chest radiograph
IPPB 12.0 FREQUENCY:
- 12.1 Critical care--q 1 h-q 6 h, for IPPB as tolerated. IPPB order should be re-evaluated at least every 24 hours based on assessments during individual treatments.
- 12.2 Acute/domiciliary care--
- 12.2.1 Common strategies for IPPB vary from qid to bid. Frequency should be determined by assessing patient response to therapy.
- 12.2.2 For acute care patients, order should be re-evaluated based on patient response to therapy at least every 72 hours or with any change of patient status.
- 12.2.3 Domiciliary patients should be reevaluated periodically and with any change of status.
IPPB 13.0 INFECTION CONTROL:(42)
Aerosol Therapy Guidelines Committee:
- 13.1 Caregivers should implement Universal Precautions(63) and appropriate guidelines for prevention of tuberculosis transmission.(64)
- 13.2 Caregivers should observe all infection control guidelines posted for patient.
- 13.3 All reusable equipment should be disinfected between patients.
- 13.4 Nebulizers should be changed or subjected to high-level disinfection
- 13.4.1 at conclusion of dose administration (for single treatment), or
- 13.4.2 every 24 hours with continuous administration, or more often when visibly soiled.
- 13.5 Nebulizers should not be rinsed with tap water between treatments,(65,66) but may be rinsed with sterile water or sterile saline and allowed to air dry.
Jon Nilsestuen PhD RRT, Chairman, Houston TX
James B Fink MBA RRT, Chicago IL
James K Stoller MD, Cleveland OH
James Volpe RRT, San Diego CA
Theodore Witek Jr DrPH RPFT RRT, Ridgefield CT
- Agency for Health Care Policy and Research (AHCPR). Health Technology Reports: intermittent positive pressure breathing (IPPB) therapy. 1991, Number 1.
- The IPPB Trial Group. Intermittent positive pressure breathing therapy of chronic obstructive pulmonary disease: a clinical trial. Ann Intern Med 1983;99:612-620.
- Ostrow DN. Managing chronic airflow obstruction. Part II. Geriatrics 1985;40(3):51-53,56,59 passim.
- Gonzalez ER, Burke TG. Review of the status of intermittent positive pressure breathing therapy. Drug Intell Clin Pharm 1984;18:974-976.
- Pedersen JZ, Bundgaard A. Comparative efficacy of different methods of nebulising terbutaline. Eur J Clin Pharmacol 1983;25:739-742.
- Weber RW, Petty WE, Nelson HS. Aerosolized terbutaline in asthmatics: comparison of dosage strength, schedule, and method of administration. J Allergy Clin Immunol 1979;63:116-121.
- Moore RB, Cotton EK, Pinney MA. The effect of intermittent positive-pressure breathing on airway resistance in normal and asthmatic children. J Allergy Clin Immunol 1972;49:137-141.
- Dolovich MB, Killian D, Wolff RK, Obminski G, Newhouse MT. Pulmonary aerosol deposition in chronic bronchitis: intermittent positive pressure breathing versus quiet breathing. Am Rev Respir Dis 1977;115:397-402.
- Bartlett RH, Gazzaniga AB, Geraghty TR. Respiratory maneuvers to prevent postoperative pulmonary complications: a critical review. JAMA 1973;224:1017-1021.
- Bartlett RH. Respiratory therapy to prevent pulmonary complications of surgery. Respir Care 1984;29(6):667-679.
- Marini JJ. Postoperative atelectasis: pathophysiology, clinical importance, and principles of management. Respir Care 1984;29(5):516-528.
- American Thoracic Society (ATS). As quoted in Intermittent Positive Pressure Breathing Therapy. AHCPR Health Technology Assessment Reports, 1991, No. 1:5.
- National Association of Medical Directors of Respiratory Care (NAMDRC). As quoted in Intermittent Positive Pressure Breathing Therapy. AHCPR Health Technology Assessment Reports, 1991, No. 1:6.
- American College of Chest Physicians (ACCP). As quoted in Intermittent Positive Pressure Breathing Therapy. AHCPR Health Technology Assessment Reports, 1991, No. 1:6.
- De Troyer A, Deisser P. The effects of intermittent positive pressure breathing on patients with respiratory muscle weakness. Am Rev Respir Dis 1981;124(2):132-137.
- Rodenstein DO, Stanescu DC, Delguste P, Liistro G, Aubert-Tulkens G. Adaptation to intermittent positive pressure ventilation applied through the nose during day and night. Eur Respir J 1989;2(5):473-478.
- Brochard L, Harf A, Lorino H, Lemaire F. Inspiratory pressure support prevents diaphragmatic fatigue during weaning form mechanical ventilation. Am Rev Respir Dis 1989;139(2):513-521.
- McKim DA, Dales RE, Lefebvre GG, Proulx M. Nocturnal positive-pressure nasal ventilation for respiratory failure during pregnancy. Can Med Assoc J 1988;139 (11):1069-1071.
- Bach JR, Alba A, Mosher R, Delaubier A. Intermittent positive pressure ventilation via nasal access in the management of respiratory insufficiency. Chest 1987;92(1): 168-170.
- Kinnear WJ, Shneerson JM. Assisted ventilation at home: is it worth considering? Br J Dis Chest 1985;79(4):313-351.
- Splaingard ML, Frates RC Jr, Jefferson LS, Rosen CL, Harrison GM. Home negative pressure ventilation report of 20 years of experience in patients with neuromuscular disease. Arch Phys Med Rehabil 1985;66(4):239-242.
- Fergusson RJ, Carmichael J, Rafferty P, Willey RF, Crompton GK, Grant IW. Nebulized salbutamol in life-threatening asthma. Is IPPB necessary? Br J Dis Chest 1983;77:255-261.
- Loren M, Chai H, Miklich D, Barwise G. Comparison between simple nebulization and intermittent positive-pressure in asthmatic children with severe bronchospasm. Chest 1977;72:145-147.
- Patterson JW. A comparison of three different techniques for giving nebulized albuterol to asthmatic patients Am Rev Respir Dis 1974;110:293-300.
- Eggertsen SC. Intermittent positive pressure breathing and the treatment of acute asthma. J Fam Pract 1983;16: 909-913.
- Choo-Kang YF, Grant IW. Comparison of two methods of administering bronchodilator aerosol to asthmatic patients. Br Med J 1975;2:119-120.
- Aelony Y. "Noninvasive" oral treatment of asthma in the emergency room. Am J Med 1985;78(6, Part 2):929-936.
- Cayton RM, Webber B, Paterson JW, Clark TJ. A comparison of salbutamol given by pressure-packed aerosol or nebulization via IPPB in acute asthma. Br J Dis Chest 1978;72:222-224.
- Webber BA, Collins JV, Branthwaite MA. Severe acute asthma: a comparison of three methods of inhaling salbutamol. Br J Dis Chest 1982;76:69-74.
- Chang N, Levison H. The effect of a nebulized bronchodilator administered with or without intermittent positive pressure breathing on ventilatory function in children with cystic fibrosis and asthma. Am Rev Respir Dis 1972;106:867-872.
- Branscomb BV. Metaproterenol solution in the treatment of asthmatic patients by intermittent positive pressure breathing. J Clin Pharmacol 1982;22:231-235.
- Anderson PB, Goude A, Peake MD. Comparison of salbutamol given by intermittent positive-pressure breathing and pressure-packed aerosol in chronic asthma. Thorax 1982;37:612-616.
- Webber BA, Shenfield GM, Paterson JW. A comparison of three different techniques for giving nebulized albuterol to asthmatic patients. Am Rev Respir Dis 1974; 109:293-295.
- Shapiro BA, Peterson J, Carne RD. Complications of mechanical aids to intermittent lung inflation. Respir Care 1982;27(4):467-470.
- Schilling JP, Kasik JE. Intermittent positive pressure breathing: a continuing controversy. J Iowa Med Soc 1980;70:99-100,102-103.
- Branson RD, Campbell RS. Sighs: wasted breath or breath of fresh air? Respir Care 1992;37(5):462-468.
- Newman SP. Aerosol deposition considerations in inhalation therapy. Chest 1985;88(2, Suppl):152S-160S.
- Tashkin DP. Dosing strategies for bronchodilator aerosol delivery. Respir Care 1991;36(9):977-988.
- Nelson HS, Spector SL, Whitsett TL, George RB, Dwek JH. The bronchodilator response to inhalation of increasing doses of aerosolized albuterol. J Allergy Clin Immunol 1983;72:371-375.
- Dolovich M. Clinical aspects of aerosol physics. Respir Care 1991;36(9):931-938.
- Kacmarek RM, Hess D. The interface between patient and aerosol generator. Respir Care 1991;36(9):952-976.
- American Association for Respiratory Care. Clinical practice guideline: selection of aerosol delivery device. Respir Care 1992;37(8):891-897.
- Allen SC, Prior A. What determines whether an elderly patient can use a metered dose inhaler correctly? Br J Dis Chest 1986;80:45-49.
- Lindgren S, Bake B, Larsson S. Clinical consequences of inadequate inhalation technique in asthma therapy. Eur J Respir Dis 1987;70:93-98.
- Orehek J, Gayrard P, Grimaud C, Charpin J. Patient error in use of bronchodilator metered aerosols. Br Med J 1976;1:76.
- Guidry GG, Brown WD, Stogner SW, George RB. Incorrect use of metered does inhalers by medical personnel. Chest 1992;101:31-33.
- Crompton GK. Problems patients have using pressurized aerosol inhalers. Eur J Respir Dis 1982; 119(Suppl): 101-104.
- O'Connell MB, Hewitt JM, Lackner TE. Consistency of evaluators assessing inhaler technique. Ann Allergy 1991;67:603-608.
- De Tullio PL, Corson ME. Effect of pharmacist counseling on ambulatory patients' use of aerosolized bronchodilators. Am J Hosp Pharm 1987;44:1802-1806.
- Self TH, Brooks JB, Lieberman P. Ryan MR. The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators. Can Med Assoc J 1983;128:129-131.
- Woodcock A. Training aid for pressurized inhalers. Br J Dis Chest 1980;74:395-397.
- Sterk PJ, Plomp A, van de Vate JF, Quanjer PH. Physical properties of aerosols produced by several jet- and ultrasonic nebulisers. Bull Eur Physiopathol Respir 1984;20: 65-72.
- Alvine GF, Rodgers P, Fitzsimmons KM, Ahrens RC. Disposable jet nebulizers: how reliable are they? Chest 1992;101:316-319.
- Newman SP. Aerosol generators and delivery systems. Respir Care 1991;36(9):939-951.
- Mestitz H, Copland JM, McDonald CF. Comparison of outpatient nebulized vs metered dose inhaler terbutaline in chronic airflow obstruction. Chest 1989;96:1237-1240.
- Bowton DL, Goldsmith WM, Haponik EF. Substitution of metered-dose inhalers for hand-held nebulizers: success and cost savings in a large, acute-care hospital. Chest 1992;101:305-308.
- Tenholder MF, Bryson MJ, Whitlock WL. A model for conversion from small volume nebulizer to metered dose inhaler aerosol therapy. Chest 1992;101:634-637.
- Jasper AC, Mohsenifar Z, Kahan S, Goldberg HS, Koerner SK. Cost-benefit comparison of aerosol bronchodilator delivery methods in hospitalized patients. Chest 1987;91:614-618.
- Summer W, Elston R, Tharpe L, Nelson S, Haponik EF. Aerosol bronchodilator delivery methods: relative impact on pulmonary function and cost of respiratory care. Arch Intern Med 1989;149:618-623.
- Schoonover G, Olsen GN. Pulmonary function testing in the preoperative period: a review of the literature. J Clin Surg 1982;1:125-138.
- Ruffin RE, Kenworthy MC, Newhouse MT. Response of asthmatic patients to fenoterol inhalation: a method of quantifying the airway bronchodilator dose. Clin Pharmacol Ther 1978;23:338-345.
- Berry RR, Shinto RA, Wong FH, Despars JA, Light RW. Nebulizer vs spacer for bronchodilator delivery in patients hospitalized for acute exacerbations of COPD. Chest 1989;96:1241-1246.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immuno deficiency virus, hepatitis B virus, and other blood-borne pathogens in health-care settings. MMWR 1988;37:377-388.
- Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990; 37(RR-17):1-29.
- Brady MT. Nosocomial Legionnaires disease in a children's hospital. J Pediatr 1989;115(1):46-50.
- Mastro TD, Fields BS, Breiman RF, Campbell J, Plikaytis BD, Spika JS. Nosocomial Legionnaires' disease and use of medication nebulizers. J Infect Dis 1991;162(3):667-671.
Jenkins SC, Heaton RW, Fulton TJ, Moxham J. Comparison of domiciliary nebulized salbutamol and salbutamol from a metered-dose inhaler in stable chronic airflow limitation. Chest 1987;91:804-807.
Sackner MA, Kim CS. Recent advances in the management of obstructive airways disease: auxiliary MDI aerosol delivery systems. Chest 1985;88(2, Suppl):161S-169S.
O'Reilly JF, Gould G, Kendrick AH, Laszlo G. Domiciliary comparison of terbutaline treatment by metered dose inhaler with and without conical spacer in severe and moderately severe chronic asthma. Thorax 1986;41:766-770.
Cissik JH, Bode FR, Smith JA. Double-blind crossover study of five bronchodilator medications and two delivery methods in stable asthma: is there a best combination for use in the pulmonary laboratory? Chest 1986;90:489-493.
Morgan MDL, Singh BV, Frame MH, Williams SJ. Terbutaline aerosol given through pear spacer in acute severe asthma. Br Med J Clin Res Ed 1982;285:849-850.
Melville C, Phelan PD, Landau LI. Nebulized fenoterol compared with metered aerosol. Arch Dis Child 1985;660:257-259.
Levison H, Reilly PA, Worsley GH. Spacing devices and metered dose inhalers in childhood asthma. J Pediatr 1985;107:662-668.
Turner JR, Corkery KJ, Eckman D, Gelb AM, Lipavsky A, Sheppard D. Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction. Chest 1988;93:476-481.
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