For Thomas F. Plaut, MD, an author and asthma specialist in Amherst, Mass, selecting a nebulizer system comes down to one main factor: the nebulizer cup.

While some nebulizer compressors are smaller and run more quietly than others, for him, the bottom line when deciding the best possible product for a patient is how much medicine the device delivers into the lungs, and that is determined almost solely by the cup that produces the medicine mist.

A good nebulizer cup does two things, Plaut says. First, it has a high percentage of particles in the respirable range, and, second, it traps the medication the patient breathes out and recycles it so less is wasted when the patient exhales.

“The best nebulizer will be more than four times as effective as the worst, the worst being one that has a low percentage of particles in the respirable range and, second, does not recycle,” he says.

For Tom Fry, a registered pharmacist and owner of Pharmacy Inc, Murray, Ky, having a good nebulizer is important because it helps with patient compliance. “If patients notice significant results with treatment, they are a lot more likely to become compliant,” he says. “And the smaller the particle size, the greater the chance that they will see a significant result.”

The other factor Fry finds important in his three HME stores and one pharmacy in western Kentucky is treatment time. “We like to use the high-speed reusable [nebulizer circuits] because they are faster, and the biggest reason patients are not involved in taking their medications is time involved in doing it,” he says. “If it were as simple as taking a pill, compliance would be much greater. But the patients perceive it as being a hassle, an inconvenience, and a time-consuming job that they don’t want to perform several times a day. So they avoid it. Anything you can do to cut down on the length of their treatment is going to have a positive effect on their compliance.”

Poor compliance hurts not only the patient. It can also causes problems for referral sources, and dissatisfied referral sources are not good for Pharmacy Inc. “It is better for everyone when patients are getting better and not getting sick and going to the doctor or to the hospital,” Fry says.

Minimizing Billing Hassles
Another reason Fry prefers the reusable nebulizer circuits over the disposable ones is that they simplify his internal billing processes. Rather than having to bill for a fairly low reimbursement item every other week, he can bill for one high reimbursement item once every 6 months.

“Disposables are so inexpensive that a lot of people hardly even think it is worth the trouble to do the paperwork to bill for them,” he says.

The one downside of reusables is that some patients like having a backup nebulizer circuit, as they would if they had a few disposables on hand. But Fry has an easy solution to this problem. “As a rule, I put all of my patients on a high-speed reusable circuit, and if they express a concern that they only have one, then I would provide them with a non-reusable, disposable circuit, so they can keep that in the event they misplace their reusable circuit,” he says.

This is a solution also adopted by the national HME company Apria, based in Lake Forest, Calif. It gives all of its nebulizer patients a kit with an educational video, a high-speed reusable nebulizer circuit, and a disposable circuit as a backup, says Robert Fary, its director of respiratory care.

“Sometimes they might have a problem when they are cleaning and reassembling their reusable and we don’t want them missing a treatment while they are waiting for a replacement nebulizer from us,” Fary says.

Keep it Clean
The other issue with reusable nebulizers, of course, is cleanliness. The two most likely sources of contamination are a multi-dose medicine vial and the nebulizer cup. Two hospital studies report that they found bacteria in the nebulizers of 31 of 43 patients. However, no patient had colonization in the throat or developed pneumonia.

Plaut has reviewed home use of nebulizers and says he has never seen a problem related to a contaminated nebulizer used in the home. Certainly, cleaning according to the manufacturer’s directions will keep the likelihood of infection low. Nebulizer providers should educate patients on cleaning the nebulizer.

“Most patients—if you train them properly on how to clean their nebulizer, whether they are using a vinegar and water solution for a device that can’t be put into a dishwasher, or they are using a reusable that can go into a dishwasher and can be washed in hot water—are pretty good about doing it,” Fry says.

In addition, it is important to make sure patients replace their nebulizer circuits when they are supposed to. “It is extremely common for patients to keep using disposable nebulizer cups for weeks,” Plaut says.

Whether this is dangerous or not may depend on whom you consult, but it is definitely a missed opportunity for any equipment provider who does not encourage patients to replace their equipment when they are eligible to do so.

And while only you can determine which products are right for your company to stock, don’t be shy about questioning manufacturers on the specifics of their products, such as the percentage of particles in the respirable range, Plaut counsels.

Lena Lindahl is editor of Dealer/Provider.