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ORIGINAL ARTICLE
Advanced Emergency Medicine Volume 7 Issue 1 | 2018 | 1
A comparative study of two pneumatic nebulizers for the treatment of
Chronic Obstructive Pulmonary Disease (COPD); pre and post
modification with polypropylene membrane
Lei Liu1, Bin Liu2
1Department of Respiratory Medicine, the Fourth Affiliated Hospital of Harbin Medical University, Harbin 150001, China
2The First Affiliated Hospital of Harbin M edical University, Harbin 150001, China
Abstract: Background and Objective: Pneumatic nebulizers (PN) are commonly used to treat COPD. We aimed to
evaluate and compare two PNs with respect to effectiveness and delivery, and the effect of using a membrane filter to
prevent drug wastage. Methods: COPD patients (240) were divided into an experimental group (EG); treated with a
YZB/GEM1058-2009 medical atomizer, and a control group (CG); treated with a DNA100 medical atomizer. A
polypropylene membrane was then applied to each nebulizer. Results: Wastage per inhalation was 79.56% in the EG,
and 87% in the CG and reduced to 35.3% in the EG and 42.1% in the CG following application of a polypropylene
membrane. The ratio of drug not atomised per inhalation was 10.32% in the EG, and 24.52% in the CG and altered to
30.2% and 37.3% with the polypropylene membrane. The total effective rate, cure rate and weekly efficiency were
96.7%, 73.3% and 93.3%, respectively in the EG, and 93.3%, 60% and 83.3% respectively in the CG, and increased to
100%, 93.3% and 100%, respectively in the EG, and 100%, 83.3% and 93.3%, respectively, in the CG with the
membrane application. The number of days required to be effective was 4±2.4 days in the EG, and 7±3.8 in the CG and
decreased to 3±1.4 in the EG, and 5±3.1 in the CG with the membrane. Conclusions: There was a high percentage of
drug wastage with both PNs. YZB/GEM1058-2009 was significantly more effective than DNA100 but a polypropylene
microporous membrane significantly improved the effectiveness of both.
Keywords: Chronic Obstructive Pulmonary Disease; pneumatic nebulizer; drug waste; polypropylene microporous
membrane
1. Introduction
COPD is a common and frequently occurring disease of the respiratory system. [1]COPD has risen to the fourth
leading cause of mortality world-wide[2]. COPD represents an important public health challenge[3].
Aerosol inhalation is a commonly used method for the clinical treatment of acute exacerbation of COPD.[4,5]
Pneumatic nebulizers are commonly used in clinics and are usually connected to the central oxygen supply system of
the hospital; also called an oxygen nebulizer.[6] Pneumatic atomizer models are diverse, however, there are no literature
reports on the use of pneumatic nebulizers with respect to drug wastage. This study compared the effectiveness and
drug wastage of two types of pneumatic nebulizers widely used in two large teaching hospitals.
Polypropylene microporous membrane is a non-toxic polymer material used as a membrane filter in a wide number
Copyright © 2018 Lei Liu et al.
doi: 10.18686/aem.v7i1.121
This is an open-access article distributed under the terms of the Creative Commons Attribution Unported License
(http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
2 | Lei Liu et al. Advanced Emergency Medicine
of applications including medicine, chemicals, food, beverages and other fields[7]. We applied this polypropylene
microporous membrane to the pneumatic nebulizer with the aim of reducing drug wastage, and further compared the
two pneumatic nebulizer types following the application of this membrane.
2. Methods
This study was approved by the Harbin Medical University Medical Ethics Committee and having been informed
of the purpose of the study, all patients agreed to participate. A total of 240 patients hospitalized with COPD
exacerbations were selected from June 2016 to April 2017 in the Department of Respiration of the First and Fourth
Affiliated Hospitals of Harbin Medical University. The experimental group (EG) and the control group (CG) both
comprised 120 COPD patients from the Fourth Affiliated Hospital of Harbin Medical University. Both groups
comprised 60 males and 60 females, and their age ranged from 55 to 65 years old. The average age was 61±5.4 years in
the EG group and 61±4.9 years in the CG. The two groups of patients were comparable. Patients were excluded from
the study if they did not cooperate with aerosol inhalation.
The 60 cases of EG were treated with the YZB/GEM1058-2009 medical atomizer (PARI GmbH, Germany),
(Figure 1C). The 60 cases of CG were treated with the DNA100 medical atomizer (Chong Ren Medical Devices Co.,
Ltd Xiamen, China), (Figure 1C). The two nebulizers were connected to the central oxygen supply system of the
hospital. The two groups of patients were treated with aerosol inhalation of budesonide suspension (2 mg per treatment,
AstraZeneca Pty Ltd, UK), a compound ipratropium bromide solution (2.5 mL per treatment, Boehringer Ingelheim,
Germany), and an ambroxol hydrochloride injection（15 mg per treatment, Tianjin Pharmaceutical Research Institute
Pharmaceutical Co., Ltd., China). The pressure outlet of the nebulizers was in contact with activated carbon particles
(Wanjia Group Co., Ltd. China) that are able to adsorb the atomised drugs (Figure 1A and 1B). An electronic balance
（ED224S-PCE, Sartorius, Germany) was used to weigh the drugs.
Nebulizer inhalation was conducted as follows: The nebulizer was placed next to the patient’s bed and the air inlet
of the nebulizer was connected to the central oxygen support system of the hospital. The suction nozzle was placed into
the mouth of the patient, the pressure outlet of the nebulizer was connected to the activated carbon particles, and the
central oxygen support system was opened at a flow rate of 5-6 L/min for 30 min, (Figure 1A and 1B).
Figure 1, A; Working diagram of the nebulizer used in the experimental group.
Figure 1, B; Working diagram of the nebulizer in the control group.
Figure 1, C; A static display of the nebulizers in the experimental group and in the control group.
Advanced Emergency Medicine Volume 7 Issue 1 | 2018 | 3
The 60 cases of EG were treated with the YZB/GEM1058-2009 medical atomizer with a polypropylene
microporous membrane modification. The 60 cases of CG were treated with the DNA100 medical atomizer with a
polypropylene microporous membrane modification. The operation processes were the same as with application of a
polypropylene microporous membrane (pore size, 1µm, Hai-ning Yan-guan Long-shun Filtration Equipment Factory,
Zhe-jiang Province, China) to the pneumatic nebulizer and the pressure outlet. (Figure 2D and 2E).
Figure 2, D; Working diagram of the nebulizer in the experimental group with polypropylene microporous membrane.
Figure 2, E; Working diagram of the nebulizer in the control group with polypropylene microporous membrane.
To calculate the average amount of drug wastage per inhalation we used the formula: the average amount of
residual drug in the atomizer cup + the average amount of drug discharged into the air - the average amount of water
vapour discharged by the human body with exhalation. Drug wastage ratio per inhalation = the average amount of drug
wastage per inhalation / net weight of atomized medicine per inhalation ×100%. The ratio of drug not atomised per
inhalation = the average amount of residual drug dose in atomizer cup per inhalation / net weight of atomized medicine
per inhalation ×100%. The average amount of money wasted per inhalation = drug wastage ratio × the purchase fee
per inhalation.
The criteria for efficiency were defined as recovery, i.e. if the patient's symptoms and lung wheeze completely
disappeared, improvement, i.e., the patient's symptoms and lung wheeze improved significantly, and an invalid response,
i.e., no improvement of symptoms and lung wheeze.
Total effective rate was calculated as [(number of cured cases + number of improved cases) / total number of cases]
× 100%. Cure rate = (number of cured cases / total number of cases) × 100%. Weekly efficiency was calculated as
[(number of cured cases of aerosol inhalation weekly + number of improved cases of aerosol inhalation weekly) / total
number of cases] × 100%. The average time required to achieve an effective outcome (improved or cured) was
calculated on a daily basis (d).
Statistical methods: The measurement data were expressed as ±s, and the enumeration data were expressed as a
percentage. SPSS17.0 software was used for statistical analysis (P<0.05 was considered statistically significant). The
measured results were in accord with the normal distribution, homogeneity of variance of measured values using
Levene's Test. The t test value was used if the variance was homogeneous, the Satterthwaite approximate t test was used
4 | Lei Liu et al. Advanced Emergency Medicine
if the variance was not uniform, and the Chi square test value was used to compare the rate.
3. Results
The average net weight of the drugs per inhalation was 8.7984±0.0385 grams.
The total cost of each inhalation was 7.18 USD and included 5.33 USD for the budesonide suspension, 0.91 USD
for the compound ipratropium bromide solution and 0.94 USD for the ambroxol hydrochloride injection. The average
amount of drug wastage per inhalation was 6.9998 ±0.004 grams (79.56%) for the EG, and 7.6546±0.0029 grams (87%)
for the CG (P<0.001). The average ratio of drug not atomized per inhalation was 10.32% for the EG, and 24.52% for
the CG. The total effective rate was 96.7% for the EG, and 93.3% for the CG (P>0.05). The cure rate (P<0.001) and
weekly efficiency (P<0.05) were 73.3%, and 93.3%, respectively for the EG, and 60%, and 83.3%, respectively for the
CG. The average number of days required to be effective was 4±2.4 days for the EG, and 7±3.8 days for the CG
(P<0.05, Table 1).
Table 1. Comparison of the experimental group(EG) and the control group(CG)
After application of the polypropylene microporous membrane the average amount of drug wastage per inhalation
was reduced to 3.1032 ±0.025 grams (35.27%) in the EG, and 3.7015±0.0339 grams (42.07%) in the CG (P<0.001).
The average amount of drug not atomised per inhalation process was 2.6571±0.1325 grams (30.2%) in the EG, and
Advanced Emergency Medicine Volume 7 Issue 1 | 2018 | 5
3.2818±0.4234 grams (37.3%) in the CG (P<0.001). The average amount of money wasted per inhalation was 0.32
USD in the EG and 0.39 USD in the CG. The total effective rate was 100% in the EG and 100% in the CG (P>0.05).
The cure rate (P<0.05) and weekly efficiency (P<0.05) were 93.3% and 100%, respectively in the EG, and 83.3% and
93.3%, respectively in the CG. The average number of days required to be effective was 3±1.4 days in the EG and
5±3.1 days in the CG.
Thus, the use of the polypropylene membrane improved the total effective rate in the EG from 96.7% to 100%
(P>0.05), the cure rate from 73.3% to 93.3% (P<0.05), the weekly efficiency from 93.3% to 100% (P<0.05), and the
average number of days required to be effective from 4±2.4 to 3±1.4 (P>0.05). In the CG total effective rate improved
from 93.3% to 100% (P<0.05), cure rate improved from 60% to 83.3% (P<0.05), weekly efficiency from 83.3% to
93.3% (P<0.05), and the average number of days required to be effective improved from 7±3.8 to 5±3.1 (P<0.05) (Table
3).
Table 3. Comparison of the curative effect of nebulizers before(A) and after(B) the application of the polypropylene membrane
in the experimental group (EG) and control group (CG)
4. Discussion
Aerosol inhalation is undertaken via a specialised atomization device that sprays the medicinal solution or
suspension into tiny droplets or particles that can be suspended as a gas and inhaled into the airways and alveoli to
6 | Lei Liu et al. Advanced Emergency Medicine
target lesions and treat disease. As it directly targets the lesions in the airway, the liver can be bypassed, unlike other
medicinal applications. It also has the advantages of rapid onset, good curative effect, convenient use, less side effects,
etc., and has thus become one of the most commonly used methods for the treatment of respiratory diseases.[4,5]
There are three types of medical nebulizers including the pneumatic nebulizer, the ultrasonic nebulizer, and the
vibrating-mesh nebulizer. Oxygen delivery devices with a pneumatic nebulizer function are widely used in
Japan[6],China[8] and the world[9]. Disposable pneumatic nebulizers not only protect patients from infection, but are also
low cost and easy to use. Yin Xiao-Jing[8] reported that treating the acute exacerbation of COPD with a pneumatic
nebulizer not only improves blood oxygen saturation, but also alleviates the incidence of symptoms such as shortness
of breath. The curative effect was superior to the medical ultrasonic atomizer.
Pneumatic nebulizers are currently the most commonly used inhalation method in clinical practice in China despite
still having many shortcomings. The results of this study showed that the ability of the two different pneumatic
nebulizers to atomize the drug was different. The aerodynamic atomizer used in the EG was more capable of atomizing
the drug than the atomizer used in the CG where the amount of drug not atomized was significantly higher than in the
EG. Thus, it would seem that the clinical selection of pneumatic nebulizer is important to avoid drug wastage.
Drug wastage in the EG was 79.56% and 87% in the CG. The cost of the drugs per inhalation was 7.18 USD, thus
the amount wasted equated to a staggering 5.71 USD per inhalation in the EG and 6.24 USD in the CG. Similarly, our
data on the effective rates, cure rates, weekly efficiency and number of days required to be effective also prompted us to
look for better pneumatic nebulizers, and highlighted the need for more innovative designs. Disposable pneumatic
nebulizers are currently widely used in clinical practice, and with atmospheric pollution levels, infection rates and
airway disease rates as they are; there is a greater need for inhalation treatment and pneumatic nebulizers. Thus, better
nebulizers, in particular pneumatic nebulizers, may have a significant economic benefit in China, and the rest of the
world.
Polypropylene microporous membrane is a non-toxic polymer that is widely used in medicine, chemicals,
food, beverages and other fields. We applied the polypropylene microporous membrane to the pneumatic nebulizer,
resulting in a significant decrease in the amount of drugs, and money, wasted per inhalation in both groups. Similarly,
all other factors tested were improved, i.e. the amount of drug not atomized, the total effective rate, the cure rate, the
weekly efficiency and the average number of days required to be effective. The reduction in drug loss and amount of
drug not atomised may have been because some of the droplets produced by the nebulizer were unable to pass through
the membrane, and eventually attached to the wall of the pneumatic nebulizers. This minor modification resulted in a
major improvement and would seem worth applying to the clinical setting.
5. Conclusions
The ability of the two different pneumatic nebulizers to atomise the drug differed; the YZB/GEM1058-2009
medical atomizer was significantly more capable of atomisation than the DNA100 medical atomizer. Thus, the clinical
selection of pneumatic nebulizer is important to avoid drug wastage. With such a high rate of waste and such a large
amount of money wasted in the inhalation process there is a need for better pneumatic nebulizers, and a call for more
innovative designs.
We were able to significantly improve the delivery and effectiveness of two pneumatic nebulizers with the simple
application of a polypropylene microporous membrane.
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