Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011;40:247-255. [PMID: 19081697 DOI: 10.1016/j.jemermed.2008.06.029]

Emergency physicians' preferences in bronchodilator delivery for asthma exacerbations: a cross-sectional study

OBJECTIVE

Asthma is a chronic respiratory disorder characterized by airway inflammation and narrowing often leading to acute exacerbations that necessitate a visit to the emergency department (ED). While life threatening cases usually require bronchodilator delivery by nebulizers, mild to moderate acute asthma exacerbations can be treated by bronchodilators delivered either by metered dose inhalers (MDI). Numerous studies have attempted to compare between the two modalities and have drawn similar conclusions in that both are comparable in efficacy with minimal differences. What is evident, however, is that physicians remain inclined to favor nebulizers in the majority of acute asthma exacerbations.

METHODS

In this questionnaire-based study, a survey was distributed to physicians who treat asthma exacerbations to examine demographics, knowledge, beliefs, and current practice in regard to bronchodilator therapy.

RESULTS

The majority (90.8%) of physicians prefer short-acting beta agonists via nebulizer, with 9.2% favoring MDI + spacer. Participants include consultants, residents, and specialists across various emergency disciplines. While 90.1% find MDI + spacer equally effective as nebulizers, advantages cited include cost-effectiveness (49.6%), shorter ED stays (63.4%), quicker administration (67.9%), and ease of use (58.8%). Challenges include availability (66.4%) and ineffectiveness in younger patients (45%). Despite this, 65.6% are willing to switch to MDI for initial asthma management in the ED, while 34.4% are resistant.

CONCLUSION

Concerns about availability and effectiveness in younger patients remain barriers. However, a significant number are willing to adopt MDIs with spacers, indicating potential for broader use with better availability and training.

A Retrospective Review of an Inhaler to Nebulizer Therapeutic Interchange Program Across a Health System

Background: The hospitals of the Saint Alphonsus Health System (SAHS) have implemented a metered dose inhaler (MDI) to nebulization therapeutic interchange program in which all orders for albuterol/ipratropium and inhaled corticosteroid/long-acting beta agonists (ICS/LABA) MDIs are therapeutically interchanged to nebulizers by pharmacy. Objectives: The primary outcome measure is to assess the percent of albuterol/ipratropium and ICS/LABA inhalers therapeutically interchanged to nebulized solutions. Secondary outcomes include assessment of readmission rates, the percentage of patients discharged with the appropriate MDI, and a financial analysis of the implementation of the therapeutic interchange program. Methods: This retrospective observational cohort study was approved by the system's institutional review board and conducted between October 15, 2019, and February 15, 2020. Adult patients with history of asthma or COPD admitted to one of the SAHS hosptials with an order placed for ipratropium/albuterol, fluticasone/salmeterol, mometasone/formoterol, or budesonide/formoterol MDIs were eligible for inclusion. Patients were excluded if they were presumed to have or tested positive for COVID-19. Results: Therapeutic interchanges were successfully completed in 94.3% of the orders included in this evaluation. Discharge discrepancies occurred in 14.3% of orders assessed. No correlation was found between discharge discrepancies and 30-day readmissions. The MDI to nebulized solution interchanges saved $13,908.16 in medication cost in the sample population. Conclusion: The first phase of implementing the SAHS inhaler to nebulizer therapeutic interchange program was operationally and clinically successful. The program is projected to continue to reduce medication waste and provide cost savings for the health system.

Nebulizer versus metered dose inhaler with space chamber (MDI spacer) for acute asthma and chronic obstructive pulmonary disease exacerbation: attitudes of patients and healthcare providers in the COVID-19 era

OBJECTIVE

Short-acting bronchodilators for asthma and chronic obstructive pulmonary disease (COPD) exacerbations are commonly delivered by nebulizers although administration using metered dose inhaler with space chamber (MDI spacer) has been shown to be equally efficacious. There are few studies examining patients' and healthcare providers' attitudes on the two administration methods in adults. This study explores patients' and healthcare providers' attitudes on the use of nebulizer versus MDI spacer for acute asthma and COPD exacerbations in adults.

METHODS

Patients admitted for asthma or COPD exacerbations, doctors, and nurses in a university-affiliated hospital were surveyed from 1 April 2021 to 30 September 2021 regarding their views on the effectiveness, ease of use, preparation and administration, side effects, and infection risk of the two administration methods.

RESULTS

Ninety-nine patients, 103 doctors, and 650 nurses completed the survey. 60.6% of patients perceived nebulizer to be more effective. Patients who found nebulizer more comfortable were more likely to prefer nebulizer (OR 43.97, p = 0.01), while those who associated it with a greater infection risk were less likely to prefer nebulizer (OR 0.15, p = 0.03). 49.5% of doctors and 49.1% of nurses perceived nebulizer to be more effective, compared to 10.7% and 34.5%, respectively, for MDI spacer. Effectiveness and patient comfort influenced doctors' and nurses' preference for nebulizer while ease of preparation and administration influenced nurses' preference only.

CONCLUSIONS

Patients and healthcare providers perceived nebulizer to be more effective. Factors unique to each group influenced their preference for nebulizer.

Quality of acute asthma care: an audit of clinical practice in a Victorian health service

OBJECTIVES

To describe acute asthma care at a large health network in metropolitan Melbourne, and evaluate the extent to which Emergency Department (ED) treatment was consistent with National Asthma Council guidelines.

DESIGN

A retrospective audit of medical records for patients admitted between July 2017 and June 2019.

SETTING

Two tertiary campuses within the Western Health network, located in Melbourne, Victoria.

PARTICIPANTS

Adult patients admitted to hospital for at least 12 hours, with a primary discharge diagnosis of asthma.

RESULTS

493 admissions were included in the analysis, representing 392 individual patients. 71% patients were female and 27% were current smokers. 96% patients had a prior asthma diagnosis, 63% had a previous hospital presentation, and 75% were prescribed an inhaled preventer. In ED, systemic corticosteroids and inhaled salbutamol were prescribed in 65% and 82% admissions respectively; adjunctive treatments included ipratropium (67% admissions), magnesium sulfate (30%), adrenaline (11%) and non-invasive ventilation (9%). Overall, ED care was guideline concordant in 59% admissions. On the wards, treatments prescribed within 24 hours of admission included corticosteroids (90% admissions), salbutamol (84%), ipratropium (64%) and inhaled preventers (63%). The proportion of patients prescribed these treatments, as well as documented follow up (for example, asthma action plans), varied significantly dependent on treating specialty.

CONCLUSION

The emergency treatment of patients with acute asthma frequently deviated from guidelines, and there was significant variation in inpatient treatment. Quality improvement initiatives which incorporate structural changes are required to improve asthma care. This article is protected by copyright. All rights reserved.

Practicing What We Teach: Increasing Inhaler Use for Mild Asthma in the Pediatric Emergency Department

INTRODUCTION

Asthma is a leading cause of pediatric emergency department (ED) visits. A metered-dose inhaler and spacer (MDI-S) device is equivalent to and more cost effective than delivery by nebulization in the ED management of mild asthma exacerbations. We aimed to increase the use of albuterol MDI-S among patients with mild asthma exacerbations using a quality improvement framework.

METHODS

We evaluated albuterol use for mild asthma exacerbations between January 2019 and March 2020 in our pediatric EDs.

RESULTS

Our primary outcome was the proportion of albuterol delivered through an MDI-S. Our process measure was the use of a new electronic order set. Balancing measures included ED length of stay, admission rates, and the use of intravenous magnesium. Interventions included forging multidisciplinary partnerships, revising clinical practice guidelines, establishing an electronic order set, and leading educational initiatives for clinicians. We demonstrated a center line shift of MDI-S use from 34.4% to 47.7%. The average length of stay, hospital admissions, and magnesium use were not affected by our interventions.

CONCLUSION

Forging multidisciplinary partnerships, creating an electronic order set prioritizing albuterol MDI-S use, and educational initiatives led to a sustained increase in albuterol MDI-S use for mild asthma in our pediatric EDs.

Confidence of nurses with inhaler device education and competency of device use in a specialised respiratory inpatient unit

We performed a cross-sectional study within a specialised respiratory inpatient unit assessing 25 nurses' [85% female, 8.0 ± 7.9 (mean ± SD) years' experience in nursing] confidence in providing inhaler device education using a self-reported questionnaire, and their competency (% correct steps) in using eight different inhaler devices. Sixteen percent of participants were 'not confident' providing inhaler education, while 84% were 'moderately' or 'extremely' confident. The mean (±SD)% correct steps for all devices was 47 ± 17%. There was no correlation between % correct steps and nursing years (r = 0.21, p = 0.31), or 'confidence' with providing inhaler education (r = 0.02, p = 0.91) but % correct steps strongly correlated with number of individual device prescriptions within the hospital in the preceding year (r = 0.78, p = 0.039). Most respiratory nurses felt confident in teaching inhaler technique but their overall demonstrated ability to correctly use inhalers was poor, especially for less frequently prescribed devices within our hospital. Regular assessment and ongoing education on correct inhaler technique for respiratory nurses is necessary to optimise all device usage by nurses, irrespective of experience or confidence.

Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes

Exercise-induced bronchoconstriction, otherwise known as exercise-induced bronchoconstriction with asthma or without asthma, is an acute airway narrowing that occurs as a result of exercise and can occur in patients with asthma. A panel of members from the American Academy of Allergy, Asthma & Immunology Sports, Exercise, & Fitness Committee reviewed the diagnosis and management of exercise-induced bronchoconstriction in athletes of all skill levels including recreational athletes, high school and college athletes, and professional athletes. A special emphasis was placed on the recommendations and regulations set forth by professional athletic organizations after a detailed review of their collective bargaining agreements, substance abuse policies, antidoping program manuals, and the World Anti-Doping Agency antidoping code. The recommendations in this review are based on currently available evidence in addition to providing guidance for athletes of all skill levels as well as their treating physicians to better understand which pharmaceutical and nonpharmaceutical management options are appropriate as well as which medications are permitted or prohibited, and the proper documentation required to remain compliant.

Metered-dose inhalers vs nebulization for the delivery of albuterol in pediatric asthma exacerbations: A cost-effectiveness analysis in a middle-income country

OBJECTIVES

Although the benefits of albuterol delivered via metered-dose inhalers with a spacer (MDI+S) have been increasingly recognized, the evidence regarding the cost-effectiveness of MDI+S compared to nebulization (NEB) is not sufficient, especially in less-affluent countries, where the clinical and economic burden of the disease is the greatest. The aim of the present study was to evaluate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations.

METHODS

A decision-analysis model was developed to estimate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was the avoidance of hospital admission.

RESULTS

For the base-case analysis, the model showed that compared to NEB, using MDI+S for the delivery of albuterol was associated with lower total costs (US$96.68 vs US$121.41 average cost per patient) and a higher probability of hospital admission avoided (0.9219 vs 0.8900), thus leading to dominance.

CONCLUSIONS

This study shows that in Colombia, an MIC, compared with NEB, the use of MDI+S for delivering albuterol for the treatment of pediatric asthma exacerbations is the preferred strategy because it is associated with a lower probability of hospital admission at lower total treatment costs.

Association of various weight-based doses of continuous albuterol on hospital length of stay

Introduction: Continuous albuterol is a mainstay in management of pediatric status asthmaticus. While the National Heart Lung and Blood Institute Asthma Guidelines suggest 0.5 mg/kg/h as the recommended dosage, there is a paucity of evidence comparing different weight-based rates on hospital outcomes.Methods: Patients requiring continuous albuterol for asthma exacerbation from January 2015 to December 2016 were identified using ICD codes. The concentration of albuterol (5 mg/h-20 mg/h) and the duration of treatment were used to determine total albuterol administration. After dividing by patient weight, average weight-based doses were divided into equal quintiles. Unadjusted and length of stay adjusted for age, initial asthma severity score, and administration of magnesium were compared among the quintiles. The same multivariate analysis was used for duration of continuous albuterol.Results: Five hundred thirty-three hospitalizations for asthma were identified of which 289 received continuous albuterol. Weight-based dosage quintiles ranged from lowest (0.07-0.29 mg/kg/h) to the highest (>0.76-3.2 mg/kg/h). Baseline characteristics were similar aside from age, race, and magnesium administration. There was no difference in adjusted length of stay or adjusted duration of continuous albuterol therapy among the five quintiles.Conclusion: No optimal weight-based dose of continuous albuterol was found. Further investigation is needed to see if lower amounts of continuous albuterol may be as efficacious as higher doses. This could improve cost of status asthmaticus management and limit the number of adverse events associated with high exposure to continuous albuterol.

Repeated doses of salbutamol and aeroallergen sensitisation both increased salbutamol-induced hypoxia in children and adolescents with acute asthma

AIM

We aimed to identify the frequency, magnitude and risk factors of salbutamol-induced hypoxia in children with acute asthma.

METHODS

This study was conducted at Hacettepe University on children who presented to the paediatric allergy clinic or the paediatric emergency room with acute asthma between July 2014 and June 2015. Vital signs, pulse oximetry-defined oxygen saturation and modified pulmonary index scores were evaluated before and after the first, second and third doses of nebulised salbutamol and repeated one and 10 days later.

RESULTS

We included 304 patients (65.7% male) from median age of 5.3 years (range 1-18 years). Salbutamol-induced hypoxia was detected in 14.7%, 3.9% and 1.3%, respectively, after the first, second and third doses of salbutamol. The risk factors for hypoxia were younger age and a higher modified pulmonary index score, but the risk factors for salbutamol-induced hypoxia were the number of salbutamol doses given in the last six hours and the presence of aeroallergen sensitisation. The maximum decrease in oxygen saturation after salbutamol was %5.

CONCLUSION

Although bronchodilators are the first-line treatment for acute asthma, they caused modest hypoxaemia, especially at repeated doses and, or, in patients with aeroallergen sensitisation.

Approaching Current and New Drug Therapies for Pediatric Asthma

As new therapies for pediatric asthma are approved by the Food and Drug Administration, clinicians should be aware of their benefits and limitations. Accompanying these therapies are potential obstacles, including the delivery of inhaled therapies and age-specific issues regarding implementation and adherence. New insights are being added to well-established controller medications, including inhaled corticosteroids and long-acting β-agonists, while new medications previously approved in adults, including tiotropium and biologics, are now being evaluated for use in children. These drugs can be useful additive therapies to treat patients who are currently not responding to guidelines-based therapy.

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia

BACKGROUND

Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data.

METHODS

Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used.

RESULTS

Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of $24/patient in the PED and $180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs.

CONCLUSIONS

Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.

The Effect of Spacer Morphology on the Aerosolization Performance of Metered-Dose Inhalers

PURPOSE

Respiratory drug delivery has been attracted great interest for the past decades, because of the high incidence of pulmonary diseases. However, despite its invaluable benefits, there are some major drawbacks in respiratory drug delivery, mainly due to the relatively high drug deposition in undesirable regions. One way to improve the efficiency of respiratory drug delivery through metered-dose inhalers (MDI) is placing a respiratory spacer between the inhaler exit and the mouth. The aim of this study was to assess the effect of type and shape of spacer on the aerosolization performance of MDIs.

METHODS

A commercial Beclomethasone Dipropionate (BDP) MDI alone or equipped with two different spacer devices (roller and pear type) widely distributed in the world pharmaceutical market was used. The effect of spacers was evaluated by calculating aerosolization indexes such as fine particle fraction (FPF), mass median aerodynamic diameters (MMAD) and geometric standard deviation (GSD) using the next generation impactor.

RESULTS

Although one of the spacers resulted in superior outcomes than the other one, but it was not statistically significant.

CONCLUSION

The results confirmed that the type and shape of spacer did not substantially influence the aerosolization performance of MDIs.

The World Anti-Doping Code: can you have asthma and still be an elite athlete?

KEY POINTS

The World Anti-Doping Code (the Code) does place some restrictions on prescribing inhaled β2-agonists, but these can be overcome without jeopardising the treatment of elite athletes with asthma.While the Code permits the use of inhaled glucocorticoids without restriction, oral and intravenous glucocorticoids are prohibited, although a mechanism exists that allows them to be administered for acute severe asthma.Although asthmatic athletes achieved outstanding sporting success during the 1950s and 1960s before any anti-doping rules existed, since introduction of the Code's policies on some drugs to manage asthma results at the Olympic Games have revealed that athletes with confirmed asthma/airway hyperresponsiveness (AHR) have outperformed their non-asthmatic rivals.It appears that years of intensive endurance training can provoke airway injury, AHR and asthma in athletes without any past history of asthma. Although further research is needed, it appears that these consequences of airway injury may abate in some athletes after they have ceased intensive training. The World Anti-Doping Code (the Code) has not prevented asthmatic individuals from becoming elite athletes. This review examines those sections of the Code that are relevant to respiratory physicians who manage elite and sub-elite athletes with asthma. The restrictions that the Code places or may place on the prescription of drugs to prevent and treat asthma in athletes are discussed. In addition, the means by which respiratory physicians are able to treat their elite asthmatic athlete patients with drugs that are prohibited in sport are outlined, along with some of the pitfalls in such management and how best to prevent or minimise them.

Pharmacotherapy of critical asthma syndrome: current and emerging therapies

The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.

A Rationale for Going Back to the Future: Use of Disposable Spacers for Pressurised Metered Dose Inhalers

The introduction of pressurised metered dose inhalers (MDIs) in the mid-1950s completely transformed respiratory treatment. Despite decades of availability and healthcare support and development of teaching aids and devices to promote better use, poor pMDI user technique remains a persistent issue. The main pMDI user aid is the spacer/valved holding chamber (VHC) device. Spacer/chamber features (size, shape, configuration, construction material, and hygiene considerations) can vie with clinical effectiveness (to deliver the same dose as a correctly used pMDI), user convenience, cost, and accessibility. Unsurprisingly, improvised, low-cost alternatives (plastic drink bottles, paper cups, and paper towel rolls) have been pressed into seemingly effective service. A UK law change permitting schools to hold emergency inhalers and spacers has prompted a development project to design a low-cost, user-friendly, disposable, and recyclable spacer. This paper spacer requires neither preuse priming nor washing, and has demonstrated reproducible lung delivery of salbutamol sulphate pMDI, comparable to an industry-standard VHC, an alternative paperboard VHC, and pMDI alone. This new device appears to perform better than these other VHC devices at the low flow rates thought achievable by paediatric patients. The data suggest that this disposable spacer may have a place in the single-use emergency setting.

Drug-targeting methodologies with applications: A review

Targeted drug delivery to solid tumors is a very active research area, focusing mainly on improved drug formulation and associated best delivery methods/devices. Drug-targeting has the potential to greatly improve drug-delivery efficacy, reduce side effects, and lower the treatment costs. However, the vast majority of drug-targeting studies assume that the drug-particles are already at the target site or at least in its direct vicinity. In this review, drug-delivery methodologies, drug types and drug-delivery devices are discussed with examples in two major application areas: (1) inhaled drug-aerosol delivery into human lung-airways; and (2) intravascular drug-delivery for solid tumor targeting. The major problem addressed is how to deliver efficiently the drug-particles from the entry/infusion point to the target site. So far, most experimental results are based on animal studies. Concerning pulmonary drug delivery, the focus is on the pros and cons of three inhaler types, i.e., pressurized metered dose inhaler, dry powder inhaler and nebulizer, in addition to drug-aerosol formulations. Computational fluid-particle dynamics techniques and the underlying methodology for a smart inhaler system are discussed as well. Concerning intravascular drug-delivery for solid tumor targeting, passive and active targeting are reviewed as well as direct drug-targeting, using optimal delivery of radioactive microspheres to liver tumors as an example. The review concludes with suggestions for future work, considereing both pulmonary drug targeting and direct drug delivery to solid tumors in the vascular system.

Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

BACKGROUND

In acute asthma inhaled beta(2)-agonists are often administered by nebuliser to relieve bronchospasm, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting.

OBJECTIVES

To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta(2)-agonists for acute asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Trial Register and reference lists of articles. We contacted the authors of studies to identify additional trials. Date of last search: February 2013.

SELECTION CRITERIA

Randomised trials in adults and children (from two years of age) with asthma, where spacer beta(2)-agonist delivery was compared with wet nebulisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied study inclusion criteria (one review author for the first version of the review), extracted the data and assessed risks of bias. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CIs).

MAIN RESULTS

This review includes a total of 1897 children and 729 adults in 39 trials. Thirty-three trials were conducted in the emergency room and equivalent community settings, and six trials were on inpatients with acute asthma (207 children and 28 adults). The method of delivery of beta(2)-agonist did not show a significant difference in hospital admission rates. In adults, the risk ratio (RR) of admission for spacer versus nebuliser was 0.94 (95% CI 0.61 to 1.43). The risk ratio for children was 0.71 (95% CI 0.47 to 1.08, moderate quality evidence). In children, length of stay in the emergency department was significantly shorter when the spacer was used. The mean duration in the emergency department for children given nebulised treatment was 103 minutes, and for children given treatment via spacers 33 minutes less (95% CI -43 to -24 minutes, moderate quality evidence). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -5% baseline (95% CI -8% to -2%, moderate quality evidence), as was the risk of developing tremor (RR 0.64; 95% CI 0.44 to 0.95, moderate quality evidence).

AUTHORS' CONCLUSIONS

Nebuliser delivery produced outcomes that were not significantly better than metered-dose inhalers delivered by spacer in adults or children, in trials where treatments were repeated and titrated to the response of the participant. Spacers may have some advantages compared to nebulisers for children with acute asthma.

[Inhalation devices: characteristics, modeling, regulation and use in routine practice. GAT Aerosolstorming, Paris 2011]

Aerosoltherapy is a first-line treatment for chronic obstructive respiratory diseases such as asthma and COPD. Treatment modalities and devices are varied and the choice of the device must be adapted to and optimized for every patient. Spacers can be used for some categories of patients for whom the use of other devices turns out to be complicated. The improvement of these treatments requires the optimization of the lung deposition of inhaled particles; lung modeling plays an essential role in the understanding of the mechanisms of flow in the airways. Regulations must frame prescription of inhaled treatments to optimize its quality and, thus, the care for these chronic diseases. Many generally-accepted ideas concerning these treatments turn out to be false. Inhaled treatments are constantly evolving, both pharmacologically and technologically.