1
|
Csonka P, Tapiainen T, Mäkelä MJ, Lehtimäki L. Heterogeneity of emergency treatment practices in wheezing preschool children. Acta Paediatr 2021; 110:2448-2454. [PMID: 33987866 DOI: 10.1111/apa.15915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 04/01/2021] [Accepted: 05/11/2021] [Indexed: 12/20/2022]
Abstract
AIM Our aim was to survey treatment practices used for preschool children with wheezing in emergency rooms (ER) focussing on inhalation device choice and handling, face mask use, salbutamol dosing and written instructions. We sought to assess whether current protocols are in line with published evidence and guidelines. METHODS This is a cross-sectional survey done in paediatric ER units located in Finnish municipalities with more than 10 000 inhabitants. RESULTS Of the 100 units contacted, 50% responded. More than 50% of the units used nebulisers. Only 13% of the units administered salbutamol in single puffs. More than 30% of the units lacked criteria on face mask use. Poor co-operation had no effect on the dose of salbutamol in 62% of the units. Ensuring tight mask-to-face seal was included in the training in 20% of the units. A written action plan was provided to the caregivers in 28% of the units. CONCLUSION ER treatment guidelines for preschool children with wheezing are poorly endorsed. Research is needed to identify approaches to guideline implementation that are specific for primary care. Clinical research should focus on strengthening recommendations that are currently not embraced. ER treatment protocols need to be updated and adherence to guidelines should be re-evaluated.
Collapse
Affiliation(s)
- Péter Csonka
- Centre for Child Health Research Tampere University and Tampere University Hospital Tampere Finland
- Terveystalo Healthcare Tampere Finland
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine Oulu University Hospital and PEDEGO Research Unit University of Oulu Oulu Finland
| | - Mika J. Mäkelä
- Skin and Allergy Hospital Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Lauri Lehtimäki
- Allergy Centre Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| |
Collapse
|
2
|
Seif SM, Elnady MA, Rabea H, Saeed H, Abdelrahim ME. Effect of different connection adapters on aerosol delivery in invasive ventilation setting; an in-vitro study. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2020.102177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
3
|
Csonka P, Tapiainen T, Mäkelä MJ, Lehtimäki L. Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature. Eur J Pediatr 2021; 180:3101-3109. [PMID: 33877400 PMCID: PMC8055476 DOI: 10.1007/s00431-021-04074-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/06/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
Our aim was to synthesize the published literature on factors that potentially affect the delivery of bronchodilators using valved holding chambers (VHC) in preschool children. We also aimed to identify those attributes that are not yet incorporated or clearly stated in the guidelines and those topics that are still lacking sufficient data. There is strong evidence supporting several recommendations in current guidelines. Based on present knowledge, bronchodilators should be delivered by VHC administering each puff separately. Face mask should be omitted as soon as the child can hold the mouthpiece of the VHC tightly between the lips and teeth. Based on the review, we suggest adding a specific note to current guidelines about the effect of chamber volume and the impact of co-operation during drug administration. Calming the child and securing a tight face-to-mask seal is critical for successful drug delivery. There is not enough evidence to make specific recommendations on the most reliable VHC and face mask for children. There is an urgent need for studies that evaluate and compare the effectiveness of VHCs in various clinical settings in wide age-groups and respiratory patterns. In addition, there is insufficient data on ideal chamber volume, material, and effective antistatic treatment. What is Known: • Valved holding chambers (VHC) should not be considered interchangeable when used with pressurized metered dose inhalers (pMDI). • Drug delivery is influenced by VHC volume, aerodynamic and electrostatic properties; mask fit; respiratory pattern and co-operation during inhalation; and the number of puffs actuated. What is New: • The impact of co-operation, VHC volume, and good mask-to-face fit during drug inhalation is not stressed enough in the guidelines. • Studies are urgently needed to evaluate the effectiveness of different VHCs in various clinical settings focusing on VHC electrostatic properties, respiratory patters, face masks, and ideal pMDI+VHC combinations.
Collapse
Affiliation(s)
- Péter Csonka
- Centre for Child Health Research, Tampere University and Tampere University Hospital, Kalevantie 4, 33014 Tampereen yliopisto, Tampere, Finland. .,Terveystalo Healthcare, Tampere, Finland.
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital and PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Mika J. Mäkelä
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland ,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| |
Collapse
|
4
|
Csonka P, Lehtimäki L. Antistatic treatment and salbutamol dosing have variable effect on drug delivery of valved holding chambers. Pulm Pharmacol Ther 2019; 59:101857. [DOI: 10.1016/j.pupt.2019.101857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/26/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
|
5
|
Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res 2018; 4:00065-2018. [PMID: 29928649 PMCID: PMC6004521 DOI: 10.1183/23120541.00065-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/18/2018] [Indexed: 11/05/2022] Open
Abstract
We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.
Collapse
Affiliation(s)
- Walter Vincken
- Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | - Chris J Corrigan
- Faculty of Life Sciences and Medicine, King's College London/Guy's and St Thomas's NHS Foundation Trust, London, UK
| |
Collapse
|
6
|
Dissanayake S, Suggett J. A review of the in vitro and in vivo valved holding chamber (VHC) literature with a focus on the AeroChamber Plus Flow-Vu Anti-static VHC. Ther Adv Respir Dis 2018; 12:1753465817751346. [PMID: 29378477 PMCID: PMC5937155 DOI: 10.1177/1753465817751346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022] Open
Abstract
Valved holding chambers (VHCs) reduce the need for inhalation-actuation coordination with pressurized metered dose inhalers (pMDIs), reduce oropharyngeal drug deposition and may improve lung deposition and clinical outcomes compared to pMDIs used alone. While VHCs are thus widely advocated for use in vulnerable patient groups within clinical and regulatory guidelines, there is less consensus as to whether the performance differences between different VHCs have clinical implications. This review evaluates the VHC literature, in particular the data pertaining to large- versus small-volume chambers, aerosol performance with a VHC adjunct versus a pMDI alone, charge dissipative/conducting versus non-conducting VHCs, and facemasks, to ascertain whether potentially meaningful differences between VHCs exist. Inconsistencies in the literature are examined and explained, and relationships between in vitro and in vivo data are discussed. A particular focus of this review is the AeroChamber Plus® Flow-Vu® Anti-static VHC, the most recent iteration of the AeroChamber VHC family.
Collapse
Affiliation(s)
| | - Jason Suggett
- Trudell Medical International, London, Ontario,
Canada
| |
Collapse
|
7
|
Levy ML, Dekhuijzen PNR, Barnes PJ, Broeders M, Corrigan CJ, Chawes BL, Corbetta L, Dubus JC, Hausen T, Lavorini F, Roche N, Sanchis J, Usmani OS, Viejo J, Vincken W, Voshaar T, Crompton GK, Pedersen S. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med 2016; 26:16017. [PMID: 27098045 PMCID: PMC4839029 DOI: 10.1038/npjpcrm.2016.17] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/23/2016] [Accepted: 02/09/2016] [Indexed: 01/04/2023] Open
Abstract
Health professionals tasked with advising patients with asthma and chronic obstructive pulmonary disease (COPD) how to use inhaler devices properly and what to do about unwanted effects will be aware of a variety of commonly held precepts. The evidence for many of these is, however, lacking or old and therefore in need of re-examination. Few would disagree that facilitating and encouraging regular and proper use of inhaler devices for the treatment of asthma and COPD is critical for successful outcomes. It seems logical that the abandonment of unnecessary or ill-founded practices forms an integral part of this process: the use of inhalers is bewildering enough, particularly with regular introduction of new drugs, devices and ancillary equipment, without unnecessary and pointless adages. We review the evidence, or lack thereof, underlying ten items of inhaler ‘lore’ commonly passed on by health professionals to each other and thence to patients. The exercise is intended as a pragmatic, evidence-informed review by a group of clinicians with appropriate experience. It is not intended to be an exhaustive review of the literature; rather, we aim to stimulate debate, and to encourage researchers to challenge some of these ideas and to provide new, updated evidence on which to base relevant, meaningful advice in the future. The discussion on each item is followed by a formal, expert opinion by members of the ADMIT Working Group.
Collapse
Affiliation(s)
- Mark L Levy
- General Practitioner and Respiratory Lead, Harrow, London, UK
| | - P N R Dekhuijzen
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - P J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
| | - M Broeders
- University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - C J Corrigan
- Department of Respiratory Medicine and Allergy, King's College London School of Medicine, London, UK
| | - B L Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - L Corbetta
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - J C Dubus
- Unité de Medicine Infantile, Marseille, France
| | | | - F Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - N Roche
- Service de Pneumologie et Soins Intensifs Respiratoires, Groupe Hospitalier Cochin, Université Paris-Descartes, Paris, France
| | - J Sanchis
- Departament de Pneumologia, Hospital de la Santa Creuide Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Omar S Usmani
- NIHR Career Development Fellow, National Heart and Lung Institute (NHLI), Imperial College London, UK.,Royal Brompton Hospital, London, UK
| | - J Viejo
- Hospital General Yagüe de Burgos, Spain
| | - W Vincken
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Dienst Pneumologie, Brussels, Belgium
| | | | | | - Soren Pedersen
- Pediatric Research Unit, University of Southern Denmark, Kolding Hospital, Kolding, Denmark
| |
Collapse
|
8
|
Ferré A, Dres M, Roche N, Antignac M, Becquemin MH, Trosini V, Vecellio L, Chantrel G, Dubus JC. [Inhalation devices: characteristics, modeling, regulation and use in routine practice. GAT Aerosolstorming, Paris 2011]. Rev Mal Respir 2012; 29:191-204. [PMID: 22405113 DOI: 10.1016/j.rmr.2011.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 12/27/2011] [Indexed: 10/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- A Ferré
- Service de pneumologie et réanimation, université Paris Descartes, Hôtel-Dieu, Paris, France
| | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Abstract
Albuterol (salbutamol outside the USA) is used to acutely relieve symptoms related to airway obstruction and prevent exercise-induced bronchospasm. Albuterol is most commonly administered by metered-dose inhaler (MDI). MDIs had used chlorofluorocarbon (CFC) propellants, but CFCs accumulate in the stratosphere and contribute to ozone catabolism. Loss of the 'ozone layer', which filters UVB rays, has public health concerns. Albuterol has been reformulated in MDIs using hydrofluoroalkane (HFA) propellants, which do not affect the ozone layer. Albuterol HFA MDIs deliver the same amount of drug per puff with similar particle size distributions as albuterol CFC MDIs, resulting in comparable bronchodilator efficacy of the two products. The highly favorable safety profile of albuterol has not been altered with reformulation. The propellant HFA-134a appears to be devoid of safety concerns.
Collapse
Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, and Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, 110 Irving Street, NW Washington, DC 20010, USA.
| |
Collapse
|
10
|
Lavorini F, Fontana GA. Targeting drugs to the airways: The role of spacer devices. Expert Opin Drug Deliv 2009; 6:91-102. [PMID: 19236210 DOI: 10.1517/17425240802637862] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM Spacer devices are inhalation aids of varying dimension and complexity, specifically designed to overcome problems with the use of pressurised metered dose inhalers (pMDIs). The aim of this review is to examine the current understanding about these inhalation devices and discuss their advantages and disadvantages. METHODS The pertinent literature concerning the characteristics and effects of spacers on delivery and lung deposition of inhaled medications, as well as their clinical efficacy in patients with reversible airway obstruction, is examined. RESULTS Spacers minimise problems of poor inhalation technique with pMDI, reduce oropharyngeal deposition and increase lung deposition. Spacers improve the clinical effect of inhaled medications, especially in patients unable to use a pMDI properly. Compared to both pMDIs and dry-powder inhalers, spacers may increase the response to beta-adrenergic bronchodilators, even in patients with correct inhalation technique. A pMDI plus spacer has proven to be viable lower cost alternative to the use of a nebuliser for delivering large bronchodilator doses in patients with severe acute asthma or chronic obstructive pulmonary disease. The use of large-volume spacers is recommended for delivering high doses of inhaled corticosteroids, and may permit a lower maintenance dose to be used. CONCLUSION pMDIs may be routinely fitted with a spacer, especially in situations where correct pMDI use is unlikely.
Collapse
Affiliation(s)
- Federico Lavorini
- Università degli Studi di Firenze, Dipartimento di Area Critica Medico Chirurgica, Firenze, Italy.
| | | |
Collapse
|
11
|
Design of a Device for Simultaneous Particle Size and Electrostatic Charge Measurement of Inhalation Drugs. Pharm Res 2008; 25:2488-96. [DOI: 10.1007/s11095-008-9660-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
|
12
|
Hickey AJ, Mansour HM, Telko MJ, Xu Z, Smyth HDC, Mulder T, McLean R, Langridge J, Papadopoulos D. Physical characterization of component particles included in dry powder inhalers. II. Dynamic characteristics. J Pharm Sci 2007; 96:1302-19. [PMID: 17455364 DOI: 10.1002/jps.20943] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Characteristics of particles included in dry powder inhalers is extended from our previous report (in this journal) to include properties related to their dynamic performance. The performance of dry powder aerosols for pulmonary delivery is known to depend on fluidization and dispersion which reflects particle interactions in static powder beds. Since the solid state, surface/interfacial chemistry and static bulk properties were assessed previously, it remains to describe dynamic performance with a view to interpreting the integrated database. These studies result in complex data matrices from which correlations between specific properties and performance may be deduced. Lactose particles were characterized in terms of their dynamic flow, powder and aerosol electrostatics, and aerodynamic performance with respect to albuterol aerosol dispersion. There were clear correlations between flow properties and aerosol dispersion that would allow selection of lactose particles for formulation. Moreover, these properties can be related to data reported earlier on the morphological and surface properties of the carrier lactose particles. The proposed series of analytical approaches to the evaluation of powders for inclusion in aerosol products has merit and may be the basis for screening and ultimately predicting particle performance with a view to formulation optimization.
Collapse
Affiliation(s)
- Anthony J Hickey
- Division of Molecular Pharmaceutics, School of Pharmacy, University of North Carolina at Chapel Hill, Campus Box #7360, 1310 Kerr Hall, Chapel Hill, North Carolina 27599-7360, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
The influence of formulation and spacer device on the in vitro performance of solution chlorofluorocarbon-free propellant-driven metered dose inhalers. AAPS PharmSciTech 2004. [DOI: 10.1007/bf02830575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
14
|
Smyth HDC, Beck VP, Williams D, Hickey AJ. The influence of formulation and spacer device on the in vitro performance of solution chlorofluorocarbon-free propellant-driven metered dose inhalers. AAPS PharmSciTech 2004; 5:E7. [PMID: 15198528 PMCID: PMC2784858 DOI: 10.1208/pt050107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purpose of this study was to evaluate the hypothesis that spacer devices have limited effect on the in vitro fine particle dose emitted from solution metered dose inhalers containing different proportions of HFA134a [1,1,1,2,-tetrafluoroethane] propellant. Two solution formulations (80% and 97.5% wt/wt HFA134a) were tested across the actuator alone, actuator plus Aerochamber, and Ace holding chamber. Particle size distributions were determined using laser diffraction (LD) and cascade impaction (CI). Multimodal particle size distributions were identified using LD. CI analyses were characterized by a major mode located at approximately 0.5 microm. The fine particle dose emitted from the inhaler spacer combinations containing 97.5% HFA134a was independent of the device setup used. Fine particle doses were influenced by spacer setup in 80% HFA134a formulations, indicating different plume dynamics of low vapor pressure formulations. Sampling inlet deposition was approximately 0 when spacer devices were used with either formulation. When spacers were not used, sampling inlet deposition was increased significantly. However, inlet deposition with the 97.5% HFA134a formulation was significantly less than that of the 80% HFA134a formulation (approximately 25% of emitted dose compared with 69%, respectively). Thus, high propellant concentration formulations appear to have more robust in vitro performance. This is particularly important given the preponderance of poor patient compliance that is associated with spacer use. High propellant concentrations had the advantage of fine particle doses that were independent of the device setup and significantly lowered sampling inlet deposition when no spacer was used.
Collapse
Affiliation(s)
- Hugh D C Smyth
- School of Pharmacy, University of North Carolina at Chapel Hill, NC 27599, USA.
| | | | | | | |
Collapse
|