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Hossny E, Adachi Y, Anastasiou E, Badellino H, Custovic A, El-Owaidy R, El-Sayed ZA, Filipovic I, Gomez RM, Kalayci Ö, Le Souëf P, Miligkos M, Morais-Almeida M, Nieto A, Phipatanakul W, Shousha G, Teijeiro A, Wang JY, Wong GW, Xepapadaki P, Yong SB, Papadopoulos NG. Pediatric asthma comorbidities: Global impact and unmet needs. World Allergy Organ J 2024; 17:100909. [PMID: 38827329 PMCID: PMC11141278 DOI: 10.1016/j.waojou.2024.100909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 06/04/2024] Open
Abstract
Real-world data on the range and impact of comorbid health conditions that affect pediatric asthma are scant, especially from developing countries. Lack of data hinders effective diagnosis, treatment, and overall management of these complex cases. We, hereby, describe the common pediatric asthma comorbid conditions in terms of evidence for association, potential mechanisms of impact on asthma control, and treatment benefit. Obesity, upper airway allergies, dysfunctional breathing, multiple sensitizations, depressive disorders, food allergy, and gastro-esophageal reflux are common associations with difficult-to-treat asthma. On the other hand, asthma symptoms and/or management may negatively impact the well-being of children through drug adverse effects, worsening of anaphylaxis symptoms, and disturbing mental health. Awareness of these ailments may be crucial for designing the optimum care for each asthmatic child individually and may ultimately improve the quality of life of patients and their families. A multidisciplinary team of physicians is required to identify and manage such comorbidities aiming to mitigate the over-use of asthma pharmacotherapy. Asthma research should target relevant real-world difficulties encountered at clinical practice and focus on interventions that would mitigate the impact of such comorbidities. Finally, policymakers and global healthcare organizations are urged to recognize pediatric asthma control as a healthcare priority and allocate resources for research and clinical interventions. In other words, global asthma control needs support by compassionate scientific partnership.
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Affiliation(s)
- Elham Hossny
- Pediatric Allergy, Immunology, and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Yuichi Adachi
- Pediatric Allergy Center, Toyama Red Cross Hospital, Japan
| | - Eleni Anastasiou
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Héctor Badellino
- Faculty of Psychology, UCES University, San Francisco, Argentina
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rasha El-Owaidy
- Pediatric Allergy, Immunology, and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Zeinab A. El-Sayed
- Pediatric Allergy, Immunology, and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | | | - Ömer Kalayci
- Hacettepe University School of Medicine, Ankara, Turkey
| | - Peter Le Souëf
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Michael Miligkos
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Antonio Nieto
- Pediatric Pulmonology and Allergy Unit, Hospital Universitari i Politècnic La Fe, Health Research Institute La Fe, Valencia, Spain
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ghada Shousha
- Pediatric Allergy, Immunology, and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Alvaro Teijeiro
- Respiratory Department, Pediatric Hospital, Córdoba, Argentina
| | - Jiu-Yao Wang
- Allergy, Immunology and Microbiome Research Center, China Medical University Children's Hospital, Taichung, Taiwan
| | - Gary W.K. Wong
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Su Boon Yong
- Department of Allergy and Immunology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Nikolaos G. Papadopoulos
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
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2
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Klenk FK, Schulz B. [Inhalation therapy in dogs and cats with chronic lower airway disease - a literature review]. TIERARZTLICHE PRAXIS. AUSGABE K, KLEINTIERE/HEIMTIERE 2022; 50:279-292. [PMID: 36067770 DOI: 10.1055/a-1910-3327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Chronic respiratory diseases are prevalent medical conditions in dogs and cats requiring lifelong treatment. Mainstay of therapy for chronic inflammatory respiratory diseases are glucocorticoids. Concurrent treatment with bronchodilators may be necessary to control clinical signs sufficiently. Due to the successful use in people as well as subsequent reduction of adverse effects of long-term glucocorticoid therapy, inhalative therapy has become increasingly important in veterinary medicine as well. Primarily spacers or valved holding chambers, in combination with metered dose inhalers, are used in dogs and cats. The technical properties of these devices, as well as their use and maintenance will be described in the following article. Furthermore, the existing literature regarding efficacy of inhalative medications for therapy of chronic inflammatory airway diseases in dogs and cats will be summarized.
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3
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Raherison-Semjen C, Guilleminault L, Billiart I, Chenivesse C, De Oliveira A, Izadifar A, Lorenzo A, Nocent C, Oster JP, Padovani M, Perez T, Russier M, Steinecker M, Didier A. [Update of the 2021 recommendations for the management and follow-up of adult asthmatic patients under the guidance of the French Society of Pulmonology and the Paediatric Society of Pulmonology and Allergology. Long version]. Rev Mal Respir 2021; 38:1048-1083. [PMID: 34799211 DOI: 10.1016/j.rmr.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Affiliation(s)
- C Raherison-Semjen
- Université de Bordeaux, INSERM UMR 1219, Epicene Team, Bordeaux, France.
| | - L Guilleminault
- Pôle des voies respiratoires, CHU de Toulouse, Toulouse, France; Institut toulousain des maladies infectieuses et inflammatoires (Infinity), INSERM, UMR1291, CNRS UMR5051, université Toulouse III, CRISALIS F-CRIN, Toulouse, France
| | | | - C Chenivesse
- CHRU de Lille, service de pneumo-allergologie, 59000 Lille, France
| | - A De Oliveira
- Sorbonne université, département de médecine générale, Paris, France
| | - A Izadifar
- Département de pneumologie, centre cardiologique du Nord, Saint-Denis, France
| | - A Lorenzo
- Sorbonne université, département de médecine générale, Paris, France
| | - C Nocent
- CHG Côte Basque, Bayonne, France
| | - J P Oster
- Service de pneumologie, centre hospitalier Louis-Pasteur, Colmar, France
| | - M Padovani
- Espace Santé Ii, La Seyne-sur-Mer, France
| | - T Perez
- CHRU de Lille, service d'explorations fonctionnelles, 59000 Lille, France
| | - M Russier
- Service de pneumo-allergologie, CHR Orléans, Orléans, France
| | - M Steinecker
- Sorbonne université, département de médecine générale, Paris, France
| | - A Didier
- Université de Bordeaux, INSERM UMR 1219, Epicene Team, Bordeaux, France; Pôle des voies respiratoires, CHU de Toulouse, Toulouse, France
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4
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Ari A, Blain K, Soubra S, Hanania NA. Treating COPD Patients with Inhaled Medications in the Era of COVID-19 and Beyond: Options and Rationales for Patients at Home. Int J Chron Obstruct Pulmon Dis 2021; 16:2687-2695. [PMID: 34611397 PMCID: PMC8487292 DOI: 10.2147/copd.s332021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/13/2021] [Indexed: 01/29/2023] Open
Abstract
COVID-19 has affected millions of patients, caregivers, and clinicians around the world. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads via droplets and close contact from person to person, and there has been an increased concern regarding aerosol drug delivery due to the potential aerosolizing of viral particles. To date, little focus has been given to aerosol drug delivery to patients with COVID-19 treated at home to minimize their hospital utilization. Since most hospitals were stressed with multiple admissions and experienced restricted healthcare resources in the era of COVID-19 pandemic, treating patients with COPD at home became essential to minimize their hospital utilization. However, guidance on how to deliver aerosolized medications safely and effectively to this patient population treated at home is still lacking. In this paper, we provide some strategies and rationales for device and interface selection, delivery technique, and infection control for patients with COPD who are being treated at home in the era of COVID-19 and beyond.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Karen Blain
- Department of Respiratory Therapy, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Said Soubra
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Nicola A Hanania
- Airways Clinical Research Center, Baylor College of Medicine, Houston, TX, USA
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5
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Tony SM, Abdelrahman MA, Osama H, Abdelrahim MEA. Advanced counselling using training device and smartphone application on inhalation technique from metered-dose inhaler with spacer equipped with different interfaces in asthmatic children. Int J Clin Pract 2021; 75:e14413. [PMID: 34047001 DOI: 10.1111/ijcp.14413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Spacers are equipped with either facemask or mouthpiece as an interface through which patient inhale their dose. The present study aimed to evaluate the effect of advanced counselling using training devices and smartphone applications on inhalation techniques from the metered-dose inhaler (MDI) with a spacer equipped with different interfaces. METHODS 100 paediatric asthmatic children (8-18 years) were divided into two groups. Group one was a spacer with a mouthpiece (n = 50) and group two was a spacer with a facemask group (n = 50). Both groups had three visits one month apart. At each visit, patients were asked to show the investigator their inhalation technique using MDI with spacer, and mistakes were recorded and then patients were trained on the proper inhalation technique of using MDI with a spacer. In the spacer with mouthpiece group, Flo-Tone was attached to the mouthpiece to allow the Trainhaler smartphone application to detect the duration of inhalation. In the spacer with facemask group, there was no need to use the Flo-Tone training device since the facemask was equipped with a built-in whistle detected by the Trainhaler smartphone application. RESULTS The total number of mistakes in the inhalation technique decreased significantly (P < .05) in visits 2 and 3 for both groups. Duration of inhalation increased significantly (P < .05) in the mouthpiece group at visit 2 and in the facemask group at visit 3. Achieving 5 seconds of slow deep inhalation, breath-holding for 5 seconds after inhalation and the tight fit of facemask represented the major obstacles in most children especially the youngest subjects. Breath out as far as comfortable had the highest number of mistakes in the first visit in both groups. CONCLUSION The Flo-Tone with its positive reinforcement whistle and the Trainhaler smartphone application significantly improved the inhalation technique by decreasing the total number of mistakes especially in important steps eg, shaking MDI, maintaining slow inhalation rate, breath-holding after inhalation and appropriate facemask fitting. Also, they increased the duration of inhalation of asthmatic children from MDI with a spacer. Both spacer interfaces are easy to handle once taught well.
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Affiliation(s)
- Sara M Tony
- Clinical pharmacy department, Beni-Suef Specialized Hospital, Beni-Suef, Egypt
- Technical Office of Deputy Minister of Health in Beni-Suif Directorate of Health Affairs, Beni-Suef, Egypt
| | - Mona A Abdelrahman
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hasnaa Osama
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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6
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Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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7
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Ari A. A path to successful patient outcomes through aerosol drug delivery to children: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:593. [PMID: 33987291 PMCID: PMC8105845 DOI: 10.21037/atm-20-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022]
Abstract
Although using aerosolized medications is a mainstay of treatment in children with asthma and other respiratory diseases, there are many issues in terms of device and interface selection, delivery technique and dosing, as well as patient and parental education that have not changed for half a century. Also, due to many aerosol devices and interfaces available on the market and the broad range of patient characteristics and requirements, providing effective aerosol therapy to children becomes a challenge. While aerosol delivery devices are equally effective, if they are age-appropriate and used correctly, the majority of aerosol devices require multiple steps to be used efficiently. Unfortunately, many children with pulmonary diseases have problems with the correct delivery technique and do not gain therapeutic benefits from therapy that result in poor disease management and increased healthcare costs. Therefore, the purpose of this paper is to review the current knowledge on aerosol delivery devices used in children and guide clinicians on the optimum device- and interface-selection, delivery technique, and dosing in this patient population. Strategies on how to deliver aerosolized medications in crying and distressed children and how to educate parents on aerosol therapy and promote patient adherence to prescribed medications are also provided. Future directions of aerosol therapy in children should focus on these issues and implement policies and clinical practices that highlight the potential solutions to these problems.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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8
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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.
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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
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9
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Doub W, Stein S, Mitchell J, Goodey AP. Addressing the Need for Controls on Particle Bounce and Re-entrainment in the Cascade Impactor and for the Mitigation of Electrostatic Charge for Aerodynamic Particle Size Assessment of Orally Inhaled Products: an Assessment by the International Consortium on Regulation and Science (IPAC-RS). AAPS PharmSciTech 2020; 21:239. [PMID: 32827121 DOI: 10.1208/s12249-020-01720-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 05/28/2020] [Indexed: 11/30/2022] Open
Abstract
Multi-stage cascade impactors (CI) are accepted for the determination of metrics of the drug mass aerodynamic particle size distributions (APSD) of aerosols emitted from orally inhaled products (OIPs). This is particularly important for products where the drug to excipient ratio or particle density may not be the same in each aerodynamic size fraction; examples of such products are carrier-containing dry powder inhalers (DPIs) and suspension pressurized metered-dose inhalers (pMDIs). CI measurements have been used as the "gold standard" for acceptance of alternative methods of APSD assessment, such as laser diffraction for nebulized solutions. Although these apparatus are labor-intensive, they are accepted in regulatory submissions and quality control assessments because the mass of active pharmaceutical ingredient(s) in the aerosol can be quantified by chemical assay and measured particle size is based on the aerodynamic diameter scale that is predictive of deposition in the respiratory tract. Two of the most important factors that modify the ideal operation of an impactor are "particle bounce," that is often accompanied by re-entrainment in the air flow passing the stage of interest, and electrostatic charge acquired by the particles during the preparation and aerosolization of the formulation when the inhaler is actuated. This article reviews how both factors can lead to biased APSD measurements, focusing on measurements involving pMDIs and DPIs, where these sources of error are most likely to be encountered. Recommendations are provided for the mitigation of both factors to assist the practitioner of these measurements.
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Affiliation(s)
- William Doub
- OINDP In Vitro Analysis, 1430 Neffwold Ln, Kirkwood, MO, 63122, USA.
| | - Stephen Stein
- Inhalation Product Development, Kindeva Drug Delivery, St. Paul, MN, USA
| | - Jolyon Mitchell
- Jolyon Mitchell Inhaler Consulting Services Inc., London, ON, Canada
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10
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Gleeson PK, Feldman S, Apter AJ. Controller Inhalers: Overview of Devices, Instructions for Use, Errors, and Interventions to Improve Technique. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2234-2242. [PMID: 32173505 DOI: 10.1016/j.jaip.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/16/2020] [Accepted: 03/04/2020] [Indexed: 11/28/2022]
Abstract
Inadequate inhaler technique in persistent asthma is frequently reported. However, there is little consensus on inhaler checklists, and critical elements of technique are not uniformly described. In addition, inhaler error rates and risk factors for poor technique are variable across studies. This Clinical Commentary Review summarizes the literature on inhaler design, use, and interventions to improve technique. Our aim is to help clinicians identify patients with poor inhaler technique, recognize the most important errors, and correct technique using evidence-based interventions.
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Affiliation(s)
- Patrick K Gleeson
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Scott Feldman
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrea J Apter
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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11
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A comparative analysis of changes in pMDI drug dose delivery before and after detergent coating using five antistatic valved holding chambers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1124-1125.e4. [DOI: 10.1016/j.jaip.2019.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 11/21/2022]
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12
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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]
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13
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Csonka P, Lehtimäki L. In vitro drug delivery performance of five valved holding chambers with and without facemasks. Pediatr Pulmonol 2019; 54:1457-1465. [PMID: 31254459 DOI: 10.1002/ppul.24425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Valved holding chambers (VHCs) are essential for efficient pulmonary delivery of inhaled medication in preschool children. The numerous devices in the market vary in material, aerodynamic characteristics, volume, valve properties, and mask design. Drug delivery is affected by the VHC characteristics as well as by the age and breathing pattern of the child. METHODS We measured the drug delivery efficacy of five VHCs widely available in the market, evaluated the effect of facemasks and tested the differences between manufacturing lots. A breathing simulator was used to mimic normal (respiratory rate [RR] 25/minute and tidal volume (VT ) 200 mL) and obstructive (RR 50/minute and VT 50 mL) breathing of infants and toddlers. RESULTS Salbutamol output was significantly higher with a normal breathing pattern compared to the obstructive breathing pattern in most VHCs. Without masks, the differences in the median in vitro filter doses of salbutamol were mainly from 2 to 10-fold among different types of VHCs. With masks, there was a greater than 20-fold difference in drug delivery capacity between the most and least effective devices. Most VHCs had a notable variation of performance between individual devices from different lots within the same brand. CONCLUSIONS There was an extreme variation in the salbutamol delivery performance among different types of VHCs for both normal and obstructive pediatric breathing patterns with and without masks. This magnitude of performance variability can have significant and unpredictable clinical implications.
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Affiliation(s)
- Péter Csonka
- Centre for Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland.,Terveystalo Healthcare Oy, Tampere, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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14
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D'Vaz N, Okitika TA, Shackleton C, Devadason SG, Hall GL. Bronchodilator responsiveness in children with asthma is not influenced by spacer device selection. Pediatr Pulmonol 2019; 54:531-536. [PMID: 30719873 DOI: 10.1002/ppul.24263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/19/2018] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Spacer devices optimize delivery of aerosol therapies and maximize therapeutic efficacy. We assessed the impact of spacer device on the prevalence and magnitude of bronchodilator response (BDR) in children with asthma. METHODS Children with physician confirmed asthma and parentally reported symptoms in the last 12 months were recruited for this study. Each participant completed two separate visits (5-10 days apart) with spirometry performed at baseline and following cumulative doses of salbutamol (200, 400, 800, and 200 μg) delivered by either a small volume disposable spacer or a large volume multi-use spacer. Spacer type was alternated for each participant during each visit. The primary outcome was the effect of spacer type on bronchodilator responsiveness. The secondary outcome was to assess the relationships between spacer device, salbutamol dose and the proportion of children with a clinically relevant BDR. RESULTS Thirty-two children (mean age 11.8 years) completed both visits. Change in lung function following bronchodilators was increased using the large volume spacer, for relative but not absolute increase in FEV1 [mean difference (95% confidence intervals): 1.28% (0.02, 2.54; P = 0.047) and 0.013 L (-0.01, 0.04; P = 0.288)], respectively. There was no observed difference in FVC by spacer type. Overall, 59% (n = 19) of children exhibited a clinically relevant BDR at 400 µg of salbutamol for any spacer and was independent of spacer type. CONCLUSION Spacer device was not associated with clinically important differences in lung function following bronchodilator inhalation in children with asthma. At a recommended dose of 400 μg, some children with asthma may have their bronchodilator responsiveness misclassified.
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Affiliation(s)
- Nina D'Vaz
- Respiratory Medicine, Perth Children's Hospital, Perth, Western Australia.,Telethon Kids Institute, Perth, Western Australia
| | | | - Claire Shackleton
- Respiratory Medicine, Perth Children's Hospital, Perth, Western Australia.,Telethon Kids Institute, Perth, Western Australia.,Child Health Research Centre, University of Queensland, South Brisbane, Queensland
| | - Sunalene G Devadason
- Division of Paediatrics, Medical School, University of Western Australia, Perth, Western Australia
| | - Graham L Hall
- Respiratory Medicine, Perth Children's Hospital, Perth, Western Australia.,Telethon Kids Institute, Perth, Western Australia.,School of Physiotherapy and Exercise Sciences, Curtin University, Perth, Western Australia
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15
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Csonka P, Lehtimäki L. Valved holding chamber drug delivery is dependent on breathing pattern and device design. ERJ Open Res 2019; 5:00158-2018. [PMID: 30740461 PMCID: PMC6360210 DOI: 10.1183/23120541.00158-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/28/2018] [Indexed: 11/06/2022] Open
Abstract
Small children with airway obstruction breathe with very low tidal volumes (VT) and high respiratory rates (RRs). These extreme respiratory patterns affect drug delivery unpredictably through valved holding chambers (VHCs). We compared in an in vitro study the effectiveness of two VHCs, one small (140 mL, Optichamber Diamond) and one large (350 mL, Babyhaler) without facemasks, to deliver salbutamol to filters positioned between the VHC mouthpieces and a breathing simulator. Different tidal volumes (from 30 mL to 200 mL) and RRs (25·min-1 and 50·min-1) were applied through a breathing simulator. The amount of salbutamol delivered increased with increasing VT in both VHCs for both RRs (ρ>0.87 and p<0.001 for both devices at both rates). The effect of RR was not as evident, but drug delivery tended to be higher at the higher rate. Drug delivery was significantly higher through the Optichamber Diamond as compared with the Babyhaler at every combination of RR and VT up to a 12-fold difference. We found marked differences in salbutamol delivery between the Babyhaler and Optichamber Diamond VHCs. The delivered dose of salbutamol increased with increasing VT and RR with both VHCs but with differences related to valve dead spaces. Instead of considering all VHCs equal in clinical paediatric practice, each device should be tested in vitro with respiratory patterns relevant to small children with respiratory difficulties. Children with respiratory problems are treated with inhaled drugs given via valved holding chambers (VHCs). Efficacy can vary up to 12-fold between devices. The effectiveness of VHCs should be tested in all age groups with different respiratory patterns.http://ow.ly/2Aca30mT2Pa
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Affiliation(s)
- Péter Csonka
- Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.,Terveystalo Healthcare Oy, Tampere, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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16
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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.
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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
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17
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McIvor RA, Devlin HM, Kaplan A. Optimizing the Delivery of Inhaled Medication for Respiratory Patients: The Role of Valved Holding Chambers. Can Respir J 2018; 2018:5076259. [PMID: 29849831 PMCID: PMC5904796 DOI: 10.1155/2018/5076259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 02/02/2023] Open
Abstract
Valved holding chambers (VHCs) have been used with pressurized metered-dose inhalers since the early 1980s. They have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce side effects such as throat irritation, dysphonia, and oral candidiasis that are common with use of pressurized metered-dose inhalers (pMDIs) alone. VHCs act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a two-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. The design of VHC devices can have an impact on performance. Features such as antistatic properties, effective face-to-facemask seal feedback whistles indicating correct inhalation speed, and inhalation indicators all help improve function and performance, and have been demonstrated to improve asthma control, reduce the rate of exacerbations, and improve quality of life. Not all VHCs are the same, and they are not interchangeable. Each pairing of a pMDI device plus VHC should be considered as a unique delivery system.
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Affiliation(s)
- R. Andrew McIvor
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Health Quality Ontario COPD Community Standards Project, Toronto, ON, Canada
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18
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Anderson G, Johnson N, Mulgirigama A, Aggarwal B. Use of spacers for patients treated with pressurized metered dose inhalers: focus on the VENTOLIN™ Mini Spacer. Expert Opin Drug Deliv 2018; 15:419-430. [PMID: 29415579 DOI: 10.1080/17425247.2018.1437414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Spacers offer a multitude of benefits by reducing the requirement to coordinate inhalation with actuation and improving inhaler technique in patients using a pressurized metered dose inhaler (pMDI). Spacers improve drug targeting by retaining within the spacer large particles normally deposited in the oropharynx, and by creating a prolonged aerosol cloud of fine particles to give the user increased time to inhale after actuation. This is particularly important in young children and the elderly to effectively deliver medication to the airways. AREAS COVERED By investigating the history and features of spacers, we demonstrate that the advantages of using spacers far outweigh their limitations. We also discuss the optimal characteristics of spacers in terms of shape, volume, presence of valve and static charge, and present a detailed discussion of the VENTOLIN™ Mini Spacer. EXPERT OPINION Generally, the shape and size of spacers makes them inherently inconvenient. Consideration of human factors and modern design may make them more attractive to patients. However, the incentive to use spacers should be their ability to help patients correctly use inhaled medications delivered by pMDIs. Understanding of these principles through education is key to their acceptance by patients.
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Affiliation(s)
- Gregor Anderson
- a GSK, Respiratory Centre of Excellence, Global Manufactory & Supply , Ware, Herts , UK
| | - Neil Johnson
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Aruni Mulgirigama
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Bhumika Aggarwal
- c GSK , Respiratory, Global Classic & Established Products , Singapore
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19
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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.
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Affiliation(s)
| | - Jason Suggett
- Trudell Medical International, London, Ontario,
Canada
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20
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Nagel MW, Suggett JA, Coppolo DP, Mitchell JP. Development and Evaluation of a Family of Human Face and Upper Airway Models for the Laboratory Testing of Orally Inhaled Products. AAPS PharmSciTech 2017; 18:3182-3197. [PMID: 28536796 DOI: 10.1208/s12249-017-0802-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/03/2017] [Indexed: 11/30/2022] Open
Abstract
Many orally inhaled products are supplied with a facemask instead of a mouthpiece, enabling aerosolized medication to be transferred from the inhaler to the lungs when the user lacks the capability to use a mouthpiece. Until recently, laboratory evaluation of an orally inhaled product-facemask was frequently undertaken by removing the facemask, treating the facemask adapter as being equivalent to a mouthpiece. Measurements of delivered drug mass were therefore subject to bias arising from the absence of dead volume, had the facemask been present. We have described the development of the Aerosol Delivery to an Anatomic Model (ADAM) infant, small child, and adult faces and upper airways, and their subsequent evaluation. Each model possesses physical features of appropriate size, and the soft tissues are also simulated. Rudimentary underlying bony structure is also present, because its purpose is only to provide support, enabling the mechanical response of the facial soft tissues when a facemask is applied to be realized. A realistic upper airway (nasopharynx for the infant model, naso- and oropharynx for the child and oropharynx for the adult models) is also incorporated, so that each model can be used to determine the mass of inhaled medication likely to penetrate as far as the lungs where therapy is intended to be applied. Measurements of the mass of pressurized metered-dose inhaler-delivered salbutamol at a filter distal to the upper airway of each model, simulating age-appropriate tidal breathing, were remarkably consistent, almost all being in the range 0.3 to 1.0 μg/kg across the model age ranges, when expressed as a fraction of body weight.
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21
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Schor D, Rizzo JÂ, Medeiros D, Dela Bianca AC, Silva AR, Nunes C, Morais-Almeida M, Sarinho E. Home-made spacer as an auxiliary device in administration of beclomethasone via pressurized metered dose inhaler for asthma control. A randomized controlled pragmatic trial. Respir Med 2017; 126:52-58. [PMID: 28427550 DOI: 10.1016/j.rmed.2017.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/16/2017] [Accepted: 03/21/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Holding chambers or spacers can enhance the efficacy of pressurized metered dose inhalers (pMDI) in delivering inhaled medications, as they reduce the need for hand-breath coordination and improve lower airways deposition. Nevertheless, their cost can be high for patients in low-income countries. OBJECTIVE To compare asthma control achieved with beclomethasone-dipropionate administered through a hydrofluoroalkane-driven pMDI (BDp-pMDI) coupled to a home-made spacer (HmS) or to a valved commercial spacer (VCS) as auxiliary devices. METHODS Sixty-three patients with poorly controlled asthma that had a BDp-pMDI prescription were randomized to use the inhaler coupled to a HmS made of 500 ml plastic bottles (Group HmS, n = 32) or to a VCS (Group VCS, n = 31) for 60 days. All were given training sessions. Asthma control was assessed through the Asthma Control Test (ACT) and forced expiratory volume in the first second (FEV1), both measured before, and 30 and 60 days after treatment began. RESULTS Both groups showed significant improvement in ACT scores after 30 and 60 days compared to baseline values (an increase of 7 and 7.8 points for the HmS group and 5.9 and 7.0 points for the VCS group, respectively, p < 0.001). There was no statistically significant difference in ACT scores between groups at any observation time (P = 0.261). FEV1 showed the same behavior. CONCLUSIONS A similar level of asthma control was achieved with beclomethasone-dipropionate administered through a pMDI whether the inhaler was coupled to the HmS or VCS. These results are significant for asthma control planning strategies in low-income communities. (Trial Register Number: RBR-5x4dc9).
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Affiliation(s)
- Deborah Schor
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - José Ângelo Rizzo
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Pneumology Department, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Decio Medeiros
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Ana Carolina Dela Bianca
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Almerinda Rego Silva
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
| | - Carlos Nunes
- Algarve Immuno-Allergology Center, Portimão, Portugal.
| | - Mário Morais-Almeida
- CUF Descobertas Hospital, Immuno-Allergy Department, Lisbon and CINTESIS (Center for Research in Health Technologies and Information Systems), Faculdade de Medicina Do Porto, Portugal.
| | - Emanuel Sarinho
- Center for Research in Allergy and Clinical Immunology, Health Sciences Post-Graduation Program, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil.
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22
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Leung SSY, Chiow ACM, Kwok PCL, Ukkonen A, Chan HK. Effect of Spacers on the Bipolar Electrostatic Charge Properties of Metered Dose Inhaler Aerosols-A Case Study With Tilade ®. J Pharm Sci 2017; 106:1553-1559. [PMID: 28238902 DOI: 10.1016/j.xphs.2017.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 11/26/2022]
Abstract
Aerosols emitted from metered dose inhalers (MDIs) are generally electrically charged and bipolar in nature. Although a spacer can effectively dampen the charge magnitude of aerosols, the electrostatic interactions between the positively and negatively charged particles and the spacer have not yet been characterized separately. The Bipolar Charge Analyzer (BOLAR) was employed to investigate interactions between the spacer and the charged aerosols. Three individual actuations of Tilade® MDI were introduced without a spacer and through an antistatic AeroChamber Plus® Z Stat®, an uncoated and a detergent-coated AeroChamber Plus® spacer into the BOLAR at 60 L/min. Charge and mass profiles were determined. The surface potential of spacers followed the order of uncoated > detergent-coated > antistatic spacer. The spacers had minimal impact on the positively charged particles but the charge magnitude of the negatively charged particles was in the opposite order as the spacer surface potential. The charge-to-mass ratio of particles had little alteration for all measurements. Negatively charged particles had a higher tendency to deposit on the spacer walls, possibly due to their higher abundance in the confined spacer volume. The bipolar data may prove useful for designing better MDIs and spacers and modelling lung deposition of charged aerosol particles.
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Affiliation(s)
- Sharon Shui Yee Leung
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Adam Chong Ming Chiow
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Philip Chi Lip Kwok
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ari Ukkonen
- Dekati Ltd., Tykkitie 1, Kangasala FIN-36240, Finland
| | - Hak-Kim Chan
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales 2006, Australia.
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23
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Berlinski A, von Hollen D, Hatley RHM, Hardaker LEA, Nikander K. Drug Delivery in Asthmatic Children Following Coordinated and Uncoordinated Inhalation Maneuvers: A Randomized Crossover Trial. J Aerosol Med Pulm Drug Deliv 2016; 30:182-189. [PMID: 27977309 DOI: 10.1089/jamp.2016.1337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Valved holding chambers (VHCs) are used in children to deliver pressurized metered dose inhalers (pMDI). In vitro data suggest that uncoordinated use decreases the amount of drug available for inhalation. We hypothesize that in an ex vivo study, the coordinated maneuver will deliver more drug than the uncoordinated one. PATIENTS AND METHODS Thirty-two clinically stable asthmatic children, ages 5-8 years, completed the study. An aerosol filter was interposed between a small-volume nonelectrostatic VHC and a mouthpiece to capture the drug emitted by one puff of Flovent® 220 mcg during tidal breathing. Inhalation and actuation parameters were measured by an electronic monitor, and the number of breaths required to empty the VHC was calculated. Subjects completed three coordinated and three uncoordinated (actuation at the beginning of inhalation and exhalation, respectively) runs in random order. Drug content from the filter and VHC was measured by high-performance liquid chromatography and expressed as percentage of emitted dose. RESULTS [mean (99% confidence interval)] Filter dose was higher during coordinated technique 46% (43%-50%) than during uncoordinated technique 41% (37%-44%) (p < 0.001). Peak inspiratory flow and tidal volume were 23.2 L/min (21.3-25.1 L/min) and 281 mL (251-311 mL), respectively. Subjects required three breaths to empty the VHC in 96% of the tests. CONCLUSIONS Actuating the pMDI into a small-volume nonelectrostatic VHC during exhalation reduced by 11% the amount of fluticasone captured at the exit of the VHC. Asthmatic children (5-8 years old) need three or less breaths to empty the small-volume VHC (NCT01714063).
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Affiliation(s)
- Ariel Berlinski
- 1 Pulmonology Section, Department of Pediatrics, UAMS/COM , Pediatric Aerosol Research Laboratory, Little Rock, Arkansas
| | - Dirk von Hollen
- 2 Respironics, Inc. , a Philips Healthcare Company, Murrysville, Pennsylvania
| | - Ross H M Hatley
- 3 Respironics Respiratory Drug Delivery (UK) Ltd , a Business of Philips Electronics UK Ltd, Chichester, United Kingdom
| | - Lucy E A Hardaker
- 3 Respironics Respiratory Drug Delivery (UK) Ltd , a Business of Philips Electronics UK Ltd, Chichester, United Kingdom
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24
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Ari A. Drug delivery interfaces: A way to optimize inhalation therapy in spontaneously breathing children. World J Clin Pediatr 2016; 5:281-287. [PMID: 27610343 PMCID: PMC4978620 DOI: 10.5409/wjcp.v5.i3.281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/03/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
There are several different types of drug delivery interfaces available on the market. Using the right interface for aerosol drug delivery to children is essential for effective inhalation therapy. However, clinicians usually focus on selecting the right drug-device combination and often overlook the importance of interface selection that lead to suboptimal drug delivery and therapeutic response in neonates and pediatrics. Therefore, it is necessary to critically assess each interface and understand its advantage and disadvantages in aerosol drug delivery to this patient population. The purpose of this paper is to provide a critical assessment of drug delivery interfaces used for the treatment of children with pulmonary diseases by emphasizing advantages and problems associated with their use during inhalation therapy.
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25
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Kamin W, Ehlich H. In Vitro Comparison of Output and Particle Size Distribution of Budesonide from Metered-Dose Inhaler with Three Spacer Devices during Pediatric Tidal Breathing. ACTA ACUST UNITED AC 2016; 5:503-8. [PMID: 17154677 DOI: 10.2165/00151829-200605060-00013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES The aim of this in vitro study was to determine the delivered dose of budesonide 200mug via a chlorofluorocarbon-free pressurized metered dose inhaler (pMDI) when administered through different spacers in tidal breathing patterns of young children. METHODS Tidal breathing was simulated for toddlers and children. Spacers tested were Babyhaler((R)), AeroChamber((R)) Plus small and medium; the pMDI was Budiair((R)) 200microg. Output was measured after one actuation and five inhalations in primed and unprimed spacers. Cumulated output was evaluated after each of five simulated inhalations. Aerosol characteristics - i.e. particle size distribution of the output - were determined in primed spacers with a cascade impactor using high-performance liquid chromatography and UV detection. RESULTS Total output from primed spacers after five inhalations was determined between 37.9microg and 40.9microg with little differences between spacers and breathing patterns. About 58-79% of this total output was inhaled with the first breath from the AeroChamber((R)) Plus and about 26% from the Babyhaler((R)). The fine particles <5mum ranged between 87% and 92% of the delivered dose for all three spacers. DISCUSSION AND CONCLUSION The nominal dose (200microg) of the Budiair((R)) 200microg inhaler is reduced to 40microg delivered dose or less by using Babyhaler((R)) and AeroChamber((R)) Plus spacers taking five breaths. With a single breath the delivered dose can be reduced further to a minimum of 10microg using the Babyhaler((R)). Clinical studies are warranted in the future for decisions on 'clinical efficacy', safety, and exact dose adjustment.
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Affiliation(s)
- Wolfgang Kamin
- Pediatric Pneumology and Allergology, Childrens Hospital, Mainz University, Mainz, Germany
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26
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Raherison C, Bourdin A, Bonniaud P, Deslée G, Garcia G, Leroyer C, Taillé C, De Blic J, Dubus JC, Tillié-Leblond I, Chanez P. Updated guidelines (2015) for management and monitoring of adult and adolescent asthmatic patients (from 12 years and older) of the Société de Pneumologie de Langue Française (SPLF) (Full length text). Rev Mal Respir 2016; 33:279-325. [PMID: 27147308 DOI: 10.1016/j.rmr.2016.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C Raherison
- Inserm U1219, ISPED, service des maladies respiratoires, pôle cardio-thoracique, CHU de Bordeaux, université de Bordeaux, 33000 Bordeaux, France.
| | - A Bourdin
- Inserm U1046, département de pneumologie et addictologie, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, université Montpellier 1, 34000 Montpellier, France
| | - P Bonniaud
- Inserm U866, service de pneumologie et soins intensifs respiratoires, CHU de Bourgogne, université de Bourgogne, 21079 Dijon, France
| | - G Deslée
- Service de pneumologie, CHU Maison-Blanche, université de Reims - Champagne-Ardennes, 51000 Reims, France
| | - G Garcia
- Inserm, UMRS 999, service de pneumologie, département hospitalo-universitaire (DHU) thorax innovation, hôpital de Bicêtre, Centre national de référence de l'hypertension pulmonaire sévère, faculté de médecine, université Paris-Sud, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - C Leroyer
- Département de médecine interne et de pneumologie, CHU de la Cavale-Blanche, université de Bretagne Occidentale, 29000 Brest, France
| | - C Taillé
- Service de pneumologie, département hospitalo-universitaire FIRE, centre de compétence des maladies pulmonaires rares, hôpital Bichat, université Paris-Diderot, AP-HP, 75018 Paris, France
| | - J De Blic
- Service de pneumologie et allergologie pédiatriques, hôpital Necker-Enfants-Malades, 75743 Paris, France
| | - J-C Dubus
- Unité de pneumologie et médecine infantile, hôpital Nord, 13000 Marseille, France
| | - I Tillié-Leblond
- Service de pneumo-allergologie, CHRU de Lille, 59000 Lille, France
| | - P Chanez
- UMR 7333 Inserm U 1067, service de pneumologie, hôpital Nord, université Aix Marseille, AP-HM, 13000 Marseille, France
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Ditcham W, Murdzoska J, Zhang G, Roller C, von Hollen D, Nikander K, Devadason SG. Lung deposition of 99mTc-radiolabeled albuterol delivered through a pressurized metered dose inhaler and spacer with facemask or mouthpiece in children with asthma. J Aerosol Med Pulm Drug Deliv 2015; 27 Suppl 1:S63-75. [PMID: 25054483 DOI: 10.1089/jamp.2014.1139] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Research on the use of a pressurized metered dose inhaler (pMDI) with spacer (pMDI/spacer) in children has indicated oral inhalation via the spacer mouthpiece is more efficient than the combination of oral and nasal inhalation that occurs when a pMDI/spacer is used with a facemask. Changes in pMDI formulations and developments in spacer and facemask designs have highlighted the need for new comparative studies of spacer use, particularly focusing on the age at which children can be taught to transition from use of a pMDI/spacer with facemask to use of the spacer mouthpiece. METHODS Twelve children aged 3-5 years (7 males) with stable asthma were recruited. Of these, 10 children (6 males) completed both arms of the study. A transmission scan of each compliant subject was taken using a 37 MBq (99m)Tc flood source. Actuations (2-3) of a (99m)Tc-radiolabeled albuterol pMDI were administered through an antistatic spacer (OptiChamber Diamond) via either a facemask (medium LiteTouch facemask), or the spacer mouthpiece. The subject's inhalation pattern was simultaneously recorded using a pMDI Datalogger, and narrative data relating to tolerance and compliance were documented. Anterior and posterior planar scintigraphic scans were taken immediately after aerosol administration. RESULTS Mean (SD) lung deposition (% total dose) was 18.1 (9.1)% with the facemask and 22.5 (7.9)% with the spacer mouthpiece (p>0.05). Peripheral lung deposition (expressed as peripheral:central (P:C) ratio) was higher in 7 out of 10 children with the facemask compared with the spacer mouthpiece: 1.3 (0.26) vs. 1.2 (0.35); (p=0.11). Head and neck deposition was higher with use of the facemask compared with the spacer mouthpiece: 19.7 (10.6)% vs. 10.8 (5.3)% (p=0.011). CONCLUSIONS Lung deposition achieved using the spacer with facemask was higher than previously reported, with a difference of only 4.4% of total dose measured compared to the deposition with mouthpiece. This may be due to a combination of factors including pMDI formulation, and use of an antistatic spacer with a flexible, well-fitting facemask.
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Affiliation(s)
- William Ditcham
- 1 School of Paediatrics and Child Health, University of Western Australia , Perth, Western Australia, Australia
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Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv 2015; 27 Suppl 1:S4-23. [PMID: 25054481 DOI: 10.1089/jamp.2013.1076] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Spacers and valved holding chambers (VHCs) are pressurized metered dose inhaler (pMDI) accessory devices, designed to overcome problems that patients commonly experience when administering aerosol via a pMDI. Spacers were developed in direct response to patient-related issues with pMDI technique, particularly, poor coordination between actuation and inhalation, and local side-effects arising from oropharyngeal deposition. Current clinical guidelines indicate the need for widespread prescription and use of spacers, but, despite their apparent ubiquity, the devices themselves are, unfortunately, all too commonly "disused" by patients. An understanding of the background from which spacers developed, and the key factors influencing the optimization of the spacer and the later VHC, is crucial to developing an appreciation of the potential of these devices, both contemporary and future, for improving the delivery of pressurized aerosols to patients. This review, informed by a full patent search and an extensive scientific literature review, takes into account the clinical and laboratory evidence, commercial developments, and the sometimes serendipitous details of scientific anecdotes to form a comprehensive perspective on the evolution of spacers, from their origins, in the early days of the pMDI, up to the present day.
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Mitchell JP. Comments Regarding the Article: "In Vitro Comparison of the Effect of Inhalation Inhalation Delay and Flow Rate on the Emitted Dose from Three Valved Holding Chambers". J Aerosol Med Pulm Drug Deliv 2014:jamp.2014.1135. [PMID: 25259649 DOI: 10.1089/jamp.2014.1135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jolyon P Mitchell
- Jolyon Mitchell Inhaler Consulting Services, Inc. , London, ON, Canada
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Sandell D, Mitchell JP. Considerations for Designing In Vitro Bioequivalence (IVBE) Studies for Pressurized Metered Dose Inhalers (pMDIs) with Spacer or Valved Holding Chamber (S/VHC) Add-on Devices. J Aerosol Med Pulm Drug Deliv 2014; 28:156-81. [PMID: 25089555 DOI: 10.1089/jamp.2014.1150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The choice of analytical test methods and associated statistical considerations are considered for the laboratory testing of pressurized metered dose inhaler-spacer/valved holding chamber (pMDI-S/VHC) combinations for in vitro bioequivalence (IVBE). METHODS Four scenarios are presented for comparing TEST ("second entry" or "generic") versus REF ("innovator"): (1) innovator and second entry product pMDI alone without any S/VHC (baseline comparison); (2) innovator and second entry pMDI product with the same S/VHC; (3) innovator pMDI product with existing S/VHC and second entry product with a different S/VHC; and (4) introduction of a second, different S/VHC to be used with a given innovator pMDI product. The following aspects should be reviewed in the preparatory stage of designing experiments to establish IVBE: (a) the inclusion of delayed inhalation; (b) the utilization of age-appropriate flow rates; and (c) the use of anatomically appropriate face models for evaluation of devices with a facemask. Statistical considerations that fit in with such experimental methods include: selection of pMDI batches and S/VHC lots; choice of sample size and acceptance criteria; bracketing or worst case approaches; and balanced/paired designs. A stepwise approach for selection of impactor stage groupings is presented, and an approach to determine realistic acceptance criteria based on REF product characteristics is suggested. RESULTS An example of an efficient statistical design of experiment is provided for each scenario, together with alternate approaches for calculation of confidence intervals for the mean TEST/REF relationship. It is important to appreciate that the optimal design depends on balancing numerous considerations and will thus likely differ from case to case; hence, the designs presented here should be seen as illustrations rather than the only option available. More effective approaches may be found that suit a particular case at hand. CONCLUSIONS The information provided will assist in developing correlations in support of IVBE for these add-on devices.
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Affiliation(s)
| | - Jolyon P Mitchell
- 2Jolyon Mitchell Inhaler Consulting Services Inc., London, ON, Canada
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Abstract
Using aerosolized medications for the treatment of children has gained importance over the years. However, aerosol drug delivery to infants and pediatrics is not an easy task as it has been influenced by many challenges. Most aerosol devices have been designed for use in adults not for children. Therefore, they require some critical assessment in device selection and often a level of adaptation for use with smaller children. It is well documented that each aerosol device and interface that have been used for the treatment of children has its own advantages and challenges in drug delivery. This paper provides a comprehensive review of dosing, drug-device combination, aerosol devices and interfaces used for drug delivery to children with pulmonary diseases. Solutions to the challenges with the aim of optimizing aerosol therapy in this patient population are also discussed.
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Affiliation(s)
- Arzu Ari
- Georgia State University, Division of Respiratory Therapy, Atlanta, GA 30302-4019, USA
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Abstract
Electrostatics continues to play an important role in pharmaceutical aerosols for inhalation. Despite its ubiquitous nature, the charging process is complex and not well understood. Nonetheless, significant advances in the past few years continue to improve understanding and lead to better control of electrostatics. The purpose of this critical review is to present an overview of the literature, with an emphasis on how electrostatic charge can be useful in improving pulmonary drug delivery.
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Sanchis J, Corrigan C, Levy ML, Viejo JL. Inhaler devices - from theory to practice. Respir Med 2013; 107:495-502. [PMID: 23290591 DOI: 10.1016/j.rmed.2012.12.007] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 12/06/2012] [Accepted: 12/08/2012] [Indexed: 11/16/2022]
Abstract
This brief overview of the factors determining lung deposition of aerosols provides background information required by health care providers when instructing patients to use their prescribed inhalers. We discuss differences in the optimal inhalation manoeuvres for each type of aerosol generator and the difficulties patients face. Provision of short, clear instructions with demonstration of critical steps and checking technique during later clinical visits are necessary if these aerosolised medications are to be fully beneficial.
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Affiliation(s)
- Joaquin Sanchis
- Hospital Santa Creu I Sant Pau, Servei de Pneumologia, Universitat Autonoma of Barcelona, Ave. Sant Antoni Maria Claret, 167, Barcelona 08025, Spain.
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Fitch KD. Pharmacotherapy for exercise-induced asthma: allowing normal levels of activity and sport. Expert Rev Clin Pharmacol 2012; 3:139-52. [PMID: 22111539 DOI: 10.1586/ecp.09.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is experienced by the majority of an estimated 300 million individuals who have asthma, a condition that affects all ages and is increasing globally. Respiratory water loss with dehydration of the airways causing mediator release and airway narrowing is considered the cause of EIB, the severity of which will be increased if the inhaled air is cold or polluted. Adequate control of asthma is essential to minimize or prevent EIB and permit normal levels of physical activity and sport. This is important because exercise is a necessary component of daily living, assists in obtaining and maintaining a healthy body and has been demonstrated to benefit asthmatics. Inhaled glucocorticosteroids and inhaled β(2)-adrenoceptor agonists (IβA) are the pharmacological agents of choice to manage asthma and minimize EIB, assisted when necessary, by other drugs including leukotriene receptor antagonists and chromones. Tolerance from daily use of IβA is of concern and more flexible drug therapy needs to be considered. Optimal use of inhalers to deliver drugs effectively requires closer attention. Pharmacogenetics may hold the key to future drug therapy.
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Affiliation(s)
- Kenneth D Fitch
- Department of Sports Science, Exercise and Health, Faculty of Life Sciences, University of Western Australia, M408 35 Stirling Highway, Crawley 6009, WA, Australia.
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Mitchell J, Dolovich MB. Clinically Relevant Test Methods to EstablishIn VitroEquivalence for Spacers and Valved Holding Chambers Used with Pressurized Metered Dose Inhalers (pMDIs). J Aerosol Med Pulm Drug Deliv 2012; 25:217-42. [DOI: 10.1089/jamp.2011.0933] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Myrna B. Dolovich
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Papadopoulos NG, Arakawa H, Carlsen KH, Custovic A, Gern J, Lemanske R, Le Souef P, Mäkelä M, Roberts G, Wong G, Zar H, Akdis CA, Bacharier LB, Baraldi E, van Bever HP, de Blic J, Boner A, Burks W, Casale TB, Castro-Rodriguez JA, Chen YZ, El-Gamal YM, Everard ML, Frischer T, Geller M, Gereda J, Goh DY, Guilbert TW, Hedlin G, Heymann PW, Hong SJ, Hossny EM, Huang JL, Jackson DJ, de Jongste JC, Kalayci O, Aït-Khaled N, Kling S, Kuna P, Lau S, Ledford DK, Lee SI, Liu AH, Lockey RF, Lødrup-Carlsen K, Lötvall J, Morikawa A, Nieto A, Paramesh H, Pawankar R, Pohunek P, Pongracic J, Price D, Robertson C, Rosario N, Rossenwasser LJ, Sly PD, Stein R, Stick S, Szefler S, Taussig LM, Valovirta E, Vichyanond P, Wallace D, Weinberg E, Wennergren G, Wildhaber J, Zeiger RS. International consensus on (ICON) pediatric asthma. Allergy 2012; 67:976-97. [PMID: 22702533 PMCID: PMC4442800 DOI: 10.1111/j.1398-9995.2012.02865.x] [Citation(s) in RCA: 265] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2012] [Indexed: 01/08/2023]
Abstract
Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.
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Affiliation(s)
- N G Papadopoulos
- Department of Allergy, 2nd Pediatric Clinic, University of Athens, Athens, Greece.
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Araújo FDB, Corrêa RDA, Pereira LFF, Silveira CD, Mancuso EV, Rezende NAD. Spirometry with bronchodilator test: effect that the use of large-volume spacers with antistatic treatment has on test response. J Bras Pneumol 2012; 37:752-8. [PMID: 22241032 DOI: 10.1590/s1806-37132011000600008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 09/19/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate whether the use of inhaled albuterol via a metered-dose inhaler with a large-volume spacer with antistatic treatment modifies the bronchodilator test results when compared with the usual technique (no spacer). METHODS A prospective study involving 24 patients, 18-45 years of age, clinically suspected of having asthma, and under treatment at the Outpatient Pulmonary Clinic of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. All of the patients underwent two bronchodilator tests: one with and one without the use of a large-volume spacer. RESULTS There was no significant difference in the variation of FEV1 prior to and after bronchodilator use between the two techniques (mean ΔFEV1 = 0.01 L; 95% CI: -0.05 to 0.06; p = 0.824). No statistically significant difference was found between the two techniques regarding the qualitative results on the bronchodilator test (p = 1.00). There was concordance between the techniques in terms of the bronchodilator test results (kappa coefficient = 0.909; p < 0.005). CONCLUSIONS According to the results of this study, the use of large-volume spacers does not significantly modify bronchodilator test results.
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Prabhakaran S, Shuster J, Chesrown S, Hendeles L. Response to albuterol MDI delivered through an anti-static chamber during nocturnal bronchospasm. Respir Care 2012; 57:1291-6. [PMID: 22348270 DOI: 10.4187/respcare.01572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Decreasing electrostatic charge on valved holding chambers increases the amount of drug delivered. However, there are no data demonstrating that this increases bronchodilatation. OBJECTIVE To investigate the influence of reducing electrostatic charge on the bronchodilator response to albuterol inhaler during nocturnal bronchospasm. METHODS This randomized double-blind, double-dummy crossover study included subjects, 18-40 years old, with nocturnal bronchospasm (20% overnight decrease in peak flow on 3 of 7 nights during run-in), FEV(1) 60-80% predicted during the day, and ≥ 12% increase after albuterol. Subjects slept in the clinical research center up to 3 nights for each treatment. FEV(1) and heart rate were measured upon awakening spontaneously or at 4:00 am, and 15 min after each dose of 1, 2, and 4 cumulative puffs of albuterol via metered-dose inhaler. The drug was administered through an anti-static valved holding chamber (AeroChamber Plus Z-Stat) or a conventional valved holding chamber containing a static charge (AeroChamber Plus). RESULTS Of 88 consented subjects, 11 were randomized and 7 completed the study. Most exclusions were due to lack of objective evidence of nocturnal bronchospasm. Upon awakening, FEV(1) was 44 ± 9% of predicted before the anti-static chamber and 48 ± 7% of predicted before the static chamber. The mean ± SD percent increase in FEV(1) after 1, 2, and 4 cumulative puffs using the anti-static versus the static chamber, respectively, were 52 ± 26% versus 30 ± 19%, 73 ± 28% versus 48 ± 26%, and 90 ± 34% versus 64 ± 35%. The point estimates for the differences (and 95% CIs) between the devices (anti-static vs static) were 21% (4-38%) (P = .03), 23% (6-41%) (P = .02), and 25% (7-42%) (P = .01) for 1, 2, and 4 cumulative puffs, respectively. There was no significant difference in heart rate between treatments. CONCLUSIONS Delivery of albuterol through an anti-static chamber provides a clinically relevant improvement in bronchodilator response during acute, reversible bronchospasm such as nocturnal bronchospasm.
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Affiliation(s)
- Sreekala Prabhakaran
- Pediatric Pulmonary Division, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
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Blake K, Mehta R, Spencer T, Kunka RL, Hendeles L. Bioavailability of inhaled fluticasone propionate via chambers/masks in young children. Eur Respir J 2011; 39:97-103. [PMID: 21933835 DOI: 10.1183/09031936.00185510] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We determined lung bioavailability of a fluticasone propionate (FP) pressurised metred-dose inhaler (Flovent HFA; GlaxoSmithKline, Research Triangle Park, NC, USA) administered via AeroChamber Plus (Monaghan Medical, Plattsburgh, NY, USA) with Facemask and Babyhaler (GlaxoSmithKline) valved holding chambers (VHCs) using a population pharmacokinetic approach. Children from 1 to <4 yrs of age with stable asthma but a clinical need for inhaled corticosteroid therapy were administered 88 μg FP hydrofluoroalkane (2 × 44 μg) twice daily delivered through the two devices in an open-label, randomised crossover manner for 8 days each. Patients were randomised to one of three sparse sampling schedules for blood collection throughout the 12-h dosing interval on the 8th day of each treatment for pharmacokinetic analysis. The area under the FP plasma concentration-time curve (AUC) was determined for each regimen. 17 children completed the study. The population mean AUC following FP with AeroChamber Plus with Facemask was 97.45 pg·h·mL(-1) (95% CI 85.49-113.32 pg·h·mL(-1)) and with Babyhaler was 51.55 pg·h·mL(-1) (95% CI 34.45-64.46 pg·h·mL(-1)). The relative bioavailability (Babyhaler/AeroChamber Plus) was 0.53 (95% CI 0.30-0.75). Clinically significant differences in lung bioavailability were observed between the devices. VHCs are not interchangeable, as differences in drug delivery to the lung may occur. A population pharmacokinetic approach can be used to determine lung bioavailability of FP.
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Affiliation(s)
- K Blake
- Center for Pharmacogenomics and Translational Research, Dept of Biomedical Research, Nemours Children's Clinic, Jacksonville, FL, USA
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HALL GRAHAML, ANNESE TERESA, LOOI KEVIN, DEVADASON SUNALENEG. Usage of spacers in respiratory laboratories and the delivered salbutamol dose of spacers available in Australia and New Zealand. Respirology 2011; 16:639-44. [DOI: 10.1111/j.1440-1843.2011.01928.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schultz A, Le Souëf TJ, Venter A, Zhang G, Devadason SG, Le Souëf PN. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics 2010; 126:e1493-8. [PMID: 21078734 DOI: 10.1542/peds.2010-1377] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to determine the number of breaths required to inhale salbutamol from different spacers/valved holding chambers (VHCs). METHODS Breathing patterns were recorded for 2- to 7-year-old children inhaling placebo from 4 different spacers/VHCs and were simulated by a flow generator. Drug delivery with different numbers of tidal breaths and with a single maximal breath was compared. RESULTS With tidal breathing, mean inhalation volumes were large, ranging from 384 mL to 445 mL. Mean values for drug delivery with an Aerochamber Plus (Trudell, London, Canada) were 40% (95% confidence interval [CI]: 34%-46%) and 41% (95% CI: 36%-47%) of the total dose with 2 and 9 tidal breaths, respectively. Mean drug delivery values with these breath numbers with a Funhaler (Visiomed, Perth, Australia) were 39% (95% CI: 34%-43%) and 38% (95% CI: 35%-42%), respectively. With a Volumatic (GlaxoSmithKline, Melbourne, Australia), mean drug delivery values with 2 and 9 tidal breaths were 37% (95% CI: 33%-41%) and 43% (95% CI: 40%-46%), respectively (P = .02); there was no significant difference in drug delivery with 3 versus 9 tidal breaths. With the modified soft drink bottle, drug delivery. Drug delivery was not improved with a single maximal breath with any device. CONCLUSION For young children, tidal breaths through a spacer/VHC were much larger than expected. Two tidal breaths were adequate for small-volume VHCs and a 500-mL modified soft drink bottle, and 3 tidal breaths were adequate for the larger Volumatic VHC.
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Affiliation(s)
- André Schultz
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.
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Abstract
Abstract
Objectives
This review focuses on the key findings and developments in the rapidly expanding research area of pharmaceutical aerosol electrostatics.
Key findings
Data from limited in-vivo and computational studies suggest that charges may potentially affect particle deposition in the airways. Charging occurs naturally in the absence of electric fields through triboelectrification, that is contact or friction for solids and flowing or spraying for liquids. Thus, particles and droplets emitted from pulmonary drug delivery devices (dry powder inhalers, metered dose inhalers with or without spacers, and nebulisers) are inherently charged. Apparatus with various operation principles have been employed in the measurement of pharmaceutical charges. Aerosol charges are dependent on many physicochemical parameters, such as formulation composition, device construction, relative humidity and solid-state properties. In some devices, electrification has been purposefully applied to facilitate powder dispersion and liquid atomisation.
Summary
Currently, there are no regulatory requirements on characterising electrostatic properties of inhalation aerosols. As research in this area progresses, the new knowledge gained may become valuable for the development and regulation of inhalation aerosol products.
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Affiliation(s)
- Philip Chi Lip Kwok
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, New South Wales, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, New South Wales, Australia
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Nair A, Clearie K, Menzies D, Meldrum K, McFarlane L, Lipworth BJ. A novel breath-actuated integrated vortex spacer device increases relative lung bioavailability of fluticasone/salmeterol in combination. Pulm Pharmacol Ther 2009; 22:305-10. [PMID: 19489129 DOI: 10.1016/j.pupt.2009.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spacer devices facilitate respirable drug delivery. A novel breath-actuated antistatic spacer with integrated vortex chamber (Synchro-Breathe) device has been developed, which is compact,portable and user friendly as compared to conventional spacers which are bulky and cumbersome. The relative bioavailability to the lung of inhaled fluticasone and salmeterol combination is primarily dependent on respirable dose delivery and can be reliably quantified using adrenal suppression and early fall in serum potassium (marker of systemic beta-2 adrenoreceptor response) as surrogate markers for delivered lung dose. AIMS AND OBJECTIVES To compare the in vivo relative bioavailability to the lung of Hydrofluoroalkane(HFA) Seretide delivered via Synchro-Breathe (SB); an optimally prepared 750 ml large volume plastic spacer, Volumatic (VM); and conventional Evohaler pMDI (EH). METHODS Nineteen healthy volunteers completed the study using a randomised double blind, double dummy crossover design. Single doses of placebo or Seretide HFA 250 (total dose ex-valve: fluticasone 2000 mcg/salmeterol 200 mcg) were administered via SB, VM and EH. Overnight urinary cortisol creatinine (OUCC) and serum potassium (K) were measured at baseline and after each dose as systemic surrogates of relative respirable dose delivery for the fluticasone and salmeterol moieties, respectively. RESULTS Significant suppression of OUCC and K occurred from baseline with SB and VM but not EH devices(geometric mean fold suppression, 95% CI, p and arithmetic mean fall mmol/L, 95% CI, respectively); EH:1.51(0.43-1.01), p 1/4 0.06; VM: 2.52(1.57-4.04), p < 0.001; SB: 2.66(1.57-4.49), p < 0.001(equating to 33.8%,60.2% and 62.3% falls, respectively). For K, the falls for EH were 0.09(0.25 to 0.07), p 1/4 0.69; VM: 0.27(0.46 to 0.08), p 1/4 0.003; SB: 0.32(0.53 to 0.11), p 1/4 0.002 (equating to 2.2%, 6.8%, and 8.06% fall,respectively). There were no significant differences between SB and VM. CONCLUSION The breath-actuated Synchro-Breathe device was comparable to an optimally prepared Volumatic spacer, and resulted in commensurate improvement in relative lung bioavailability for both fluticasone and salmeterol moieties compared to pMDI.
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Affiliation(s)
- Arun Nair
- Asthma and Allergy Research Group, Department of Medicine and Therapeutics, Ninewells Hospital and Medical School, University of Dundee, Ninewells Avenue, Dundee, Scotland, UK
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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.
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Affiliation(s)
- Federico Lavorini
- Università degli Studi di Firenze, Dipartimento di Area Critica Medico Chirurgica, Firenze, Italy.
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Stavreska V, Verheggen M, Oostryck J, Stick SM, Hall GL. Determining the time to maximal bronchodilator response in asthmatic children. J Asthma 2009; 46:25-9. [PMID: 19191133 DOI: 10.1080/02770900802460555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The interval between bronchodilator administration and post-bronchodilator lung function testing is critical for accurate interpretation of the bronchodilator response. The time course of this response in children is not well documented. We aimed to document the time taken to achieve maximal lung function following salbutamol inhalation. METHODS Eighteen asthmatic children between 7 and 18 years of age with a history of bronchodilator responsiveness were recruited. Spirometry was performed before and at 0, 10, 15, 20, 40, 60, and 90 minutes after salbutamol inhalation 600 microg (Ventolin; GlaxoSmithKline) via a spacer (Volumatic; GlaxoSmithKline). RESULTS Spirometric indices significantly increased after salbutamol inhalation (p < 0.001). The group median time to maximal response in forced expiratory volume in 1 second (FEV(1)) was 17.5 (10-60: 10th-90th centiles) minutes after salbutamol. The magnitude of group response in FEV(1) was significantly higher at 15 and 20 minutes than at 0 and 10 minutes post-salbutamol inhalation (repeat measures analysis of variance [ANOVA] on ranks; p < 0.05). CONCLUSION We conclude that a minimal interval of 20 minutes, before re-testing spirometry, is required to document the maximal response to bronchodilators in the majority of asthmatic children.
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Affiliation(s)
- Vaska Stavreska
- Respiratory Medicine Department, Princess Margaret Hospital for Children, Perth, Australia
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Amirav I, Newhouse MT. Review of optimal characteristics of face-masks for valved-holding chambers (VHCs). Pediatr Pulmonol 2008; 43:268-74. [PMID: 18219694 DOI: 10.1002/ppul.20767] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Inhaled drugs are frequently given to infants and young children with a pressurized metered-dose inhaler (pMDI) attached to a valved-holding chamber (VHC) with face mask. In young children and infants who cannot breathe through a mouthpiece, the face mask serves as the interface between the patient and the VHC. Although the mask interface is one of the most important factors determining the dose of medication delivered from the VHC to the nose and mouth in these patients, its optimal characteristics are not well known. Recent studies clearly identify several face mask factors that determine the success or failure of drug delivery with these devices. This review summarizes the most important features of an optimal mask design such as: face seal/leak, volume of dead space, contour, flexibility, transparency, weight and cost. By optimizing these characteristics it should be possible to improve mask design. This will maximize the magnitude and reduce the variability of the dose presented to the respiratory tract while making the mask more comfortable and patient/caregiver-friendly.
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Affiliation(s)
- Israel Amirav
- Pediatric Department, Ziv Medical Center, Safed, Faculty of Medicine, Technion, Haifa, Israel.
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Finlay WH, Martin AR. Modeling of aerosol deposition with interface devices. ACTA ACUST UNITED AC 2007; 20 Suppl 1:S19-26; discussion S27-8. [PMID: 17411402 DOI: 10.1089/jam.2007.0554] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Various approaches can be used to mathematically model the performance of different masks, mouthpieces, and aerosol delivery devices. The sophistication of such models can vary widely, from the use of simple algebraic empirical correlations to advanced computational fluid dynamics simulations. Bench-top testing is also often used to model aspects of devices, since it is difficult to capture certain aspects of device behavior with mathematical models. These various approaches to modeling differ in their limitations. Empirical correlations exist for predicting the effects of varying mouthpiece diameter and mouth-throat dimensions on extrathoracic losses, but are restricted to stable, nonballistic aerosols in certain flow rate ranges. Computational fluid dynamics (CFD) simulations that solve the Reynolds-averaged Navier-Stokes (RANS) equations typically require near-wall turbulence corrections in order to adequately model mouth-throat deposition, while Large Eddy Simulation (LES) removes this deficiency. Bench-top models that use replicas of the extrathoracic airways vary in their accuracy and generality in replicating the filtering properties of these airways. Choosing and using these various modeling approaches for evaluating patient-device interfaces requires knowledge of their merits and pitfalls, a brief discussion of which is given here.
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Affiliation(s)
- W H Finlay
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
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Fiato KL, Iwamoto GK, Harkins MS, Morelos J. Monitoring flow rates and retention of inhalation techniques using the in-check dial device in adult asthmatics. J Asthma 2007; 44:209-12. [PMID: 17454340 DOI: 10.1080/02770900701209798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The In-Check-Dial (Alliance Tech Medical, Granburg, TX) was used to determine adequacy of inhalation techniques and teaching of two different devices. Retention of adequate techniques, was assessed in 234 moderate to severe asthmatics. Inhalation techniques were assessed at periodic follow-ups divided into less than 1 month return visit, between 1 and 3 months, 3 to less than 6 months, and 6 months to less than 1 year. Proper inhalation techniques worsened at greater than 3 months after the last instruction. The use of the In-Check-Dial is a useful tool in teaching proper technique and monitoring the patient's ability to correctly use inhalation devices.
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Affiliation(s)
- Karen-Lynn Fiato
- Department of Internal Medicine, University of New Mexico. Albuquerque, NM 87131, USA
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