Lung deposition of aerosol--a comparison of different spacers.

AIMS: To investigate (1) aerosol lung deposition obtained from two small volume conventional spacers (Babyhaler and Aerochamber) and a home made spacer (modified 500 ml plastic cold drink bottle); (2) the effect of using a face mask or mouthpiece; and (3) the relation between age and pulmonary deposition. METHODS: Lung deposition of aerosolised technetium-99m DTPA inhaled via spacer was measured in 40 children aged 3-7 years with stable asthma. Each patient performed sequential randomly assigned inhalations using two spacers. Three studies were performed: Babyhaler compared to Aerochamber (with facemasks); Babyhaler with facemask compared to Babyhaler with mouthpiece; and Babyhaler with mouthpiece compared to a 500 ml bottle. RESULTS: Median lung aerosol deposition from a Babyhaler and Aerochamber with masks were similar (25% v 21%, p = 0.9). Aerosol lung deposition from a Babyhaler with mask compared to a Babyhaler with mouthpiece was equivalent (26% v 26%, p = 0.5). Lung deposition was higher from a 500 ml bottle compared to a Babyhaler in both young (25% v 12.5%, p = 0.005) and older children (42% v 22.5%, p = 0.003). A notable reduction in pulmonary deposition occurred at 50 months of age. CONCLUSION: A Babyhaler or Aerochamber produce equivalent lung deposition of aerosol. There is no difference in lung deposition when a mask or mouthpiece is used. A modified 500 ml plastic bottle produces greater pulmonary aerosol deposition than a conventional small volume spacer.     

Inhalation therapy in children with asthma

Current consensus guidelines advocate the use of inhalation therapy for all children with asthma. In this paper, the published evidence on technical and practical aspects of inhalation therapy in children with asthma is reviewed. For children under 6 yr of age, nebulizers and metered dose inhaler (MDI)/spacer combinations can be used. Nebulizers are cumbersome, bulky, and difficult to operate. They require technical and hygienic maintenance. A number of studies has shown that nebulizers are no more effective in delivering bronchodilator therapy than MDI/spacer combinations. Thus, for young children with asthma, MDI/spacer combinations are the device of choice for inhalation therapy. Due to static charge, the output from plastic spacers is lower than that from metal spacers. Static charge on plastic spacers can be reduced by washing the spacer in detergent and allow it to drip dry. Most children aged 6 yr or over can use a dry powder inhaler (DPI) reliably. Modern DPIs require relatively low inspiratory flow rates for proper operation. Lung deposition from the Turbuhaler is twice as high as that from the Diskus, but the former device is slightly more difficult to operate than the latter. Many children with asthma have a poor inhalation technique. Because a reliable inhalation technique is the key to successful inhalation therapy, inhalation technique should be instructed carefully and checked repeatedly in every asthmatic child using an inhaler device.     

Lung deposition of aerosol--a comparison of different spacers

AIMS—To investigate (1) aerosol lung deposition obtained from two small volume conventional spacers (Babyhaler and Aerochamber) and a home made spacer (modified 500 ml plastic cold drink bottle); (2) the effect of using a face mask or mouthpiece; and (3) the relation between age and pulmonary deposition.METHODS—Lung deposition of aerosolised technetium-99m DTPA inhaled via spacer was measured in 40 children aged 3-7 years with stable asthma. Each patient performed sequential randomly assigned inhalations using two spacers. Three studies were performed: Babyhaler compared to Aerochamber (with facemasks); Babyhaler with facemask compared to Babyhaler with mouthpiece; and Babyhaler with mouthpiece compared to a 500 ml bottle.RESULTS—Median lung aerosol deposition from a Babyhaler and Aerochamber with masks were similar (25% v 21%, p = 0.9). Aerosol lung deposition from a Babyhaler with mask compared to a Babyhaler with mouthpiece was equivalent (26% v 26%, p = 0.5). Lung deposition was higher from a 500 ml bottle compared to a Babyhaler in both young (25% v 12.5%, p = 0.005) and older children (42% v 22.5%, p = 0.003). A notable reduction in pulmonary deposition occurred at 50 months of age.CONCLUSION—A Babyhaler or Aerochamber produce equivalent lung deposition of aerosol. There is no difference in lung deposition when a mask or mouthpiece is used. A modified 500 ml plastic bottle produces greater pulmonary aerosol deposition than a conventional small volume spacer.     

Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction

Background

Inhaled bronchodilator treatment given via a metered dose inhaler (MDI) and spacer is optimal for relief of bronchoconstriction. Conventional spacers are expensive or unavailable in developing countries, but there is little information on the efficacy of low‐cost spacers in young children.

Objective

To compare the response to bronchodilator treatment given via a conventional or a low‐cost bottle spacer

Methods

A randomised controlled trial of the efficacy of a conventional spacer compared with a bottle spacer for bronchodilator treatment in young children with acute lower airway obstruction. Bronchodilator treatment was given from an MDI via an Aerochamber or a bottle spacer. Clinical score and oximetry recording were carried out before and after 15 min of treatment. MDI–spacer treatment was repeated up to three times, depending on clinical response, after which nebulisation was used. The primary outcome was hospitalisation.

Results

400 children, aged (median (25th–75th centile)) 12 (6–25) months, were enrolled. The number of children hospitalised (n = 60, 15%) was identical in the conventional and bottle spacer groups (n = 30, 15% in each). Secondary outcomes including change in clinical score (−2 (−3 to −1)), oxygen saturation (0 (−1 to 1)) and number of bronchodilator treatments (2 (1 to 3)) were similar in both groups. Oral corticosteroids, prescribed for 78 (19.5%) children, were given to a similar number in the conventional (37 (18.5%)) and bottle spacer groups (41 (20.5%)).

Conclusion

A low‐cost bottle spacer is as effective as a conventional spacer for bronchodilator treatment in young children with acute obstruction of the lower airways.Acute obstruction of the lower airway is common in young children. Inhaled bronchodilator treatment is recommended for relief of airway obstruction. In children, a pressurised metered dose inhaler (MDI) with spacer produces bronchodilation equivalent or superior to nebulised treatment even in the case of severe airway obstruction.^1,2,3 An MDI–spacer delivery system has many advantages over nebulisation, including shorter and easier administration of drug, transportability, no need for a power source and lower risk of nosocomial infection.⁴ Moreover, use of an MDI–spacer has been reported to be cost effective; the cost and time for MDI–spacer treatment has been calculated as 40–60% that for nebulised treatment.⁵ However, a spacer is essential to minimise dependence on the child''s inhalation technique and to optimise drug delivery.^1,4Various commercially produced spacers have been developed, but expense and unavailability have limited their use in developing countries. The development of low‐cost spacers has received relatively little attention; however, a modified plastic bottle spacer has been shown to have clinical efficacy in children >5 years.^6,7 A randomised trial of a plastic bottle compared with a conventional spacer in children >5 years with acute asthma found that bottle and conventional spacers produced similar bronchodilation as measured by improvements in clinical score and pulmonary function.⁷ Another study of children aged 5–15 years with acute asthma reported similar improvements in peak expiratory flow rates and clinical parameters in patients who used a bottle spacer compared with those using a commercially produced spacer.⁸ However, the clinical efficacy of a bottle spacer has not been tested in infants or young children.The potential efficacy of a modified plastic bottle as a spacer for young children has been suggested by aerosol deposition studies in which lung deposition of nebulised technetium 99m DTPA given via a bottle or a conventional spacer was measured.⁹ In children <5 years, lung deposition from a bottle was found to be twice that obtained with a conventional small‐volume spacer.⁹ The amount of lung deposition was dependent on age, with a marked reduction occurring at around 50 months; this pattern occurred with both conventional and bottle spacers.The aim of this study was to compare the response to bronchodilator given via an MDI with bottle or conventional spacer in young children with acute lower airway obstruction (LAO).     

Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction.

BACKGROUND: Inhaled bronchodilator treatment given via a metered dose inhaler (MDI) and spacer is optimal for relief of bronchoconstriction. Conventional spacers are expensive or unavailable in developing countries, but there is little information on the efficacy of low-cost spacers in young children. OBJECTIVE: To compare the response to bronchodilator treatment given via a conventional or a low-cost bottle spacer METHODS: A randomised controlled trial of the efficacy of a conventional spacer compared with a bottle spacer for bronchodilator treatment in young children with acute lower airway obstruction. Bronchodilator treatment was given from an MDI via an Aerochamber or a bottle spacer. Clinical score and oximetry recording were carried out before and after 15 min of treatment. MDI-spacer treatment was repeated up to three times, depending on clinical response, after which nebulisation was used. The primary outcome was hospitalisation. RESULTS: 400 children, aged (median (25th-75th centile)) 12 (6-25) months, were enrolled. The number of children hospitalised (n = 60, 15%) was identical in the conventional and bottle spacer groups (n = 30, 15% in each). Secondary outcomes including change in clinical score (-2 (-3 to -1)), oxygen saturation (0 (-1 to 1)) and number of bronchodilator treatments (2 (1 to 3)) were similar in both groups. Oral corticosteroids, prescribed for 78 (19.5%) children, were given to a similar number in the conventional (37 (18.5%)) and bottle spacer groups (41 (20.5%)). CONCLUSION: A low-cost bottle spacer is as effective as a conventional spacer for bronchodilator treatment in young children with acute obstruction of the lower airways.     

Use of a tube spacer to improve the efficacy of a metered-dose inhaler in asthmatic children

Many children with asthma do not use the standard metered-dose inhaler (MDI) skillfully. To improve drug delivery, correct problems of hand-lung incoordination, and reduce local side effects, a number of spacer devices have been developed. We evaluated one such device, a tube spacer (Aerochamber), in 16 asthmatic children (5 to 12 years). On four separate days and in a randomized, double-blind, placebo-controlled manner, they received either metaproterenol sulfate by MDI aerosol (130 micrograms) or placebo with and without the tube spacer. To maximize techniques, at each visit the children had proper instructions, including viewing a videotape. Spirometry was performed at baseline and 5, 15, and 30 minutes, and hourly for six hours, and the patient was monitored. Analysis of the entire group (forced expiratory volume at 1 s and midmaximal expiratory volume) revealed no difference between metaproterenol administered with or without the tube spacer, and both were significantly different than placebo through two hours. Six children had longer and three had better bronchodilatation with the MDI plus tube spacer than with the MDI alone. Side effects and vital signs did not differ between treatments. Under the circumstances of our study, the tube spacer device might enhance the use of the MDI in children who are not properly taught and/or who forget or cannot perform proper technique.     

Efficacy of a home-made spacer with acute exacerbation of bronchial asthma : A randomized controlled trial

Metered dose inhaler (MDI) with spacer is the preferred method for administration of aerosolized medications in pediatric asthma. The expense of commercial spacers limits their use and indigenous alternatives have therefore been developed. Information on the clinical efficacy of home-made spacers is limited. This study was conducted to compare the efficacy of a valve-less home-made spacer with a commercial spacer in delivering salbutamolvia MDI in acute asthma. Asthmatic children aged 5–15 years who presented with an acute exacerbation to the pediatric chest clinic of a tertiary care hospital were enrolled in a single blinded randomized parallel group study. The study patients received 10 puffs of salbutamol (100(igJ puff)via MDI-home-made spacer or MDI-commercial spacer. Pre and post inhalation measurements of peak expiratory flow rate (PEFR), oxygen saturation (SaO2), respiratory rate (RR), pulse rate (PR) were made and compared. Sixty children were enrolled in the study, 31 were administered salbutamolvia the home-made spacer and 29via the commercial spacer. The median increase in PEFR was similar in both the groups (20.8% vs22.2%, p=0.4), clinical improvement being satisfactory in all patients. The valve-less home-made spacer is equally efficacious and cheaper than the commercial spacer in administering bronchodilators in acute exacerbations of asthma. Further studies on the efficacy of home-made spacer in delivery of inhaled steroids are needed.     

Skill Development Regarding Use of Metered Dose Inhaler (MDI) Amongst School Teachers of Northern India

Objective

To evaluate the impact of a booklet based training by a nurse on the development of skills regarding use of metered dose inhaler (MDI) among the teachers of the selected schools of Chandigarh, India.

Methods

The present study was undertaken by randomly selecting government schools of Chandigarh from where 91 school teachers were enrolled. A booklet on asthma management containing information regarding asthma, its triggers, signs and symptoms, treatment, types of inhalers and steps of using MDI with spacer was used for training the subjects. Their knowledge and skills were evaluated through observation checklist. Three return demonstrations were taken from each teacher on three successive days. Main outcome measure was skill development of the teachers in the use of MDI with spacer. Pre and post tests scores were compared by repeated measures ANOVA.

Results

Most of the teachers didn’t know theoretical or practical aspects of MDI. After training all the teachers performed correctly most of the steps of MDI use. Some teachers performed poorly in giving instruction to breathe in/out slowly and hand washing before/after MDI administration. There was a statistical significant improvement in the performance scores of the teachers after each return demonstration (p?<?0.0005).

Conclusions

Training strategy used in the study involving nursing personnel was successful in improving teachers’ skills in MDI use for asthma management. More focus should be given on breathe in/out instructions and on hand washing before/after MDI use.     

Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma

OBJECTIVE: To compare the costs and effectiveness of albuterol by metered dose inhaler (MDI) and spacer versus nebulizer in young children with moderate and severe acute asthma. DESIGN: Randomized, double-blind, placebo-controlled trial in an emergency department at a children's hospital. The participants were children 1 to 4 years of age with moderate to severe acute asthma. Patients assigned to the spacer group received albuterol (600 microg) by MDI by spacer (AeroChamber) followed by placebo by nebulizer (n = 30). The nebulizer group received placebo MDI by spacer followed by 2.5 mg albuterol by nebulizer (n = 30). Treatments were repeated at 20-minute intervals until the patient was judged to need no further doses of bronchodilator, or a total of 6 treatments. RESULTS: Clinical score, heart rate, respiratory rate, auscultatory findings, and oxygen saturation were recorded at baseline, after each treatment, and 60 minutes after the last treatment. Baseline characteristics and asthma severity were similar for the treatment groups. The spacer was as effective as the nebulizer for clinical score, respiratory rate, and oxygen saturation but produced a greater reduction in wheezing (P =.03). Heart rate increased to a greater degree in the nebulizer group (11.0/min vs 0.17/min for spacer, P <.01). Fewer children in the spacer group required admission (33% vs 60% in the nebulizer group, P =.04, adjusted for sex). No differences were seen in rates of tremor or hyperactivity. The mean cost of each emergency department presentation was NZ$825 for the spacer group and NZ$1282 for the nebulizer group (P =.03); 86% of children and 85% of parents preferred the spacer. CONCLUSION: The MDI and spacer combination was a cost-effective alternative to a nebulizer in the delivery of albuterol to young children with moderate and severe acute asthma.     

Efficacy and safety of a home-made non-valved spacer for bronchodilator therapy in acute asthma

The aim of this study was to assess the efficacy and safety of an alternative spacer to deliver salbutamol in acute asthma. A prospective randomized study was performed with 196 patients with acute asthma, aged 4-15 y. The clinical features, oxygen saturation (SaO2) and the best of three peak expiratory flow rate (PEFR) measurements were recorded in a standardized questionnaire. Each patient received up to three conventional doses of salbutamol through an alternative home-made non-valved spacer (NVS) (500 ml mineral water plastic bottle) or an oxygen-driven nebulizer (ODN). The clinical and functional respiratory parameters (PEFR and SaO2) were assessed 15 min after each administration of the bronchodilator. In the ODN (n = 99) and NVS (n = 97) groups, PEFR (p > 0.05) and SaO2 (p > 0.05) measurements improved in all stages of the treatment. During the asthma attacks, the ODN group needed a prolonged observation in the emergency room (p = 0.000000). Side effects of salbutamol, e.g. increased heart rate, were observed in 17.2% of the patients in the ODN group and 4.1% in the NVS group (p = 0.003). CONCLUSION: Both devices showed comparable efficacy in mild and moderate acute attacks, but the use of the alternative NVS resulted in a shorter observation period in the emergency room. The frequency of side effects was significantly higher in the ODN group than in the NVS group.     

Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma.

OBJECTIVE: In children with mild acute asthma, to compare treatment with a single dose of albuterol delivered by a metered dose inhaler (MDI) with a spacer in either a weight-adjusted high dose or a standard low-dose regimen with delivery by a nebulizer. STUDY DESIGN: In this randomized double-blind trial set in an emergency department, 90 children between 5 and 17 years of age with a baseline forced expiratory volume in 1 second (FEV1 ) between 50% and 79% of predicted value were treated with a single dose of albuterol, either 6 to 10 puffs (n = 30) or 2 puffs (n = 30) with an MDI with spacer or 0.15 mg/kg with a nebulizer (n = 30). RESULTS: No significant differences were seen between treatment groups in the degree of improvement in percent predicted FEV1 (P =.12), clinical score, respiratory rate, or O2 saturation. However, the nebulizer group had a significantly greater change in heart rate (P =.0001). Our study had 93% power to detect a mean difference in percent predicted FEV1 of 8 between the treatment groups. CONCLUSION: In children with mild acute asthma, treatment with 2 puffs of albuterol by an MDI with spacer is just as clinically beneficial as treatment with higher doses delivered by an MDI or by a nebulizer.     

Application and efficacy of the multi‐dose powder inhaler, Easyhaler®, in children with asthma

With powder inhalers, optimal performance is dependent on the inspiratory flow produced by the patient through the devices. The objective of this open, non‐randomized study was to evaluate the suitability of a new, multi‐dose, dry powder inhaler, the Easyhaler^®, for children with asthma. The peak inspiratory flow (PIF) through the Easyhaler (PIF_EH) was measured with a pneumotachograph in 120 asthmatic children aged 4–16 yr. The bronchodilatory effect of 0.2 mg salbutamol through the Easyhaler was compared with that of 0.2 mg salbutamol through a metered dose inhaler (MDI) with a spacer, in 15 children with obstruction. The mean PIF_EH was 56 l/min (range 22–83 l/min). The PIF_EH correlated significantly with age, height, and absolute peak expiratory flow (PEF), but not with the level of obstruction (PEF percentage of predicted, range 45–146%). Only four children (aged 5, 6, 10, and 16 yr) had PIF_EH values below 28 l/min, which has been shown in in vitro studies to be the threshold for effective use of the Easyhaler. In 15 children with PEF, < 85% of predicted bronchodilatory effects of 0.2 mg salbutamol through the Easyhaler and from an MDI‐cum‐spacer were equal. Most children aged 6–16 yr produce PIF values sufficient for the use of the Easyhaler. The gain of 0.2 mg salbutamol from the Easyhaler was equal to that from a new, unprimed, MDI with a spacer in children with asthma.     

Metered-dose inhaler: the emergency department orphan.

OBJECTIVE: Physicians providing emergency department care to children primarily use nebulizers for the delivery of bronchodilators and these physicians have misconceptions regarding the advantages and disadvantages of using metered-dose inhalers (MDIs) with a spacer (MDI + S) for acute asthma exacerbations. DESIGN: Self-administered mail survey. SETTING: Emergency department. PARTICIPANTS: Emergency medicine section members of the American Academy of Pediatrics and Canadian Pediatric Society. INTERVENTIONS: Bronchodilator delivery methods in acute pediatric asthma. MAIN OUTCOME MEASURES: The 2 principal outcomes for bivariate analysis were self-reported nebulizer use in all patients and MDI + S use in patients with mild acute asthma. RESULTS: Of eligible physicians, 333 (51%) of 567 responded. The majority were dual trained in pediatrics and pediatric emergency medicine (72%) and practiced full time (83%) in an urban (83%) pediatric emergency department (80%). The most commonly cited advantages of MDIs were their cost (33%) and speed of use (28%). The most commonly cited disadvantages were patient or parent dissatisfaction (24%) and relative ease of nebulizer use (23%). Only 10% to 21% of participants used MDIs in the emergency department and reserved this delivery method for children with mild asthma exacerbations. There were no significant associations between selected respondent demographic variables and the use of MDIs. CONCLUSIONS: Misconceptions regarding the efficacy and safety of MDI + S for the treatment of acute asthma exacerbations exist but are limited to a minority of surveyed emergency medicine physicians caring for children. Nebulizers remain the preferred method of routine bronchodilator delivery by physicians providing care to pediatric asthmatics in the emergency department.     

A non-electrostatic spacer for aerosol delivery

A pear shaped non-electrostatic spacer, composed of steel with a volume of 250 ml and equipped with a facemask containing integrated inlet and outlet valves for inspiration and expiration, was compared with three plastic spacers. The plastic spacers were primed with repeated puffs from a budesonide pressurised metered dose inhaler (p-MDI) to minimise the electrostatic charge on the plastic. The procedure prolonged the half life (t1/2) of the aerosol in the Nebuhaler from nine to 32 seconds. A normal cleaning procedure reduced the aerosol t1/2 back to baseline. The t1/2 of the aerosol in the metal spacer was 27 seconds and independent of the use of p-MDI. In vitro the maximum dose of budesonide from a p-MDI, expressed as a percentage of the nominal dose, was 56% from the non-electrostatic spacer, 61% from the Nebuhaler, 45% from the Babyhaler, and 30% from the AeroChamber. In 124 children, age 6 months to 6 years, suspected to have asthma the non-electrostatic spacer delivered a mean total dose of budesonide aerosol of 39% of the nominal dose, which was significantly higher than the Babyhaler (28%), the Nebuhaler (21%), and the AeroChamber (19%). These differences were most pronounced in children younger than 4 years. The improved dose delivery from the small volume non-electrostatic spacer is probably related to the non-electrostatic spacer material and the valves which assured unidirectional airflow from the spacer without adding any dead space in the inspiratory channel. The non-electro-static spacer should improve the cost effectiveness of aerosol treatment and, as the counteracting effects of proming and recharging of the plastic from cleaning are avoided, should deliver a more reliable dose.     

A non-electrostatic spacer for aerosol delivery.

A pear shaped non-electrostatic spacer, composed of steel with a volume of 250 ml and equipped with a facemask containing integrated inlet and outlet valves for inspiration and expiration, was compared with three plastic spacers. The plastic spacers were primed with repeated puffs from a budesonide pressurised metered dose inhaler (p-MDI) to minimise the electrostatic charge on the plastic. The procedure prolonged the half life (t1/2) of the aerosol in the Nebuhaler from nine to 32 seconds. A normal cleaning procedure reduced the aerosol t1/2 back to baseline. The t1/2 of the aerosol in the metal spacer was 27 seconds and independent of the use of p-MDI. In vitro the maximum dose of budesonide from a p-MDI, expressed as a percentage of the nominal dose, was 56% from the non-electrostatic spacer, 61% from the Nebuhaler, 45% from the Babyhaler, and 30% from the AeroChamber. In 124 children, age 6 months to 6 years, suspected to have asthma the non-electrostatic spacer delivered a mean total dose of budesonide aerosol of 39% of the nominal dose, which was significantly higher than the Babyhaler (28%), the Nebuhaler (21%), and the AeroChamber (19%). These differences were most pronounced in children younger than 4 years. The improved dose delivery from the small volume non-electrostatic spacer is probably related to the non-electrostatic spacer material and the valves which assured unidirectional airflow from the spacer without adding any dead space in the inspiratory channel. The non-electro-static spacer should improve the cost effectiveness of aerosol treatment and, as the counteracting effects of proming and recharging of the plastic from cleaning are avoided, should deliver a more reliable dose.     

Salbutamol and/or beclomethasone diproprionate in asthma

Objective: Acute severe exacerbation of asthma is potentially life threatening and requires critical assessment and appropriate therapy. Now a days, steroids are often combined with bronchodilators for the treatment of bronchial asthma. Therefore, the present study was undertaken to compare effectiveness of beclomethasone diproprionate-salbutamol combination versus salbutamol alone by MDI (with or without spacer) in acute asthma.Methods : A total of 57 paediatric patients (5–12 years) with acute attack of bronchial asthma attending emergency department of Indira Gandhi Medical College and Hospital was randomised to receive salbutamol (100 μg/puff) alone or with BDP (50 μg/puff) by metered dose inhaler with or without spacer. All baseline investigations were repeated one hour after the therapy.Results : Clinical parameters indicative of severity of asthma improved statistically in all treatment groups. The increase in PEFR was better with MDI-S+B with spacer as compared to other groups, though it failed to reach statistical significance. The fall in serum potassium level is significantly more with MDI-S+B group when spacer was not used. No serious adverse effects were observed in any of the treatment groups.Conclusions. Metered dose inhalation of BDP-salbutamol combination with spacer provides better recovery whereas fall in serum potassium with MDI-S+B suggests use of spacer and monitoring of serum potassium during treatment.     

Aerosol delivery systems in childhood asthma

Asthma in younger children appears to be increasing in prevalence, whilst at the same time it is recognized that inhaled corticosteroids and bronchodilators are the mainstay of treatment for this condition. Presently the devices available for aerosol treatment of young children are mostly developed for use in older children and adults. However, an awareness of the need for delivery systems dedicated to use by young children is increasing. The devices available at present for aerosol treatment of young children comprises the nebulizer, metered-dose inhaler with spacer, and dry powder inhaler. The inhaler strategy found most useful at present can be summarized as follows: children younger than 2 years can use MDI+spacer+mask or nebulization, while children above 2 years can use MDI+spacer (without mask). Older children (3-4 years) can be easily taught the use of a Rotahaler.     

Randomized controlled trial of ipratropium bromide and salbutamol versus salbutamol alone in children with acute exacerbation of asthma

Objective To evaluate effect of addition of ipratropium to salbutamol delivered by metered dose inhaler and spacer in the beginning of treatment of mild to moderate exacerbation of asthma. Methods Children between 5 to 15 years of age with mild to moderate exacerbation of asthma were randomized to receive either a combination of ipratropium bromide and salbutamol or salbutamol alone administered by metered dose inhaler and spacer. The effects on clinical asthma score and spirometric parameters were compared. Results A total of 60 children were randomized in the study. The baseline characteristics of two groups were comparable. Children getting combination of salbutamol and ipratropium showed significantly greater improvement in percent-predicted PEFR and FEF25–75% than children receiving salbutamol alone. Conclusion There was beneficial effect of addition of ipratropium to salbutamol administered by MDI with spacer at the beginning of therapy for mild to moderate acute exacerbation of asthma in children.     

Increasing Metered Dose Inhaler Use for Acute Asthma Exacerbations in the Pediatric Emergency Department: A Quality Improvement Challenge

Pediatric asthma is the most common chronic condition in children and results in significant disease burden and healthcare costs. The mainstay of asthma treatment is inhaled albuterol, and different modalities of albuterol delivery have been shown to affect healthcare quality measures. Albuterol delivered via metered-dose inhaler with a valved holding chamber (MDI/VHC) has been shown to be at least as effective as nebulized albuterol while also reducing medication side effects, admission rates, length of stay in the emergency department (ED) and overall costs. However, a culture of nebulized albuterol still predominates in the ED. Quality Improvement methodology is well suited to address this healthcare quality problem. The goal of this article is to utilize The Model for Improvement framework to provide a review and a critique of the literature regarding the transition to MDI/VHCs from nebulizers in the acute care of children with asthma exacerbations.     

Randomized trial of spacers in asthma

Objective To compare the efficacy of all types of spacers commonly available to children in India. Methods 150 children 5–14 yr of age with persistent asthma presenting with peak expiratory flow (PEF) <70% of personal best were randomized to receive 200μg salbutamol through one of five spacers: A) 750ml spacer with valve, B) 165ml spacer with valve, C) 250ml spacer without valve, D) 1000ml indigenously made spacer without valve and E) 500ml indigenously made spacer without valve. PEF measurement was repeated 15 minutes later. Children >8 yr old performed spirometry in addition to PEF. Absolute change and percentage improvement of PEF and FEV₁ were compared among the groups. Results Subjects in all groups had comparable baseline demographic characteristics and PEF. All showed significant improvement in PEF and FEV₁ over baseline values. The change in PEF and percentage improvement were comparable among all five groups (p=0.780 and p=0.955 respectively). Likewise change in FEV₁ and percentage improvement were also comparable. The five groups showed no difference in efficacy, irrespective of severity of baseline airway obstruction. Conclusion The five spacers were equally efficacious for the delivery of bronchodilator in children with moderate persistent asthma presenting with airway obstruction.